Course Articles

Editor’s note: This text-based course is an edited transcript of the webinar, Supporting Neurodiverse Staff, Colleagues and Patients, presented by Gabrielle Davis, MPH, MA, RRT, RRT-ACCS, RRT-NPS, TTS, LPC, NCC, FAARC. 

It is recommended that you download the course handout to supplement this text format.

Learning Outcomes

• Recognize and support neurodivergent patients, while gaining a deeper understanding of neurodiversity and its implications in healthcare
• Identify and apply strategies to dismantle barriers that limit equitable access to care for neurodivergent individuals
• Discuss the skills to implement affirming and inclusive care practices, ensuring that neurodivergent patients receive respectful and equitable respiratory care

Why This Topic? Why Now?

I chose to present this topic for several reasons. About a year ago, I attended a national conference where an educator—a college professor—asked the presenter a question that has stayed with me ever since. While I do not recall the specific topic the presenter was discussing, the professor’s question stood out: “What do we do with students who have IEPs? Should they not be discouraged from working in healthcare? Should they even be allowed to care for patients?”

Hearing those words deeply angered me. The question implied that individuals with Individualized Education Programs (IEPs) or other accommodations were inherently unfit to pursue careers in healthcare. Unfortunately, it was the final question of the session, and although I raised my hand to respond, there was no time for me to speak. That moment stayed with me, fueling my decision to address this topic—not just out of frustration but because it is an issue that demands attention.

I am someone who has ADHD, a condition I was diagnosed with later in life. Despite the challenges it presents, I have been able to achieve incredible things in my career and personal life. The idea that someone’s need for accommodations or support automatically disqualifies them from providing exceptional patient care is unfair and untrue. It perpetuates harmful stereotypes and undermines the potential of countless capable individuals.

It is essential to challenge these misconceptions and remind others that success in healthcare—or any field—is not defined by the absence of challenges. People with IEPs, ADHD, mental health conditions, or other needs for assistance prove every day that they are not only capable but can thrive in their chosen professions. By acknowledging this, we create a more inclusive and supportive environment for everyone.

Community-Powered Presentation

This presentation is community-powered, meaning it was shaped by input from individuals with lived experience related to this topic. While literature and evidence-based research are invaluable, they often exclude the voices of people from minoritized groups—particularly those with certain conditions—due to longstanding mistrust, including medical mistrust. By incorporating insights from the community, this presentation highlights perspectives that might otherwise be overlooked.

One key idea to consider as we explore this topic is that diagnosis itself is a privilege—one that not everyone has access to. For example, I am 42 years old and was only diagnosed with ADHD in 2017. My diagnosis came not through seeking medical help but because a teacher in my mental health therapy program pulled me aside and raised the possibility. Despite having access to insurance and other resources throughout my life, no one had ever brought it up before. It took someone paying close attention to connect the dots.

When I received my diagnosis, everything about my past suddenly made sense—the difficulties I had focusing on one thing, my need for extra time to complete tasks, and my tendency to juggle multiple things at once. ADHD manifests in diverse ways, and having a diagnosis provides clarity. However, not everyone is fortunate enough to have the opportunity to gain that clarity, which underscores why diagnosis is a privilege.

Another critical point is that language and science are constantly evolving. It is essential to stay informed about how terms and concepts shift over time. For instance, ongoing discussions in the neurodiversity community address the distinction between “neurodivergent” and “neurodiversity.” Some individuals do not wish to be labeled “neurodivergent,” even if science might categorize them differently. In these cases, it is vital to honor the language someone uses to describe themselves. It is not our role to correct or challenge how a person chooses to identify.

Lastly, this presentation is an educational offering, not a formal training. I use the term “educational offering” intentionally, as training often implies completion or mastery. In past presentations, I have had participants ask, “When do I get my certificate?” CEUs are valuable—clearly, or I would not be here—but it is important to understand that this is not the final destination. Instead, consider this one step on a much longer educational journey.

Let’s Talk Terms!

Let’s begin by defining some key terms, starting with neurodiversity. I say a definition because if you search for the term online, you will find countless interpretations. The one I use most often, particularly when speaking to those new to the concept, is straightforward: neurodiversity refers to the natural diversity of human brains. It emphasizes that every brain is unique. Notably, this definition does not mention diagnoses, which is intentional.

This distinction is important because when people hear terms like neurodiversity or neurodivergent, their understanding often defaults to ADHD or autism. While these are prominent examples, they are only part of the broader neurodivergent spectrum. The term encompasses a wide range of conditions, including dyslexia, dyspraxia, Tourette’s syndrome, and even mental health conditions such as bipolar disorder or generalized anxiety disorder. Each of these conditions can manifest differently from person to person. For instance, with ADHD, one individual might struggle with maintaining focus, while another thrives on multitasking but struggles with hyperfocus or emotional regulation.

One important concept within neurodiversity is acquired neurodiversity, which refers to changes in the brain resulting from life experiences, particularly trauma. Research indicates that approximately 70% of Americans have experienced some form of trauma, which can leave lasting effects on the brain. A commonly recognized example is post-traumatic stress disorder (PTSD), often associated with combat veterans. However, trauma affects people in many other ways and can stem from everyday experiences such as accidents, abuse, or even chronic stress.

Let me share a personal story to illustrate this. When I was 17, I had my first car, a 1988 Cougar. One day, while driving to my grandmother’s house, I stopped at an intersection to turn left. I noticed the car in front of me had children playing in the backseat—this was 1999, and seatbelt usage was not as rigorously enforced. I smiled at their antics, but then I glanced in my rearview mirror and saw a car speeding toward me. My immediate reaction was to press both feet on the brake to avoid being pushed into the car ahead. The impact spun my car into the opposite lane, but thankfully, I was not seriously hurt. However, the experience left a deep impression. For years, I avoided using my rearview mirror, angling it downward to avoid looking into it. I relied solely on my side mirrors, a habit born from that single traumatic moment.

Years later, in 2014, I was T-boned by another driver who ran a red light. Again, I was not seriously injured, but the trauma compounded my anxiety around driving. Now, whenever a car merges into the lane next to mine on the freeway, I instinctively assume it will swerve into my lane. This has led to unnecessary swerving on my part, even when no real danger exists. These experiences have made driving an activity I dread, not because of the act itself but because of how my brain now processes potential threats.

Trauma does not just affect conscious memories—it can also leave subconscious imprints. For example, I once worked with a client who had a debilitating fear of dogs. When I asked if she had ever been bitten or chased, she could not recall any such incident. However, after speaking with her family, she discovered she had been bitten on the foot at eight months old. She had no memory of the event, but her body retained the fear. This demonstrates how trauma, even when not consciously remembered, can shape our behaviors and responses.

This brings us back to the term neurodivergent. It stands in contrast to neurotypical, a word that has sparked debate. Referring to someone as neurotypical implies there’s a “normal” brain, but as we know, “normal” is a subjective and often unhelpful concept. As the saying goes, “Normal is just a setting on a washing machine.” Every brain is different, and these differences make humanity diverse and innovative.

Language within the neurodiversity movement continues to evolve. For instance, some people prefer the term neuroexpansive over neurodivergent. A group of Black disabled women coined Neuroexpansive as a response to how neurodivergent has been weaponized against marginalized populations. It rejects the framing of neurodivergence as a deficit and highlights the expansive possibilities of diverse brain function. For example, people with ADHD might hear statements like, “You cannot be trusted with this task because you are too distracted,” or “We cannot hire you because you are not reliable.” These statements perpetuate ableism, and while discrimination is illegal, it still happens.

Other terms are more playful, like neurospicy or neurosassy. I love these terms and often use them to describe myself. They provide a lighthearted way to embrace one’s neurodivergent identity while challenging the stigma around it.

As language and science continue to evolve, it is important to stay informed. If you are in a leadership position in healthcare or any field, listen to your colleagues and staff. When you encounter new terminology, take the initiative to learn about it—Google is free, after all. Proactively understanding these terms fosters inclusivity and ensures that everyone feels seen and respected.

Potential Challenges: Students/Colleagues

• Pushing to ‘work faster/harder’ constantly
• Being late and scheduling (coming to work or completing work)
• Being narrow-focused in providing/receiving instructions
• Completing modules or writing/reading in a loud space or tons of commotion
• Forced to be a trainer although they never received training in the same role
• Insisting on eye contact
• Varying ways of ‘reporting’
• Using colloquialisms or ‘common’ phrases

One of the potential challenges in working with students or colleagues is the pressure to constantly work faster or harder—especially when expectations are not clearly communicated up front. For example, outside of the mental health care space, I once worked with grocers. During a discussion on neurodiversity, one of them asked, “What do I do if someone takes four hours to complete a task that should take two hours?” Naturally, my first question was, “Why should it take two hours?” After some back and forth, the answer was, “Because it always has.”

When I pressed further, I learned that no one had ever explicitly told the person how long the task should take or offered guidance on how to complete it efficiently. Instead, they were told to “work faster.” This highlights an important point: definitions and expectations vary from person to person. My version of “fast” might not match yours, so clarity is key.

This is especially important when onboarding students or new hires. For instance, if you are a program director or manager, you need to be specific about expectations right from the start. Job descriptions, for example, often use vague terms like “morning shift” or “night shift.” For someone like me, with experience in hospitals where a morning shift typically runs from 7:00 a.m. to 7:00 p.m., I might assume that is what you mean. What if your morning shift starts at 6:00 a.m.? To avoid confusion, provide precise details—write the exact start and end times.

Another area where specificity matters is task instructions. Most workplaces have established ways of doing things, but new hires will not automatically know them. Be open to explaining processes in detail and, when appropriate, asking for feedback: “Is there another way to approach this?” or “What do you think could work better?” Encouraging input not only fosters collaboration but can also lead to improved workflows.

The environment where people work and learn also plays a significant role. For example, I spent nearly two decades working in hospitals, from 2000 to 2017. Many of the mandatory modules—on topics like sexual harassment or fire safety—had to be completed in break rooms, often with conversations and other distractions in the background. For people who struggle with focus, this can be a huge barrier. Simple accommodations, like providing noise-canceling headphones or allowing people to complete modules at home, can make a big difference. Additionally, naming the challenge upfront—acknowledging that the environment might be loud and suggesting alternative quiet spaces like a library—shows consideration and inclusivity.

Another challenge arises when individuals are promoted into newly created roles without formal training. For example, when I worked, we did not always have specialized roles like respiratory therapy leads or specialists. Often, someone was promoted into a role that did not previously exist, meaning they had to define the position and its responsibilities as they went. This can be especially challenging when they are later tasked with training someone else in a role they essentially created from scratch. Offering support, mentorship, and clear guidance can help ease this transition.

Cultural and neurodiverse factors also need to be considered. For instance, some neurodiverse individuals may find maintaining eye contact difficult or uncomfortable. Additionally, cultural norms influence the appropriateness of eye contact. In some cultures, avoiding eye contact is a sign of respect, while in others, it may be interpreted differently. Rather than assuming constant eye contact is necessary, be flexible and open to different forms of communication.

Reporting styles are another area where variation is common. In my own experience, the way I gave reports evolved. When I was new to the field, my reports were lengthy and detailed—sometimes overly so. As I gained experience, my reports became shorter and more concise while still covering the essentials. That said, even experienced colleagues might prefer a longer, more detailed approach. Accepting these variations ensures that everyone’s communication style is respected.

Finally, be mindful of using colloquialisms or common phrases. While these expressions might feel natural to you, they may not be universally understood. For instance, during a recent presentation, I learned that some of the phrases I commonly use did not make sense to others in the room. This reminds us that language can be exclusionary if we’re not careful. When in doubt, take the time to clarify your meaning or avoid overly specific idioms altogether.

By fostering clear communication, offering accommodations, and remaining open to diverse ways of thinking and working, we can create environments where everyone—regardless of their background or neurodiversity—can thrive.

Common Colloquialisms

A few years ago, I encountered a phrase I had never heard before: from soup to nuts. I was attending a webinar, and the presenter casually mentioned it in her talk. Immediately, my brain fixated on the unfamiliar phrase, and I felt compelled to figure out what it meant. I paused my attention on the presentation and opened Google to research it. As I went down the rabbit hole of definitions and origins, I realized I had missed about ten minutes of the webinar content.

Once I discovered the meaning—from soup to nuts refers to a complete process from start to finish, like a meal that begins with soup and ends with nuts for dessert—I found myself distracted by another question: Who actually eats nuts for dessert? So, I dived even deeper into irrelevant research while the webinar continued without me.

This experience highlights an important point about language and the unintended effects of using idiomatic expressions that might not be universally understood. Phrases like these can confuse listeners, pull them out of the moment, and detract from the message you are trying to convey.

Let’s look at some other examples of commonly used expressions and the potential issues they pose:

1. “Pounded into my brain” or “Don’t throw me under the bus”
   • Taken literally, these phrases sound harsh or even violent. While most people understand them metaphorically, their intensity can still be jarring, especially for individuals unfamiliar with the idiomatic usage.
2. “Let’s call a spade a spade”
   • This phrase has a troubling history rooted in racism, specifically targeting Black people. For a long time, I used this phrase without knowing its origins. It was not until someone pointed it out to me that I learned about its racist undertones. That realization led me to remove it from my vocabulary.
3. “It’s crazy in here”
   • The word crazy has been weaponized against individuals with mental health conditions, often used to dismiss or belittle their experiences. For me, removing this word from my everyday language has been one of the most challenging adjustments. It is commonly used in American English, and replacing it takes conscious effort. Over time, I have started using alternatives like wild or chaotic, but the habit did not change overnight.

These examples illustrate how language, even when used innocently, can carry unintended connotations or create confusion. For some phrases, the issue lies in their violent or extreme imagery. For others, the problem stems from their historical or cultural baggage. Still others, like crazy, perpetuate stigmas that we may not even realize we’re reinforcing.

How to Approach Language More Thoughtfully

The key is to question everything. Many of us grew up hearing and using phrases without knowing their origins or implications. Taking the time to research and reflect on the language we use can help us communicate more inclusively and respectfully. For instance:

• Be mindful of context. Consider whether the phrases you use might confuse or alienate your audience. If there’s even a small chance, opt for clearer, more direct language.
• Educate yourself. If you encounter a new or unfamiliar phrase, take a moment to look up its origins. This can be eye-opening, as I learned with call a spade a spade.
• Replace problematic terms. As I did with crazy, find alternatives that convey your intended meaning without perpetuating harm or stigma.

Adapting your language is a gradual process, but it is a worthwhile effort that promotes understanding and inclusivity. By questioning what we say and making conscious choices about the words we use, we can ensure that our communication uplifts rather than alienates us.

Considerations: Training-Employees/Students

When it comes to employees and students, one key consideration is whether the training process is standardized across the board. Most organizations have protocols, policies, or procedures in place for training—somewhere, someone has written them down. However, when it comes time to implement that training, there’s often a disconnect. Trainers typically teach in two ways: the right way, as outlined in the procedure, and their way, which reflects their personal habits or preferences. While this might seem harmless, it can create inconsistencies and confusion for trainees.

Personalizing the Training Process

It is worth asking: Can we adapt training to better suit individual learning styles? For example, on a new employee’s first day, you could ask how they best learn—whether through hands-on practice, visual aids, or written instructions. While it might not always be possible to fully accommodate their preferences, simply asking the question has value. It not only demonstrates that their needs are being considered but also allows them to mentally prepare to adapt if necessary. Furthermore, it provides insight for future training processes, helping you refine methods for the next employee.

Are Trainers Equipped to Train?

An often-overlooked aspect of the training process is whether trainers themselves have been adequately prepared. Training is more than teaching someone how to perform a task—it’s an interpersonal skill. Effective trainers know how to:

• Make others feel welcomed and included. A sense of belonging can significantly impact a trainee’s confidence and willingness to learn.
• Ask meaningful questions. Questions that encourage reflection or clarify understanding are essential in fostering growth.
• Receive and incorporate feedback. Training is not a one-way street; it is a dialogue. Trainers should be open to adjusting their methods based on input from their trainees.

Unfortunately, many trainers are thrust into their roles without receiving any training on how to train. This oversight can lead to awkward interactions or, worse, a trainee feeling unwelcome or unsupported.

Advance Preparation for Trainers

Another frequent issue arises when trainers aren’t given advance notice of their role. Imagine walking into work and being assigned a trainee without any prior warning. This not only catches the trainer off guard but also risks creating a suboptimal learning experience for the trainee. To address this, consider the following:

• Notify trainers in advance. For example, if there’s a position open, inform the trainer ahead of time: “We’re hiring for this role, and you will be responsible for training the new hire.” This allows them to mentally prepare and, if necessary, review the procedures they’ll be teaching.
• Identify backup trainers. Have a designated backup who can step in if the primary trainer is unavailable. Notify both trainers during the hiring process so they’re ready to fulfill their roles when the time comes.
• Ensure trainers volunteer for the role. In healthcare, it is common for people to be “voluntold” to train. While this can fill immediate gaps, it misses the opportunity to engage individuals who are genuinely interested in or suited for the role. By actively seeking out volunteers, you create a pool of trainers who are motivated and prepared to teach.

The Right People in the Right Roles

While there are people who excel at training, it is equally important to recognize that not everyone is suited for the role. Some individuals lack the interpersonal skills or patience required to guide others effectively. On the other hand, there are often untapped individuals who would thrive in a training role if given the chance. Actively engaging staff members and encouraging interest in training can expand the pool of qualified trainers while avoiding burnout among the usual go-to individuals.

Considerations: Patients

Considerations for Patient Communication and Consent

Building trust and rapport with patients starts with asking for consent—even for seemingly small actions. For instance, when approaching a patient’s room, consider saying, “Hi, I’m knocking at the door and standing in the doorway. Is it okay if I come in?” This simple request immediately establishes respect for their personal space and autonomy, setting a positive tone for the interaction. Asking for consent in these moments reinforces the idea that the patient is an active participant in their care, not just a passive recipient.

Encouraging Understanding Without Questioning

When explaining information to a patient, it is helpful to shift from yes/no questions about understanding to open-ended or declarative statements that encourage engagement. Instead of asking, “Do you understand?” (which might elicit a hesitant or automatic “yes”), try saying:

• “Please stop me if you have questions or need clarification.”
• “Let me know if I’m going too fast, and I’ll slow down.”
• “If something is not clear, feel free to ask me now, or you can let your nurse know, and they can reach out to me later.”

These statements remove the pressure of admitting confusion while still inviting dialogue. They empower the patient to take control of their learning process, making the conversation feel more collaborative.

Requesting Consent for Accompanied Visits

If you are entering a patient’s room with others—such as a student or another healthcare professional—always ask for consent. For example:

• “Is it okay if I come in? I also have a student with me who’s observing today.”

This approach respects the patient’s right to control who is present during their care. It contrasts with statements like, “We’re here, and this is my student,” which assume consent and may make the patient feel overlooked or pressured. Requesting consent in these situations protects both the patient’s comfort and the student's learning environment.

Including Family Without Shifting Focus

Family involvement in care can be valuable, but it is critical not to shift the spotlight away from the patient. This is particularly important when working with individuals with autism or mental health conditions, as it is not uncommon for providers to direct communication toward family members instead of the patient. For example:

• Rather than asking a caregiver, “What do you think is going on?” address the patient directly: “How are you feeling today?” or “Can you tell me what’s been going on?”
• You can include family members with statements like, “Let’s make sure we’re all on the same page about the care plan,” while keeping the patient at the center of the conversation.

This ensures the patient feels seen and respected, regardless of their condition, while valuing the family’s input as a secondary perspective.

Repeating Information in Different Ways

Patients may not always process information the first time it is presented—especially in stressful or unfamiliar settings. To support understanding:

• Use varied phrasing when repeating information. For example, if explaining a treatment plan, you might say, “This medication will help with your pain,” and later add, “The goal of this medication is to make you more comfortable while we work on your recovery.”
• Check in periodically: “Is this making sense so far?” or “Would you like me to go over anything again?”
• Provide written instructions or visual aids when possible, so patients and their families have something to refer back to after the conversation.

Always prioritize asking for consent, even for small actions such as entering a room or bringing additional people, like students or other staff members, into the space. These seemingly minor gestures build trust, respect the patient’s autonomy, and set a positive tone for the interaction. When explaining information, shift from yes/no questions to open-ended or declarative statements that encourage questions and engagement. This approach fosters better understanding and empowers patients to participate in their care actively.

Ensure the patient remains the central focus of all interactions, even when family members are present. While family input can be valuable, directing communication primarily toward the patient reinforces their agency and dignity, regardless of their condition. Additionally, consider repeating information multiple times and in different ways. This helps reinforce understanding, especially in stressful or unfamiliar situations. Pair verbal explanations with written instructions or visual aids whenever possible, giving patients and families a resource to revisit later. By incorporating these strategies, healthcare professionals can strengthen rapport, enhance patient-centered care, and contribute to better outcomes.

Non-Verbal Cues

Recognizing and Responding to Nonverbal Cues

Effective communication goes beyond words; nonverbal cues play a critical role in understanding and connection. If someone is nonverbal or struggles to articulate their thoughts, it is important to adapt your approach. For example, if you notice signs of discomfort or confusion, avoid pointing it out directly with statements like, “It seems like you do not understand.” Instead, rephrase your explanation or present the information in a different way. This allows the individual to remain in the loop without feeling singled out or embarrassed.

Pay close attention to nonverbal cues, as they often indicate whether someone is engaged or disconnected. Signs that you may have lost their attention or created discomfort include:

• Body language: Crossed arms, shifting in place, leaning away, or creating physical distance are all indicators that the person is disengaged or uneasy.
• Facial expressions: Frowning, pursed lips, raised eyebrows, eye rolls, or a shaking head can signal confusion, disagreement, or discomfort.
• Gestures: Fidgeting, tapping, or other closed-off gestures (such as clenching hands in pockets) may indicate frustration or discomfort.
• Eye Contact: Avoiding or limiting eye contact (if eye contact existed previously) may indicate hesitation or discomfort. Eye contact is particularly telling if it changes suddenly—though remember that cultural norms around eye contact vary.
• Tone of voice: A person’s tone can shift dramatically if they’re disengaged. Clear, steady speech may give way to mumbling, quieter responses, or even silence.

Understanding Minimal Encouragers

Minimal encouragers are subtle but essential nonverbal cues that show someone you are listening and engaged. These might include nodding, maintaining eye contact, or offering brief verbal affirmations like “Uh-huh” or “I see.” When these encouragers disappear—or are absent from the beginning—it could indicate that the person feels unheard, unvalued, or disconnected.

Tailoring Your Response

If you notice any of these cues, it is crucial to adjust your approach to bring the person back into the conversation. Here are some strategies:

• Rephrase and revisit: If you suspect they did not understand something, restate it in a different way. Instead of saying, “Let me explain that differently because I think you did not get it,” try, “Here’s another way to think about it,” or “Let’s go over this again from another angle.”
• Acknowledge and invite feedback: If you are unsure whether they’re following along, invite them to share: “Am I covering everything you need?” or “Did I miss something important?” This approach fosters collaboration and ensures they feel heard.
• Pay attention to their listening style: Some individuals might demonstrate understanding by maintaining prolonged eye contact, which can feel intense for some. If this makes you uncomfortable, address it gently: “I want to make sure I’m explaining things clearly—let me know if I missed anything.” This shifts the focus back to the conversation and reassures them of your engagement.

The Importance of Adapting

Everyone interacts with communication differently, shaped by their experiences, culture, and comfort level. By remaining attentive to nonverbal cues, adjusting your communication style, and inviting dialogue, you can create a more inclusive and understanding environment. These small but intentional efforts help ensure that both parties feel connected, respected, and aligned.

Considerations: ADA

Other Considerations: The ADA and Neurodiversity

it is important to note that the Americans with Disabilities Act (ADA) has not been updated since 2008 to reflect a broader understanding of neurodiversity. This lack of modernization is deeply problematic because the current framework primarily focuses on physical disabilities or accommodations like additional time for tasks. Neurodivergent conditions, which may require less conventional accommodations, often fall into a gray area within the ADA’s guidelines.

When we talk about reasonable accommodations, the term itself can be contentious. What is considered "reasonable" if the accommodation is not explicitly addressed by the ADA? This gap creates ambiguity for both employees requesting support and employers attempting to provide it.

Accommodations That Benefit Everyone

An important point to recognize is that accommodations designed for neurodivergent individuals often end up benefiting others as well. For example, I recently worked with an organization where an employee requested adjustments for light sensitivity. While replacing the lighting was not feasible, the company provided inexpensive, reusable tinted glasses instead. These glasses cost less than $2 each and ended up being useful for more than just the original requester.

This principle of universal benefit extends to many accommodations. Consider automatic doors: they were initially designed to help individuals using wheelchairs, but they’ve proven helpful for countless others. Parents juggling strollers and young children, shoppers carrying heavy bags, and older adults who struggle to open heavy doors all benefit from this innovation.

The same can be said for elevators in hospitals. Before elevators, staircases were the only option, creating significant barriers for individuals with mobility challenges. Today, elevators are a standard feature in nearly every multi-story building, benefiting people of all abilities.

Shifting the Lens: Equity vs. Equality

When thinking about accommodations, it is essential to approach them through an equity lens rather than an equality lens. Equality implies providing the same resources to everyone, while equity focuses on giving people what they specifically need to succeed. For neurodivergent individuals, this might mean personalized solutions that acknowledge their unique challenges.

it is also critical to acknowledge that not all accommodations are feasible. There may be instances where you have to say, “I’m sorry, we are unable to provide that accommodation right now.” This does not mean you have failed—it’s a reality of balancing resources and logistics. In these situations, it is important to give yourself grace. You cannot solve every issue, and recognizing your limits is part of creating a sustainable and thoughtful approach to accommodations.

The ADA’s outdated framework for neurodiversity highlights the need for broader societal and organizational efforts to address the unique needs of neurodivergent individuals. While not all accommodations are possible, many—such as inexpensive solutions or universally beneficial changes—are both doable and impactful. By thinking creatively and approaching these issues with an equity mindset, we can create environments that not only support individuals but also benefit entire communities.

Tips to Support

Social Etiquette and Creating Inclusive Workplaces

Understanding and fostering social etiquette in the workplace and in educational settings is vital for building an inclusive environment. Throughout my career, I have worked in diverse locations, including Detroit, Illinois, and Idaho. Moving to Idaho, however, felt like stepping into a different country—it was entirely unfamiliar. One notable experience stands out from my time in the ICU there.

Every day at 3 p.m., all the respiratory therapists would seemingly disappear. For months, I could not figure out where they went. As the only person in my department who looked like me, I hesitated to ask non-job-related questions. Eventually, I discovered that everyone was taking a collective snack break. While this was a normal routine for them, no one had thought to inform me or include me. It was not malicious—it was simply overlooked because it was ingrained in their culture.

This experience taught me the importance of explicitly sharing workplace norms, especially with new employees or students. Overlooking these small yet impactful social customs can unintentionally alienate others. For someone else, this situation could have led to feelings of not being liked or welcomed. By fostering open communication about workplace and social etiquette, you help others feel included and valued.

Addressing Stigma and Creating Safer Spaces

Many individuals, particularly those with neurodiverse conditions, hesitate to disclose their needs due to stigma. it is not required for anyone to share such personal details, but creating a safer space—a term I prefer over “safe space,” as true safety can only be governed individually—can encourage openness.

In my current job, I work on a team of five, and it was the quickest I have ever felt comfortable sharing my needs. Usually, it takes me six to nine months to open up about having ADHD and how it impacts my work. With this team, I felt safe enough to share within weeks. Their response was simple yet effective: “Okay. What do you need? How can we help?”

I explained that I struggle with abbreviations on video calls and meetings and that taking notes while leading a meeting or attending a webinar is difficult for me. They accommodated me by providing a pre-existing list of common abbreviations and even sending me Zoom messages in real-time with explanations when new ones came up. These accommodations were easy for them to implement and immensely helpful for me. Importantly, these changes weren’t formalized under the ADA—they were born out of an environment where I felt supported enough to ask for what I needed.

Understanding Different Definitions of Safety

Safety is a deeply personal concept that varies for each individual. For example, when I moved from Chicago to Idaho, many people commented, “I bet you are glad to be out of there.” For me, however, Idaho did not feel like a safe space. Safety, to me, meant being in a familiar environment surrounded by people who understood and supported me. Others may define safety differently, especially neurodiverse individuals, who may feel safest near those who have previously offered them understanding and support.

Providing advance notice about changes can also create a sense of safety. Notifying staff about upcoming fire drills, construction, or changes to routine helps them prepare physically and mentally. In healthcare, where such notice is not always possible, providing logic behind changes can help. If someone understands why something is happening, they may be more likely to accept and adapt to it.

Avoiding Assumptions

It is important not to make assumptions about people’s needs or goals. For instance, while encouraging someone to apply for a leadership role might come from a good place, it may not align with their aspirations. Some people find fulfillment in their current roles and do not seek additional responsibilities, and that’s perfectly valid. Share your observations and let them decide; do not push them into something they’re not ready for.

Similarly, avoid assumptions about what accommodations someone might need. Instead, foster open communication and allow them to share their preferences. Even simple accommodations, like addressing light sensitivity with inexpensive glasses, can make a significant difference.

Avoiding Sarcasm and Euphemisms

Lastly, be mindful of how sarcasm and euphemisms might be interpreted, especially by neurodiverse individuals or those unfamiliar with certain cultural norms. Sarcasm, while a common communication style, can be confusing or even hurtful if taken literally. For example, phrases like “That’s just great” in a sarcastic tone might be misunderstood. While avoiding sarcasm entirely can be challenging—especially for those who use it frequently—adopting clearer, more direct language fosters better understanding and connection.

Creating inclusive environments requires attention to both overt and subtle dynamics. From sharing workplace norms to fostering safer spaces and avoiding assumptions, these efforts build trust, encourage participation, and promote equity. By considering the varied needs and experiences of colleagues, staff, and students, we can work toward a culture where everyone feels valued and supported.

Common Euphemisms

The Importance of Direct and Thoughtful Language

Language carries weight, and the phrases we use—even those that seem harmless or commonplace—can have unintended consequences. Being direct and mindful of the words we choose not only reduces confusion but also helps avoid causing unintended harm.

Direct Language vs. Euphemisms

When discussing sensitive topics, it is important to prioritize clarity. For example:

• “They passed away” vs. “They died.” While "passed away" is often used to soften the reality of death, being direct by saying “they died” leaves less room for misinterpretation.
• “He is between jobs” vs. “He is unemployed.” The phrase “between jobs” can obscure the reality of unemployment, which may unintentionally downplay someone's situation. Being straightforward acknowledges their experience without unnecessary ambiguity.
• “She is feeling under the weather” vs. “She is sick.” While phrases like "under the weather" are commonly understood, their literal interpretation can spark confusion. A 19-year-old once pointed out to me, “If you think about it, everything is under the weather.” Technically, they’re not wrong, but this example highlights how being direct avoids unnecessary misinterpretations.

Phrases with Harmful Histories

Many common expressions have origins or implications that can be hurtful or harmful. For instance:

• “I’m gassed.” This phrase, used to express exhaustion, was pointed out in one of my conversations as having ties to the Holocaust. While not everyone may associate the phrase with this context, it is worth considering its potential impact.
• “Gone a bit baddie” or “That’s bonkers.” These terms, like "crazy," have historically been used to marginalize or demean people with mental health challenges. Even when used casually, they can reinforce harmful stereotypes or stigmas.

Recognizing Puzzled Reactions

Sometimes, people’s body language or expressions can indicate confusion or discomfort with a phrase you have used. If you notice puzzled looks or hesitation, take the opportunity to clarify. For example:

• If someone looks confused after hearing “He is between jobs,” you can follow up with, “I mean, he’s currently unemployed.”
• If you use a phrase with negative connotations and notice a reaction, acknowledge it: “I realize that phrase might not be the best choice—let me explain more clearly.”

Avoiding Harmful Expressions

Even phrases spoken lightly can have lingering effects. Words like “baddie,” “crazy,” or “bonkers” may seem innocuous but can sit with someone far longer than you realize. These terms, often weaponized against people with mental health challenges, can perpetuate stigma. The goal is not to be perfect but to strive for sensitivity and thoughtfulness in our speech.

Practical Tips for Mindful Communication

1. Be direct when possible. Use clear and straightforward language, especially for sensitive topics. This minimizes confusion and ensures your message is understood as intended.
2. Reflect on the origins of phrases. Many idiomatic expressions have negative or harmful histories. While you may not know every origin, being open to learning and adapting your language is key.
3. Pay attention to reactions. If you notice someone looks puzzled or uncomfortable, take it as an opportunity to clarify or adjust your phrasing.
4. Avoid stigmatizing terms. Words like “crazy” or “baddie” might feel casual, but they carry harmful connotations. Replace them with neutral or descriptive alternatives whenever possible.
5. Acknowledge mistakes. If you use a problematic phrase and realize it later, address it openly. This demonstrates a willingness to learn and grow.

Communication Tips for Workplaces and Interviews

Effective communication is the cornerstone of a supportive and inclusive environment. Patience is a critical component, even in fast-paced settings like hospitals. While time may be limited, making the effort to provide clear, concise instructions can prevent confusion and errors. For example, instead of saying, “Check everyone’s oxygen,” be explicit: “Check everyone’s oxygen using the pulse oximeter and document the readings.” Even if it feels overly specific, clear communication helps ensure tasks are completed accurately.

Job descriptions should also reflect clarity and modern standards. Use precise details such as shift times instead of vague terms like morning shift or afternoon shift. If weekend work is required, specify whether it is “every other weekend” or “every third weekend.” Additionally, reevaluate outdated requirements. For example, including phrases like “must lift 50 pounds” in office-based or non-physical job descriptions is unnecessary. Updating these descriptions ensures they accurately reflect the role’s demands and avoids perpetuating irrelevant or exclusionary criteria.

In interviews, move away from archaic definitions of professionalism that emphasize attire over qualifications. Judging candidates based on their clothing, particularly when the job involves wearing uniforms like scrubs, is both outdated and unfair. Focus on their skills, experiences, and responses rather than their outfit. It is also essential to ensure equity and relevance in interview questions. Regularly review and update questions to ensure they’re inclusive, free from bias, and directly related to the job’s requirements.

Creating inclusive and thoughtful interviews involves several steps. In group interviews, ensure the panel is diverse, with representation across genders and other identities. Mispronouncing a candidate’s name can cause disengagement, so practice names in advance and confirm pronunciation during the interview by asking, “Do I have this right?” If not, take the time to learn and use the correct pronunciation moving forward. Normalize sharing your pronouns and asking candidates for theirs to set a respectful and inclusive tone. Provide an overview of the interview process upfront, such as, “We’ll spend 60 minutes together, and I have 12 questions for you.” This helps candidates feel prepared and reduces anxiety.

Encourage candidates to take their time answering questions by saying, “You do not need to respond immediately—feel free to take a moment to think.” This fosters a more thoughtful and confident exchange. Additionally, remind candidates they can take notes during the interview. This small but meaningful gesture can help them organize their thoughts and feel more in control of the process.

By prioritizing clear communication, modernizing outdated practices, and fostering inclusivity, workplaces and interviews can become more equitable and supportive. These changes benefit individuals by creating a welcoming environment and enhance the organization by promoting fairness and collaboration.

Tips for Interviewing

During most interviews, it is common for the interviewer to take notes, so why shouldn’t the interviewee be allowed to do the same? Encouraging candidates to take notes during the interview helps them process questions and organize their responses. Additionally, a best practice is to provide interview questions in advance. While this suggestion often receives pushback from leaders—who worry it gives candidates an unfair advantage—it’s worth considering the benefits. Sharing common questions, such as “Tell me about your strengths and weaknesses” or “Describe a time when you faced a challenge and how you handled it,” allows candidates to prepare and present their best selves. This is not about providing clinical or technical questions in advance, but rather creating an environment where candidates can thoughtfully showcase their qualifications. After all, in most jobs, employees rarely need to respond to situations with the immediacy required in interviews, so giving them time to prepare aligns more closely with real-world expectations.

Another valuable question to ask during an interview is, “What makes a workplace feel safe or unsafe for you?” While you may not be able to fully meet their vision of a safer workplace, their response can offer insights into their values and needs. This information is useful not only for evaluating the candidate but also for shaping future policies and practices—even if they are not ultimately hired. Encouraging thoughtful responses and creating a supportive interview process fosters mutual respect and allows both parties to engage meaningfully.

Tips for Sensory

Supporting individuals with sensory needs involves practical solutions that promote comfort and inclusivity. For sound sensitivity, offering a quiet break space can make a significant difference. When quiet spaces aren’t feasible, providing noise-canceling headphones is an effective alternative. These headphones do not have to be expensive brands like Bose or Beats; affordable, reusable options are widely available, and many can be wiped clean for hygiene purposes.

For movement-related needs, allowing the use of fidget toys and offering flexible seating options, even briefly, can help individuals self-regulate. Healthcare environments often limit choices for seating or movement, but creating a comfortable space in break rooms can provide some relief. For instance, having chairs of varying heights ensures everyone can find a seat that suits them. Encouraging brief moments for physical movement outside of task-related rushing can also be beneficial.

Tactile accommodations might include allowing modifications to work uniforms, such as adding felt to scrub necklines for those with skin sensitivities. Providing tactile items like fidget toys in break areas is another simple yet effective solution. Many professionals, including mental health therapists, use fidget toys during their workday, and these items can be easily stored in pockets for convenience.

Lighting is another key consideration. Offering blue light screen covers or glasses can alleviate light sensitivity. Some organizations have even created sensory kits that include noise-canceling headphones, fidget toys, and light-filtering glasses. These kits can be purchased pre-made or assembled in-house at a lower cost, making them accessible for various settings. Sensory bags are increasingly common in workplaces, hospitals, hotels, and even retail environments, where they may be offered upon request.

Encouraging employees and students to take their breaks rather than skipping them is essential, especially in demanding fields like healthcare. Breaks aren’t just a luxury; they’re necessary for maintaining mental and physical well-being. While it is common for healthcare workers to skip breaks out of concern for burdening their colleagues, organizations should emphasize the importance of rest and recovery.

Neurodiversity Affirming Practice

• Core Principles
  • Intersectionality
  • Respecting autonomy
  • Validating differences
  • Presuming competence
  • Reframing expectations
  • Promoting self-advocacy
  • Rejecting neuronormativity
  • Prioritizing lived experience
  • Nurturing positive self-identity
  • Adapting systems and environments
  • Honoring all forms of communication

Watch Your Words!

Mindful language use is crucial in creating inclusive environments. Avoid using terms with stigmatizing or harmful connotations, particularly those related to mental health. For example, phrases like “this weather is so bipolar” misuse a serious condition and can deeply harm individuals who live with it. Similarly, casual remarks like “I’m a little OCD” or “take your happy pills” trivialize conditions like OCD and depression, which can be life-altering and debilitating for many.

In professional settings, it is especially important to avoid derogatory or dismissive terms. For instance, calling someone “psycho” or referring to a patient as “crazy” is not only disrespectful but also perpetuates harmful stereotypes. Such language can alienate colleagues or patients who may have experienced these terms as weapons against them or their loved ones. Even when used casually or jokingly, phrases like “bat-blank crazy” or “stop acting so schizo” are deeply problematic, particularly in healthcare or educational settings where trust and professionalism are paramount.

When communicating about a patient, stick to objective, clinical terms found in their chart or your observations. Avoid making assumptions or using colloquial terms, as these can harm your relationships with both colleagues and patients. It is impossible to know everyone’s personal history or how they may react to certain words. While true "safe spaces" may not exist, we can govern our own actions by being mindful of our language and fostering a more inclusive environment.

By implementing sensory accommodations and adopting mindful language practices, workplaces and educational settings can foster inclusivity and support individuals with diverse needs. Small changes, such as providing sensory tools, updating outdated language, and avoiding stigmatizing phrases, can have a significant impact on creating a respectful and welcoming environment for all.

Neurodiversity-affirming practices are rooted in principles that align closely with the framework of disability justice. There are ten principles of disability justice, and while all are significant, a few stand out as particularly relevant to this work. If you are interested in learning more, the QR code provided leads to additional information about the ongoing fight for disability justice in America.

Intersectionality

One critical principle is intersectionality, which is about recognizing that people have multiple, overlapping identities that shape how they experience the world. For example, I’m not just a person with ADHD—I’m also Black, queer, a woman, and I live in a fat body. All these parts of who I am come together in ways that influence how I move through life. Sometimes, certain spaces might feel safe or comfortable because of one part of my identity, but not for others.

For instance, as a Black person, I might face racial biases in certain settings, and as someone with ADHD, I might also deal with misunderstandings about how I work or communicate. Add in being queer and a woman, and it can feel like there are a lot of different layers to navigate at once. Living in a fat body adds yet another layer, especially when it comes to assumptions people make or the way healthcare is approached. All these identities do not exist separately—they mix and interact in ways that make my experiences unique.

Understanding intersectionality means keeping in mind that no one is just one thing. It is about seeing the whole person and recognizing how their different identities shape their experiences. For neurodivergent people, this is especially important because their challenges and needs might look different depending on the other parts of who they are. For example, a Black neurodivergent person might face both the stigma of neurodivergence and the impact of systemic racism, which creates a very different experience from someone who does not have those same layers.

When we think about inclusion, it is important to make room for all these different identities and how they overlap. It is not about treating everyone the same—it is about really listening to people and understanding how their unique mix of identities impacts their lives. That way, we can create spaces that feel welcoming and supportive for everyone, not just one part of who they are.

Prioritizing Lived Experience

Another key principle is prioritizing lived experience, which means valuing the voices of people who live with neurodivergence. While academic research and literature can provide useful information, there’s nothing more authentic than hearing directly from those who experience it firsthand. People with lived experience offer insights that no textbook or study can fully capture because they’re speaking from their day-to-day realities—their successes, challenges, and everything in between.

Resources created by neurodivergent individuals are incredibly valuable because they come from a place of personal understanding. They reflect real needs, practical solutions, and the nuanced ways neurodivergence impacts life. For example, a neurodivergent person sharing how they manage sensory overload or communicate at work provides actionable advice that feels relatable and grounded in reality. Whenever possible, we should prioritize learning from these voices rather than relying only on external analysis or theories written by people who do not share the experience.

It is not about dismissing academic research—it’s about balancing it with the perspectives of those who live it every day. By centering lived experience, we get a more complete, human understanding of what neurodivergence means and how to better support individuals in meaningful ways.

Recognizing Wholeness

Recognizing Wholeness is another essential principle. Neurodiversity is just one piece of a person’s identity, and it is important not to define someone solely by that one characteristic. People are complex, with many layers to who they are—interests, skills, values, and other parts of their identity that make them unique.

Recognizing wholeness means seeing and valuing the complete person—not just one part of their identity. It is about creating spaces where people can show up as their authentic selves without feeling like they’re being reduced to a single narrative or stereotype.

Sustainability

Sustainability is not just about protecting the planet—it is also about supporting people. To truly advocate for neurodivergent individuals, we need to adopt practices that prioritize their long-term well-being. This means understanding how neurodivergence affects them and making thoughtful changes to minimize stress and negative impacts in our interactions and shared environments.

Sustaining people goes beyond just meeting basic needs; it is about creating conditions where they can genuinely thrive. For neurodivergent individuals, this might include offering accommodations, fostering inclusive spaces, and ensuring that environments are flexible and supportive. Whether providing sensory-friendly workspaces or being mindful of clear communication, these efforts help people feel valued and empowered, not just tolerated.

Sustainability for people means moving past a survival mindset—where individuals are simply “getting by”—and instead focusing on helping them flourish in every aspect of life, whether at work, school, or within the community. By investing in practices that support long-term growth and well-being, we create a culture that uplifts everyone.

Collective Access

Collective access is vital. This principle highlights the importance of creating environments that support a wide range of needs, including cognitive, visual, auditory, motor, and speech-related accommodations. The idea is that accessibility is not just an individual responsibility—it’s a shared effort that benefits everyone. By working together to remove barriers and create inclusive spaces, we ensure that everyone has the opportunity to participate fully and equitably.

Collective access goes beyond meeting minimum standards. It is about recognizing that accommodations often serve more than just the individuals who request them—they enhance the environment for entire communities. For example, providing cognitive supports like clear instructions or sensory-friendly tools can improve focus and comfort for everyone in a workspace or classroom. Similarly, ensuring visual and auditory accessibility can make events or materials easier to engage with for a wider audience.

By embracing collective access, we take a proactive approach to inclusion, building environments that reflect the diversity of those who inhabit them. It reminds us that equity and justice aren’t one-time goals but ongoing commitments that require us to listen, learn, and act. When we prioritize accessibility and inclusivity, we create spaces where everyone feels valued, supported, and able to contribute their full potential.

Collective Liberation

Collective Liberation emphasizes that supporting neurodivergent individuals is not only about helping a specific group—it is about uplifting everyone. When we fight for equity and create spaces where neurodivergent individuals can thrive, the entire organization benefits. Inclusivity fosters collaboration, innovation, and mutual respect, making it easier for all employees to feel valued and supported, regardless of their identity.

By addressing barriers and implementing accommodations, we create a culture where diverse perspectives and strengths are welcomed and celebrated. This environment encourages people to bring their authentic selves to work, resulting in stronger teams and more meaningful contributions. The fight for equity is not just about fairness; it is about building a community where everyone benefits from understanding, respect, and shared success.

Sample of Neurodivergent Inclusion Policy

"This policy outlines our commitment to providing a workplace that embraces neurodiversity and challenges neuronormativity. Our workplace is dedicated to creating an inclusive environment for neurodivergent people where neurodivergent people feel welcome, accepted, and supported (livedexperienceeducator.com)."

Commitment to Inclusion and Support

• We strive to create a workplace where neurodivergent individuals can fully participate and thrive without facing stigma or discrimination.
• Accommodations are provided to ensure equitable opportunities for success, acknowledging that supporting one group often benefits the entire organization.
• We recognize the importance of learning from individuals with lived experience and incorporating their insights into our policies and practices

Guiding Principles

1. Embracing Neurodiversity:
   We challenge neuronormativity by recognizing and valuing the unique contributions of neurodivergent individuals. This means rejecting a "one-size-fits-all" approach and embracing diverse ways of thinking, working, and communicating.

2. Universal Benefits of Accommodations:
   Accommodations like flexible schedules, sensory-friendly environments, and clear communication practices often improve the workplace for everyone. By meeting diverse needs, we enhance productivity, collaboration, and employee satisfaction across the board.

Core Practices

1. Accessibility:

   • Provide accommodations for sensory, cognitive, and communication needs, including noise-canceling headphones, flexible seating, and quiet spaces.
   • Offer training to all staff to promote awareness and understanding of neurodiversity.

2. Clear Communication:

   • Use direct and inclusive language in all interactions.
   • Ensure transparency in processes like onboarding, meetings, and evaluations, with space for feedback and clarification.

3. Flexibility:

   • Allow for flexible work schedules and breaks to support individual productivity and mental well-being.
   • Provide tools such as sensory kits or assistive technology as needed.

4. Feedback and Collaboration:

   • Regularly seek input from neurodivergent employees to inform and improve policies.
   • Encourage open dialogue and create systems for anonymous feedback to ensure all voices are heard.

Implementation and Accountability

• Training: All staff, particularly managers and supervisors, will receive training on neurodivergent inclusion and best practices.
• Policies: Accommodations and inclusive practices will be clearly outlined and communicated during onboarding and revisited regularly.
• Monitoring: The effectiveness of this policy will be assessed through regular surveys, feedback sessions, and updates informed by lived experiences.

R.A.T.S. Framework for Inclusion

The R.A.T.S. framework—Relationship and Rapport, Accommodations, Time, and Sensory Support—offers a practical approach to fostering inclusion and accessibility in diverse environments. When in doubt, remember to focus on R, relationships, and rapport. Building strong connections with others provides valuable insights into their experiences, enabling you to identify ways to support them effectively and leverage your resources or privileges to help.

Relationship and Rapport Building

Strong relationships are the foundation of understanding and support. By taking the time to genuinely connect with others, you can gain deeper insight into their unique challenges and needs. This relationship-building allows you to move beyond assumptions and instead create meaningful, individualized solutions. Relationships are not just about listening—they’re about acting on what you have learned to make environments more inclusive and supportive.

Accommodations

The Americans with Disabilities Act (ADA) has not been updated since 2008, leaving many needs of neurodivergent individuals and others unmet. It is crucial to look beyond what the ADA defines as “reasonable accommodations” and instead focus on what is truly needed. When we move past the bare minimum and provide thoughtful accommodations, we make environments better for everyone—not just for those with neurodivergent conditions but for all individuals navigating shared spaces.

Time

Explicit communication about time, needs, and expectations is essential. Never assume someone “just knows” something because of their age, experience, or tenure. Share critical information early, repeat it often, and clarify as necessary. Clear and transparent communication ensures everyone has the tools they need to succeed.

Sensory Support

Sensory experiences play a significant role in accessibility. For example, at a recent AARC conference, I wore sunglasses indoors because of light sensitivity caused by the bright overhead lights. Similarly, sensory accommodations such as noise-canceling headphones, quiet spaces, or flexible seating can significantly improve accessibility for many individuals.

During my presentation at the same conference, I noticed an attendee with a service dog and a leading cane, indicating visual impairment. Recognizing the need for immediate adjustments, I modified my presentation on the spot. I announced that I would read more directly from the slides to ensure accessibility for everyone. The response was overwhelmingly positive—several people, including the attendee with the cane, stood up to thank me, sharing that this adjustment allowed them to participate fully for the first time. This experience highlighted the importance of anticipating and addressing accessibility needs, even when they aren’t immediately visible. While I made these changes on the fly, it reminded me of areas where I can improve and be more proactive in creating inclusive spaces.

The Importance of Accessibility and Understanding

For me, being diagnosed with ADHD in 2017 was a transformative experience. It gave me clarity and validation, enabling me to better understand the adjustments I had been making throughout my life. Despite being told that certain achievements were out of reach for me, I have built a meaningful career—first in respiratory therapy and now in mental health, where I run a private practice. My journey underscores an important truth: a diagnosis or condition does not define what someone can or cannot do. It might mean working harder or differently, but it does not mean the goal is unattainable.

As you interact with individuals with diverse conditions, remember that these conditions do not stop people from achieving their goals. Instead, they highlight the importance of support, understanding, and collaboration in fostering success. Advocating for neurodivergent inclusion and better clinical practices requires systemic change and individual action. By questioning outdated systems, choosing respectful language, and fostering collaborative communication with patients, we can create environments that support diverse needs and empower individuals to thrive. Every small adjustment we make contributes to a culture of inclusivity and care.

Questions and Answers

Thank you for sharing your personal examples of how neurodivergent individuals can advocate for themselves. How can we advocate more for inclusion, especially in clinical or workplace settings?

This is such an important question. Advocacy for inclusion begins with examining and questioning the systems already in place. For example, I once spoke with professors about challenges they faced in clinical settings, like students who struggled with social cues. These students were not harming patients but were seen as "different" in how they built relationships. One takeaway I shared was that we need to avoid boxing people into specific expectations—like assuming the ICU is the only viable path in healthcare. Not everyone wants to work in the ICU, and that's perfectly fine. We must create space for diverse skills and paths.

From a student perspective, creating safer spaces early on is key. For instance, I once attended a session where students asked questions about accommodations for exams, such as needing more time or using a standing desk. While the session leader provided information about accommodation forms, we later found significant barriers to accessing those accommodations, such as requiring doctor approvals or insurance. This underscores the importance of interrogating outdated systems: when were they last updated, and how can we make them better? Regularly seeking input from students and staff can lead to meaningful improvements.

On your slide about harmful phrases, you highlighted how language can create a silencing effect. Could you expand on why this is important?

Absolutely. Language has immense power, and harmful phrases—like using terms such as "bipolar" or "OCD" casually—can perpetuate stigma and silence individuals who live with these conditions. For example, jokingly saying someone is "so bipolar" trivializes a serious and life-changing condition. Similarly, calling medication "happy pills" dismisses the importance of treatment. In diverse settings, it is crucial to think critically about language and choose words that foster understanding rather than harm. This self-awareness can create a culture of respect and inclusivity.

In a clinical setting, how would you adjust your approach if a patient shows signs of sensory overload during suctioning or an ABG draw?

The first step is to acknowledge the situation and communicate openly. For example, you might say, “This might be uncomfortable or even painful—what can we do to make it a little easier for you?” Many patients, especially those who have undergone frequent procedures, may already have strategies that help them cope. Including them in the conversation gives them a sense of control. For suctioning, there may be fewer options due to its inherently uncomfortable nature, but for needle-related procedures, patients often have preferences that can reduce their discomfort.

Building on that, what about addressing sensory overload in the environment, such as bright lights or loud TVs?

That’s a great point. Creating a low-stimulus environment can significantly reduce sensory overload. When entering a room, I always try to explain what I’m doing: “It’s bright in here—I’m going to turn down the lights a bit. Does that work for you?” or “Let’s turn off the TV for more clarity during this conversation. Is that okay?” If the patient declines, I offer alternatives, such as writing things down or finding another way to communicate. Including the patient in these decisions is essential because hospital stays often strip individuals of their sense of control. Anytime we can return even a small measure of control to them, it builds rapport and trust.

References

Beatty, J. E. (2016). 10 principles of DJ-ing (2nd ed.). Squarespace. https://static1.squarespace.com

Bernstein, E. S. (2020, December 3). Why you need to stop using these words and phrases. Harvard Business Review. 

https://www.institute4learning.com/

Doyle, N. (2020, March 24). The world needs neurodiversity: Unusual times call for unusual thinking. Forbes. https://www.forbes.com.

Ngwagwa. (2021, December 15). Neuroexpansive™️ thoughts. Medium. https://medium.com/@ngwagwa

The following is an edited transcript of the course, Breathing Easy: Building Psychological Safety for Respiratory Therapists and Healthcare Teams, presented by Gabrielle Davis, MPH, MA, RRT, RRT-ACCS, RRT-NPS, TTS, LPC, NCC, FAARC.

It is recommended that you download the course handout to supplement this text format.

Learning Outcomes

After this course, participants will be able to:

• Define psychological safety and explain its significance in healthcare settings, particularly for respiratory therapists and interdisciplinary teams.
• Identify common barriers to psychological safety in the workplace and their impact on communication, decision-making, and patient care.
• List strategies to cultivate a psychologically safe environment that encourages openness, collaboration, and continuous learning among healthcare professionals.

Psychological Safety

Psychological safety is the shared belief that individuals can speak up, take interpersonal risks, and voice concerns without fear of blame, ridicule, or retaliation. It is critical in complex, multidisciplinary settings such as healthcare, where open communication and trust are essential for effective teamwork and patient safety. Psychological safety allows us to ask questions, report errors, and share new ideas, fostering an environment where everyone feels valued and supported in contributing to high-quality care.

In simpler terms, psychological safety is the ability to speak up without fear of punishment. It encompasses the encouragement of varying ideas and feedback when appropriate, and places an emphasis on learning from mistakes rather than assigning blame. Punishment, it is worth noting, does not only mean formal consequences. It can also take the form of ridicule, embarrassment, or social exclusion.

I have thought about psychological safety in different contexts over my years as a respiratory therapist (RT), but I could not fully conceptualize it until I went to school to become a mental health therapist. Bridging the gap between healthcare and mental healthcare brought a great deal into focus.

Real-World Examples from Clinical Practice

To illustrate what psychological safety looks like in practice, I want to share a few scenarios from my own career.

The last time I worked bedside was in 2021. I was in a PICU helping out at a new hospital. The person assigned to orient me had been a therapist for about three or four years. At that point I had been a therapist for approximately ten years and had worked in multiple states. There was a child, twelve or fourteen years old, on the ventilator. The report indicated ventilator settings that I was unsure were appropriate, so I asked my preceptor whether we should speak with the physician.

She agreed it was a good idea. I approached the doctor, explained what I had observed, and said that in my experience those settings had not worked before and sounded potentially dangerous. I asked if he could say more about his reasoning. The doctor was visibly surprised that I was questioning him. He ultimately defended his position, but the next day the settings had been changed to what I had suggested. I found myself wondering: what if we could have had that conversation twenty-four hours earlier? Could we have mitigated harm more quickly?

What I also noticed in that moment was that my preceptor had privately agreed with my concern but was not comfortable voicing that agreement in front of the physician. She did not feel psychologically safe enough to speak up. That gap matters.

A second scenario involved me, a student, in 2008 during my final clinical rotation in the emergency room. A trauma came in, and the patient was a young woman who so closely resembled my sister that I froze. I could not function. My preceptor had to redirect me to the head of the bed by calling out to me. What brought me back was seeing the patient's mother enter the room, which reminded me that this was not my family.

After the patient was stabilized, my preceptor immediately moved on to the next room as if nothing had happened. I asked to use the restroom, went in, cried, and called my family. When I returned, my preceptor was irritated. There was no debriefing, no checking in, no acknowledgment of what had just occurred. What if there had been a psychologically safe space to say, "Do you want to talk about what just happened?" That conversation does not have to happen before the next patient. It can happen after. Any event can be debriefed at any time.

A third scenario took place during medical rounds. I was the only person of color in a group of ten medical professionals. The physician made a racially derogatory comment about the patient, who was also a person of color, and nobody responded. I asked the physician directly whether he had meant to say that aloud. He seemed surprised that anyone had challenged him. He eventually apologized. But I want to highlight something: nine other professionals were present, and not one of them said anything. Some were visibly uncomfortable and knew the comment was wrong. What would have happened if even one of them had felt safe enough to speak up?

These examples illustrate that psychological safety reaches beyond patient safety metrics and anti-bullying policies. It shapes every interaction in the clinical environment.

Outcomes of Psychological Safety

When healthcare teams operate in psychologically safe environments, the outcomes are significant. According to the Joint Commission, approximately 70% of medical errors are communication errors. If we create safer spaces for communication, we create safer outcomes for patients.

The benefits of psychological safety include:

• Safer patient care through reduced communication errors
• Enhanced collaboration and team learning, including input from dietary, environmental services, and other non-clinical roles
• Decreased errors and near misses
• Decreased compassion fatigue, which is the stress that comes from chronically caring for others, and is something every clinician experiences, whether they name it or not
• Decreased burnout

It is also worth noting that medical professionals are less likely to report their own mental health struggles. They may acknowledge that mental health challenges exist in the medical field broadly, but are far less likely to speak about their own. When the environment is not psychologically safe, this silence is reinforced.

Barriers to Psychological Safety

Several factors commonly work against psychological safety in healthcare settings.

Hierarchical Structures

Healthcare is structured around clear hierarchies: physicians, nurses, respiratory therapists, dietary staff, environmental services, and so on. These hierarchies affect who feels entitled to speak. In 2008, when I began my career, I lacked the confidence to challenge physicians. By 2021, after working in multiple states and building a reputation, I had more latitude. But that latitude came from privilege accumulated over time, not from a change in the hierarchy itself. Those structures exist whether we acknowledge them or not.

Fear of Blame or Punishment

Fear of blame or punishment does not always involve formal disciplinary action. It can be as simple as fearing ridicule, embarrassment, or a tense interaction with a colleague. If someone forgot to document a call-off and is afraid to admit it, the solution is not to hide the mistake. What would happen if the environment normalized saying, "I forgot to write that down"? Learning cannot happen in an environment of fear.

Time Pressures and High Workload

In the ER example I described earlier, there was almost certainly time to check in with me briefly after that traumatic event, but it was not prioritized. We tend to deprioritize emotional processing in favor of the next task. That breathing treatment for a patient could have waited a few minutes so we could have done a brief debrief. Beyond time, workload is an ever-present barrier. In my career, I have never worked at or consulted for a hospital without open positions. Short staffing makes everything harder, including creating space for psychological safety.

Bias, Discrimination, and Cultural Norms

Bias and discrimination within teams are real barriers. So are cultural norms that discourage vulnerability. Early in my career, I was taught to keep my feelings outside of the patient's room. For a while that seemed to work. Over time, I noticed that when I showed authentic emotion, it actually brought me closer to patients and families. Vulnerability in appropriate measure is not a weakness. Saying "I do not know" when you genuinely do not know is a form of professional integrity.

Power Distance, Privilege, and Intersectionality

Power distance refers to the degree to which societally perceived "less powerful" individuals accept and expect an unequal distribution of power. In healthcare, this concept is highly relevant. Those with high power distance have often been conditioned to know their place or have been minoritized by society. Those with lower power distance tend to be more comfortable addressing authority. If you are in a position of lower power distance, meaning you have more privilege in a given space, I encourage you to use it. If a colleague feels afraid to raise a concern because they fear losing their job, ask for their consent to raise it on their behalf.

Intersectionality, a term coined in the 1980s by Professor Kimberly Crenshaw, is a lens through which we can see where power comes and collides, where it interlocks and intersects. It is not simply that there is a race problem here, a gender problem here, and a class or LGBTQ+ problem there. Many times, that fragmented framework erases what happens to people who are subject to all of these things simultaneously.

I spent five years working in Idaho, where I was the only Black respiratory therapist in a seven-hospital system. Patients sometimes questioned whether I was really the person on my business card. Some asked if I was sure. I had to navigate, in real time, decisions about authenticity: when asked what brought me to Idaho, I had to decide whether to reveal that I had moved there because my wife had taken a job. I had already been asked to leave rooms because of my race. If I added being a queer person to that disclosure, what would happen? These are decisions people with marginalized identities make constantly. If that is the calculation someone must run in every interaction, it is not a psychologically safe environment.

Identity dimensions that can affect psychological safety include, but are not limited to: race and racism, sexual identity, gender identity, body size, ageism, educational background (both formal and experiential), geographic location, visible and invisible disability, socioeconomic status, literacy, mental wellness and access to resources, and personal history. These factors compound and intersect in ways that affect every interaction in a clinical setting.

Recognizing Safe and Unsafe Environments

Signs of a Safer Environment

In psychologically safe environments, staff feel comfortable raising concerns without fear of retaliation. Constructive feedback is both given and received. Diversity of thought is welcomed and encouraged rather than suppressed. For example, in my COPD and nicotine cessation program, I built a team primarily composed of students and newer RTs, despite pressure from colleagues to use only senior staff. Those newer voices brought value. Diversity of thought is not just about demographics. It includes professional experience, clinical setting, and role.

Red Flag Environments

Several behaviors and patterns can signal that an environment is not psychologically safe:

• Unusual silence during meetings and huddles, particularly from team members who are normally engaged
• Defensive responses when concerns are raised, which make it unlikely that the person will raise a concern again
• Chronic interruptions, particularly affecting women, younger professionals, and newer clinicians. I spoke with one department in which the women tracked how often they were interrupted over an hour and found that, collectively, they completed only 6 sentences during that period.
• Lack of accountability: a culture where errors are attributed to others rather than owned
• Changes in nonverbal communication, which I consider the most immediately observable signal

Nonverbal Communication as a Signal

Nonverbal cues can tell you a great deal about whether someone feels safe. Crossed arms, leaning away, creating physical distance, and shifts in posture all indicate disengagement or discomfort. Facial expressions such as frowns, pursed lips, eye rolls, or a head shaking with disappointment signal that something is wrong. Gestures like fidgeting, foot tapping, or clenching hands can indicate anger or anxiety.

Eye contact is culturally variable and should not be used as a universal marker. However, if someone who previously made eye contact suddenly stops, that shift is meaningful. Similarly, a sudden drop in vocal tone, giving only short responses, or the absence of minimal encouragers all suggest a person has withdrawn from the interaction.

Minimal Encouragers

Minimal encouragers are verbal and nonverbal cues that signal to a patient or colleague that you are actively listening and that they can continue sharing. Most people use them instinctively without knowing there is a name for them. They foster an environment where patients feel safe to tell their story, and stories yield more clinically useful information than closed-ended yes-or-no questions.

Verbal minimal encouragers include phrases such as "I see," "Go on," "That sounds difficult," "Mhm," and "Tell me more." These signals communicate that you are present, that you hear what is being said, and that the person should continue. The specific phrasing can be adjusted for the audience. With a pediatric patient, "That is tough" may feel more natural than "That sounds difficult." The goal is authenticity, not formula.

Nonverbal minimal encouragers include nodding, maintaining eye contact (where culturally appropriate), leaning forward slightly, and using facial expressions that convey concern or empathy. I have found in my mental health practice that allowing myself to have genuine reactions, including surprise or visible concern, actually helps patients open up more than a trained neutral expression does. People need to see that you are human.

Minimal encouragers help patients feel heard and understood, promote sharing of critical health information, demonstrate genuine care and attentiveness, lead to better understanding of patient needs, and contribute to more accurate diagnoses and treatment plans.

Case Study: Minimal Encouragers and COPD Management

I had a patient with COPD, whom I will call Mary, who had been managing well through a program we developed together with her daughter. She had stopped coming in. Then, shortly before COVID emerged, she was readmitted and described by staff as non-compliant with her medication regimen.

Because I had a relationship with her, I asked simply: what was going on? She mentioned that her daughter was not with her. I asked where her daughter was. Through that conversation, I learned that her daughter had fractured her femur and had been bedridden for forty days. Her daughter's husband, overwhelmed by caring for everything, had not been getting Mary's medications to her. She was not non-compliant. She did not have access to her medication.

The fix was simple: arrange for the medication to be mailed. But we never would have reached that solution without asking open-ended questions and listening for the story behind the symptom.

Case Study: A Patient Refusing Discharge

Another patient was ready for discharge but was refusing to leave. Staff were frustrated and described her in negative terms. Because I had an established relationship with her, I approached her directly and asked why she wanted to stay. In conversation, it came out that her daughter would be paroled in two weeks and released to her home. She was afraid.

All it took was a conversation with the social worker. The social worker contacted the parole officer, the daughter was discharged to a halfway house instead, and the patient went home the next day. Relationships built on genuine listening and rapport resolve problems that checklists and protocols cannot.

Best Practices for Using Minimal Encouragers

Be fully present during patient and colleague interactions. Avoid overusing verbal encouragers, as they can feel like interruptions when used excessively. Combine verbal and nonverbal cues for greater impact. Avoid colloquialisms and euphemisms, which can mean different things to different people or fall into unintended meanings. One time I returned to a patient's room and said "I am back like a bad rash," and the patient was startled because she was covered in a rash. We cannot always anticipate every context, but we can be thoughtful.

Creating Safer Environments

Creating a psychologically safe environment involves four interconnected practices: building trust, reducing fear, promoting openness, and fostering mutual respect.

Building Trust

Trust is built through consistent communication using varied formats, demonstrating humility and integrity, showing care and empathy, and checking in proactively rather than only reactively. You do not have to wait for a death or a critical incident to check in with a colleague. You can check in about everyday stressors, organizational changes, or just how someone is doing.

Do what you say you will do. If you cannot, be honest about it. Shift the idea of 'leader' to 'leadership': leadership is not a title. Everyone has the capacity to practice leadership behaviors. When people understand that leadership is a practice available to all, it creates a safer environment because the hierarchy feels less absolute.

There is no such thing as cultural competency, despite how often the term is used. We only know what we know. We should always be on a path toward learning more. Humility is the posture; cultural humility is the ongoing practice.

Reducing Fear

One of the most powerful fear-reducing practices is normalizing "I do not know." In healthcare, where knowledge is associated with authority and credentialing, admitting uncertainty is difficult. But it is far better to say "I do not know" electively than to pretend you know emergently. I have even said "I do not know" when I did know, specifically to invite a patient or colleague to teach me something. It creates space for others to contribute.

Encourage question-asking and model it yourself. When someone asks me a question in a group setting, I sometimes answer and then turn it back to the group: what do others think? This moves away from the idea that one person holds all the answers and toward a shared learning environment.

When errors occur, the response should focus on learning rather than on admonishment, where appropriate. This is why near-miss reporting programs exist. Refraining from mistakes as learning opportunities rather than grounds for punishment encourages team members to report issues promptly.

Promoting Openness

Be mindful of your tone when collecting information after a mistake is made. An interrogative tone shuts people down. Be aware of your own nonverbal communication. Share your own stories about mistakes made. I tell my mentees about failing a certification exam by six points. That six-point margin stung more than the failure itself. Sharing that story out loud normalized failure for them in a way that abstract encouragement never could.

Active listening is the cornerstone of openness. One evidence-based framework for active listening is O.A.R.S., drawn from motivational interviewing. O.A.R.S. stands for:

• Open-ended questions, such as "Tell me how you believe your life is impacted by your smoking."
• Affirmations, such as "I appreciate you sharing that with me."
• Reflections, such as "It sounds like no one has really paid attention to this issue for you before."
• Summarize: briefly paraphrase what you have heard to confirm understanding. You do not have to repeat everything, but enough to demonstrate that you received what was said.

Fostering Mutual Respect

Avoid interrupting and dismissing. Recognize and celebrate contributions from all team members, particularly those from minoritized identities who may not have been recognized in similar ways before. Establish shared goals and values. Learn how teammates prefer to receive both feedback and recognition. Some people find public recognition mortifying. If you are in a leadership role, ask new hires early on: how do you want to receive feedback, and how do you want to be recognized when you do something well? Then honor that.

Clinical Scenarios

Scenario 1: Wrong Equipment During Emergency Intubation

During an emergency intubation, an RT notices that the wrong-sized endotracheal tube is being prepared but hesitates to speak up, fearing backlash from the lead physician. The patient develops complications, leading to more difficult airway management.

If the RT had felt secure enough to raise concerns, the appropriate equipment could have been used from the outset, avoiding complications and improving patient outcomes. Open communication in high-pressure scenarios is critical for effective teamwork and patient safety. This is exactly the kind of situation where pre-established psychological safety pays off. If a newer RT or younger clinician has been told that their voice matters, they are far more likely to speak up when it counts.

Scenario 2: Medication Protocol Error

An RT realizes they administered the wrong oxygen therapy protocol but avoids reporting the mistake due to fear of reprimand. This delay in addressing the error leads to prolonged hypoxia for the patient.

In a psychologically safe environment, the RT could report the mistake promptly, allowing for a swift corrective response, minimizing harm, and framing the error as a learning opportunity for the team.

Scenario 3: Conflict Between Orders and Patient Directives

An RT is asked to continue aggressive ventilation on a terminally ill patient despite the patient's advanced directives. The RT feels conflicted but fears repercussions for questioning the order.

In a psychologically safe workplace, the RT could discuss their ethical concerns without fear, leading to a reassessment of the care plan in alignment with the patient's wishes and ethical practices. This is where leadership is especially important. People with formal titles have the responsibility to lead by example and demonstrate that ethical questions are welcome.

Strategies for Leaders and Teams

Leadership Strategies

Leaders set the tone for psychological safety. When you make a mistake in front of a group, correct it in front of the group. If you realize after the fact that you gave incorrect information, send a follow-up email to the whole team. When you make errors visible and correctable, you model that it is safe for others to do the same.

Create clear expectations for behavior and communication. Provide educational resources that support team development. Psychological safety resources are widely available, many of them free, and can be incorporated into huddles. The huddle does not have to be only about census and staffing. Small, consistent touchpoints around team culture accumulate over time.

Feedback Strategies

Use "I" statements when giving feedback. Ensure feedback is specific and actionable. If you are pointing out a missed step or a problem, pair it with a suggestion for what could be done differently. Do not deliver a complaint without a path forward.

If you are a colleague rather than a supervisor, ask for consent before offering feedback. I recently said to a colleague, "I have some feedback specific to you. Are you willing to hear it?" She said yes. I offered it. She received it well. But asking for consent is what made that possible. It shifts the power dynamic and demonstrates respect.

Addressing Challenges to Change

When organizations push back with "this is how it has always been done, and it has worked," I always ask: has it, though? If there is a need for this conversation, something has happened. The fact that something has persisted does not mean it is working well. Resistance to change is best addressed through gradual implementation rather than sweeping mandates.

Time constraints are real, but they can be addressed by integrating psychological safety practices into existing workflows rather than adding separate programming. Hierarchy concerns can be mitigated by intentionally involving leaders in modeling desired behavior so that change is visible at the top.

Takeaways

Psychological safety enhances patient outcomes. In environments where team members feel safe to speak, there are fewer medical errors, earlier identification of patient risk, and higher-quality care. Additionally, patients lose a sense of control when they enter the hospital. Building rapport early in a patient's stay is not just a relational nicety. It is a clinical strategy.

Leadership sets the tone. How leaders respond to questions, errors, and dissenting voices tells the entire team what is and is not safe to bring forward. Building trust is a deliberate act, not a passive outcome. It requires consistent communication, modeling of vulnerability, and follow-through.

Errors are opportunities for learning. Reframing mistakes in this way changes a team's entire culture. When people do not fear punishment for mistakes, they report them. When they report them, those mistakes can become the basis for improved protocols and processes.

Inclusion of all voices matters. Psychological safety relies on valuing every team member's contribution regardless of role, experience level, or identity. Inclusion is not passive. It is something you do on purpose. You have to actively invite voices in. I was not the most diverse hire at the Idaho hospital system, where I worked for five years, but I was included. My ideas were sought, heard, and sometimes acted upon. That distinction, between diversity and inclusion, is meaningful. Inclusion is the mechanism that creates the conditions for psychological safety to exist.

Questions and Answers

How do I recover mentally after making a mistake in patient care?

The first thing to recognize is that you are not the only person who has ever made a mistake. You are not alone, even though it feels that way in the moment. There is a model called the CLAIM model that can be helpful to review after a clinical error.

The most important step in the immediate aftermath is to own the mistake and apologize. Not a prolonged apology that shifts focus to your distress, but a clean one: acknowledge what happened, apologize, and ask if there is anything else the patient or colleague needs. Do not fill the apology with explanations. The explanation does not serve the person harmed in that moment.

Later, in private, reflect on what you can do differently in the future. The most important ongoing practice is to give yourself grace. A mistake is not the last mistake you will ever make. What changes over time is the rate and the severity, and your capacity to catch yourself earlier. Do not measure your career against other people's benchmarks. We set goals based on external comparisons that often do not serve us. You get to define what success means, and that definition can evolve.

References

References are provided in the course handout.

Editor’s note: This text-based course is an edited transcript of the webinar, Bridging the Gap: From Student to Professional, presented by Jessica Hewitt, MSOL, RCP, RRT. 

It is recommended that you download the course handout to supplement this text format.

Learning Outcomes

After this course, participants will be able to:

• Identify the different ways a gap between student knowledge and professional practice may appear.
• List the factors contributing to the disparity in readiness between respiratory therapy school and clinical practice.
• Identify personal strategies for participants to help bridge this readiness gap.

Memory Lane

Let’s begin by reflecting on your time as a student. Think back to when you were first learning about the respiratory therapy profession. I have a few key questions to help guide this reflection. How well did you understand the role of a respiratory therapist before entering the field? Did your education fully prepare you for the hands-on realities and challenges of the job? What specific experiences or skills do you wish you had developed before stepping into the role of an RT? As you think about these questions, consider the gap that often exists between academic training and clinical practice. We’ll use this reflection to discuss how we can better prepare new graduates for the field by strengthening their transition from education to real-world practice.

Reasons for Choosing Respiratory Therapy

Student Perspectives

To begin, let’s explore why students choose respiratory therapy as a career. I look at it from two perspectives: the student viewpoint and insights from the American Association of Respiratory Care (AARC). From my experience as an educator and through interviews with incoming students, many of them are drawn to this field after working in other healthcare roles. Some come from positions like phlebotomists or certified nursing assistants (CNAs), bringing with them valuable experience, but often with limited understanding of the specific demands of respiratory therapy.

These students often choose respiratory therapy because it offers a hands-on, patient-centered career with opportunities to make a direct impact on patient outcomes. The promise of specialized skills and the ability to work across diverse healthcare settings—like emergency departments, ICUs, and neonatal care—makes it a unique and appealing profession.

Sometimes, students are motivated by personal experiences as patients. For example, I had one student who chose respiratory therapy after being hospitalized with COVID-19. That experience gave her firsthand insight into what respiratory therapists do, from patient care to the critical role of ventilation.

For others, it is family connections. Many students have family members with respiratory illnesses, which introduces them to the profession early on. Then there are those who do not have direct contact with RTs but are drawn to the profession for its job stability and increasing demand. Post-COVID, the need for respiratory therapists has escalated, and we have gained more visibility in the news. The competitive compensation that has followed also makes it an attractive option for many.

Despite being a relatively short program—typically about two years, sometimes even less with accelerated options—respiratory therapy offers strong career prospects. In some cases, students can complete their associate's degree in respiratory therapy in under two years and still enter the workforce with competitive wages.

Another appeal of the field is the potential for a good work-life balance. Many respiratory therapists work three 12-hour shifts per week, which allows for flexibility—something that is especially valuable for parents or those with other family responsibilities.

Student and AARC Perspectives

A common theme I hear from students is how rewarding this career can be. They are motivated by a desire to help others, find purpose in their work, and know they are making a real difference in someone’s life. From the AARC perspective, this sentiment remains consistent.

The AARC emphasizes that respiratory therapy is a solid and growing career. According to their projections, the demand for respiratory therapists is expected to increase significantly in the coming years. Many of us have heard about the looming shortage of RTs, driven in large part by a wave of retirements. This will create a critical need for new graduates to enter the field and keep the profession thriving.

It is more important than ever to ensure that these new graduates are well-prepared and strong in their practice. By doing so, we can maintain the stability of our profession and continue making a meaningful impact on the lives of our patients.

Respiratory therapy also offers a path for lifelong learning. Many of us will continue to grow in our careers by exploring different areas of the hospital, working with various patient populations, and staying current with continuing education units (CEUs). These ongoing challenges contribute to making the career even more rewarding.

In fact, I recently spoke with a prospective student who mentioned that she was specifically drawn to the idea that high stress leads to high rewards. This mindset speaks to the heart of what many of us seek—a career that is challenging but deeply fulfilling.

At its core, respiratory therapy is about service to others. Making patient needs the top priority and showing genuine care allows us to truly make a difference in people’s lives.

RT School and The Gap

RT School: CoARC

First, let’s examine the structure of respiratory therapy programs. A significant aspect of this is the role of the Commission on Accreditation for Respiratory Care (CoARC). Students must graduate from a CoARC-accredited program to sit for their board exams and earn their credentials, making this accreditation crucial.

CoARC sets the standards to ensure that RT schools provide a high-quality education. These standards help guarantee that graduates are not only well-prepared for the profession but are also equipped with strong practical skills, a solid academic foundation, and the ability to engage in research. Ultimately, this accreditation ensures that new respiratory therapists can provide excellent patient care and contribute meaningfully to the healthcare field.

CoARC also ensures that schools maintain their accreditation through continuous improvement. To keep this accreditation, programs must undergo regular audits and follow several processes to ensure their curricula stay current and relevant.

A key part of this is the professional development of faculty and administrators. This often involves regular meetings to review and update the curriculum as needed. If evidence-based medicine evolves, those changes are integrated into the program to ensure students receive the most up-to-date education.

Quality assurance is a critical component of the accreditation process. Schools are required to track and report several key performance indicators, ensuring transparency and accountability. The three primary metrics I will focus on are graduation rates, credentialing rates, and job placement rates.

We consistently monitor the number of students who begin and successfully complete the program, the number of graduates who go on to earn their credentials—both Certified Respiratory Therapist (CRT) and Registered Respiratory Therapist (RRT)—and the number who secure employment in the field after graduation. These metrics are not just numbers; they reflect the program's effectiveness in producing competent and hireable respiratory therapists.

Programs are also held accountable to ensure students are not only graduating but are fully prepared for the profession's demands. High credentialing and placement rates demonstrate that graduates are ready to pass board exams and succeed in clinical environments. This continuous tracking helps identify areas for improvement, ensuring that the education provided is aligned with industry needs, emerging trends in healthcare, and the evolving standards of evidence-based practice. Additionally, these indicators offer valuable feedback for faculty, allowing them to adjust teaching methods and curricula as needed to maintain high performance and meet accreditation standards.

CoARC also plays a crucial role in ensuring that best practices are being taught and that any developments in respiratory care are incorporated into the curriculum. They are strong advocates for the respiratory therapy profession, helping to shape its future. In fact, CoARC has been instrumental in the creation and expansion of bachelor’s and master’s programs in respiratory therapy, which are gaining increasing attention.

I have noticed a growing interest from students asking about master’s programs—something that was not even an option when I was in school. This reflects the evolving nature of the profession and the drive for continued academic advancement within respiratory care.

Beyond advancing degree options, CoARC is committed to maintaining a student-centered focus. Their goal is to ensure that each student receives a high-quality education, fully preparing them for their careers. This dedication helps guarantee that students graduate not only with the necessary credentials but also with the skills and knowledge to thrive in the field.

What Is “The Gap?”

What is this gap I keep referring to? It is the difference between what is taught in RT school and what is commonly practiced at the bedside, including the emotional intelligence required to work in a clinical setting. Many students are surprised—and sometimes even frustrated—when they learn that what is in the textbook does not always match what they see in the real world. This variation comes from different hospital protocols and varying scopes of practice depending on the facility or region.

One major aspect of this gap is the challenge of applying textbook concepts to real-world scenarios. Learning from books and passing exams is one thing; being confronted with a live patient is another. Even when students have the necessary knowledge, putting it into practice can be difficult.

Another critical aspect of the gap is emotional preparedness. This is often overlooked in education and can be a tough conversation to have. As respiratory therapists, we work in high-stress environments, and our work carries significant emotional weight—not only for us but for our patients and their families. The ability to relate to patients, manage emotions, and cope with the stress of critical care situations can be incredibly challenging for new graduates transitioning to bedside care.

The Emotional Gap

Building on this emotional gap, a significant challenge for many new graduates is the transition to working independently. The shift from a supervised learning environment to the autonomy of being on your own can be overwhelming. I actually had a former student reach out to me after starting their first job in the field, asking, "How do you get rid of imposter syndrome?"

This student was incredibly intelligent—at the top of their class—and felt well-prepared academically. However, once they were faced with the reality of making decisions on their own, the weight of responsibility hit them hard. They experienced a sense of panic, realizing they were now responsible for managing high-stress situations and severe illnesses. This feeling of not being ready, despite their training, is a common experience and adds to the emotional challenge of transitioning from student to practicing professional.

A significant challenge for new graduates is managing the emotional trauma that comes with coping with patient loss. This aspect of the job can be incredibly difficult, and teaching students various coping techniques is essential to bridging this emotional gap. Coping skills cannot be entirely taught from a textbook, but they need to be discussed and developed throughout their education.

An area I did not anticipate as a student but now make a point to address in my classes is navigating complex family dynamics. As respiratory therapists, we often provide care not just to the patients but also to their families. In some situations, particularly when patients are critically ill or unable to communicate, our interactions with families can be even more intense. Helping families understand medical interventions, managing their emotions, and offering support during critical moments are all parts of the job. In some cases, the ability to guide families through end-of-life situations with empathy and compassion becomes just as important as the technical aspects of care.

Encouraging students to build strong personal and professional support systems is critical. These systems help them manage the emotional demands of the profession and foster resilience. Peer networks, mentorships, and even mental health resources can be invaluable as new graduates adjust to the pressures of working in such a high-stress, emotionally charged environment.

Personally, I do not have any family in the healthcare field. While my family has always been incredibly supportive, they could not fully understand or relate to the challenges I was facing. What ultimately helped me find the best coping strategies and feel more secure in my role was finding a support system of people who truly understood the demands of the job.

Helping students understand the importance of finding these support systems—whether through coworkers, mentors, or even their current classmates—is critical to easing their transition into the respiratory therapy world. Having a network of individuals who can relate to what they are experiencing can make a huge difference in navigating the emotional and professional challenges they will face.

Reasons for the Educational to Clinical Gap

What are the reasons for this gap I have been discussing? A significant factor is that each institution and setting has its own priorities and focus. Respiratory therapy schools emphasize foundational knowledge, critical thinking, and meeting accreditation standards, ensuring students are prepared for their credentialing exams. However, a trauma hospital may prioritize rapid, life-saving interventions, quick decision-making, and managing high-acuity cases in a fast-paced environment. In contrast, home healthcare focuses more on long-term patient care, rehabilitation, and chronic disease management. Each of these settings requires different skills, and the divergence between academic preparation and real-world practice becomes more evident based on the focus of each institution.

The gap between academic and clinical settings is often substantial. In school, the goal is often to ensure that students understand theoretical concepts and protocols, while clinical settings require them to apply this knowledge in dynamic, real-world scenarios. We will explore these differences in more detail shortly.

A contributing factor is the varied expectations between the classroom and the bedside. In an academic environment, students are evaluated primarily on their ability to memorize information, pass exams, and perform in controlled simulations. In contrast, at the bedside, they are expected to apply this knowledge in unpredictable, high-pressure situations. They must navigate not only the medical complexities of patient care but also interpersonal dynamics, emotional intelligence, and decision-making in real-time. This is where the gap widens—bridging the transition from textbook learning to patient-centered care can be a challenge.

The healthcare landscape is constantly evolving. New technologies, updated protocols, and emerging evidence-based practices are introduced regularly. Schools may struggle to keep up with the rapid changes in clinical practice, meaning that by the time students enter the workforce, they may encounter new methods or tools they had limited exposure to during their education. This creates another layer of difficulty when transitioning from the classroom to the clinical environment.

Focuses of RT Education

Let’s talk about the focus on the education side of respiratory therapy. One of the primary emphases in RT programs is preparation for the board exams. As I mentioned earlier, credentialing rates are tracked as part of CoARC’s accreditation requirements. We place a heavy emphasis on ensuring students are fully prepared to pass these exams because this is essential for maintaining accreditation.

This focus is critical, as passing the board exams is the gateway to becoming a licensed respiratory therapist. Without these credentials, students cannot enter the field. Therefore, much of the curriculum and academic effort is geared toward equipping students with the knowledge and skills they need to succeed on these exams. Whether it is through test simulations, practice questions, or in-depth reviews of core concepts, we do everything we can to help students reach that goal.

A key part of the educational focus is hands-on competency. Students need to demonstrate their practical skills through hands-on assessments, which might involve working with simulated patients or practicing with each other. These exercises help prepare them not only for the real-world scenarios they will face but also for the multiple-choice Therapist Multiple Choice (TMC) exam, which is required to earn their CRT credential.

In addition, we emphasize developing critical thinking skills, which are essential for passing the RRT credential. This is assessed through the Clinical Simulation Exam (CSE), where students must demonstrate their ability to think critically and make sound decisions in complex clinical scenarios. We work hard to prepare them for both exams by simulating real-life challenges as much as possible.

• Focuses of RT Education: Focuses on individual subjects
  • Educational programs and instructors determine the integration of topics based on curriculum design
• Balancing act of mitigating content overload
  • Balances depth of learning to prevent memorization without understanding

One challenge in RT education that can make it difficult for students to apply their knowledge to real-world situations is the way subjects are taught in a very compartmentalized manner. Most schools break down topics into distinct categories, like pulmonary anatomy and physiology, therapeutics, and mechanical ventilation, each taught separately. However, in practice, all of this knowledge needs to come together to treat a single patient.

Initially, students tend to think of these subjects as isolated areas of learning. While this may change as they progress through the program, it often leads to difficulty connecting concepts from one class to another—and, ultimately, applying them in a clinical setting. This disjointed approach can result in students struggling to integrate what they learned in different courses when faced with real patients.

Students may experience content overload, trying to absorb a vast amount of information in a short time. One of the most common issues we see is what we call "memorize and dump"—students memorize information for exams but quickly forget it afterward rather than retain and understand the material deeply enough to apply it effectively in practice. This can create a significant gap between what they know in theory and what they can actually do in a clinical environment.

This "memorize and dump" cycle is incredibly difficult to combat, largely because students are bombarded with a vast amount of information in a short period. As soon as they finish one class, they move on to the next, often forgetting much of what they just learned. By the time they have completed a final exam, their focus shifts to the next set of material, and the knowledge from the previous class starts to fade.

The challenge is finding a balance—helping students truly understand and internalize the material so that it sticks, rather than just memorizing it for a test. We need to ensure that students recognize the long-term importance of what they are learning rather than simply focusing on short-term retention for exams. It is crucial to foster a deeper understanding so that the knowledge stays with them as they progress through the program and into their clinical practice.

Positives and Challenges of RT Education 

• Promotes critical thinking
  • May be difficult to teach
• Addresses the importance of evidence-based medicine and patient-centered care
  • Difficult to evaluate and score in the classroom

There are several challenges in RT education, but they often go hand in hand with the positives. One of the key strengths of RT school is that it promotes critical thinking, which is essential for success in the field. However, teaching critical thinking is not easy. Each student approaches situations differently, and no two clinical scenarios are exactly the same. For critical thinking to be effective, students need to integrate their knowledge with personal insights—yet, as students, they often lack the real-world experience to fully develop this skill.

This is where the challenge arises. Critical thinking improves with time and practice, and experienced therapists benefit from drawing from personal experiences—whether successes or mistakes—to guide their decision-making. Students, on the other hand, have not yet had the opportunity to build that reservoir of experience, which can make developing strong critical thinking skills more difficult in an academic setting.

That being said, the promotion of critical thinking in RT education remains a major positive. While it takes time to develop fully, students are introduced to the importance of problem-solving and learning to approach complex patient situations with a critical, analytical mindset. As they gain more clinical exposure and experience, their ability to think critically will naturally grow, building a strong foundation for their professional careers.

As new graduates, they have not yet developed the depth of insight that comes with experience. They rely heavily on their academic knowledge, trying to piece together everything they have learned to care for their patients. This is where the challenge lies—being able to synthesize and apply their knowledge effectively in real-world situations.

A critical aspect of thinking through patient care, which is often overlooked from the student's perspective, is the presence of subconscious biases. These biases, whether cultural, social, or emotional, can significantly influence how a therapist approaches patient care. Factors such as a patient's race, socioeconomic status, gender, or lifestyle choices can unintentionally affect how care is delivered. It is crucial to make students aware that biases exist in healthcare and to help them recognize their own subconscious biases as much as possible.

By acknowledging these biases, students can begin to reflect on how these influences might shape their interactions with patients, whether through assumptions about a patient’s condition or judgments regarding their behavior. Once students recognize these biases, they can learn how to set aside emotional or biased barriers and focus on delivering patient-centered, objective care that aligns with the best clinical practices.

Understanding and addressing these subconscious biases is an essential, yet often underestimated, part of developing as a healthcare professional. Healthcare providers, including respiratory therapists, frequently interact with patients from diverse backgrounds, and their ability to recognize and mitigate these biases directly affects the quality of care. Helping students to confront and manage these biases early on not only improves patient outcomes but also equips students to be more compassionate, culturally competent, and effective therapists. It fosters an environment where patients feel seen, heard, and understood, which is vital for building trust and ensuring that care is equitable for all patients.

RT school also emphasizes the importance of evidence-based medicine and patient-centered care, which ties directly into addressing subconscious biases. The goal is to help students make decisions based on the best available research while also keeping the individual needs and preferences of the patient at the forefront. However, applying evidence-based medicine can be challenging because it is constantly evolving. What we know today may change tomorrow, and students must learn to adapt to this ever-shifting landscape.

A clear example of this was during COVID-19, when we all witnessed the scientific method in real-time. Guidelines, treatments, and protocols were rapidly updated as new evidence emerged. This experience reinforced the idea that learning in healthcare is never static. In RT, everything builds on prior knowledge, and no matter how long we have been in the field, we are always learning and adapting. Evidence-based medicine is a lifelong commitment, and understanding this early on prepares students to be more flexible and responsive to new developments in the profession.

While we can emphasize the importance of evidence-based medicine in RT education, its rapid evolution makes it difficult to keep up with—and even harder to evaluate in the classroom. The fast pace of medical advancements creates challenges in ensuring students not only understand the current best practices but are also able to apply them effectively in a real-world setting.

This makes it particularly difficult to assess and score in a traditional classroom environment. While we can stress the significance of evidence-based practice, testing its real-world application is much more complex. The dynamic nature of healthcare means students must continuously adapt, and measuring their ability to do so can be challenging. Ultimately, while we can provide the foundation for evidence-based medicine, the true test comes when they are on the job, continually learning and integrating new knowledge into their practice.

• Ample class time, less clinical exposure
  • Leading to a lack of understanding of how to triage, time management, and scope of practice
• Difficulty in keeping instructors up-to-date
  • Exposure to new equipment and technological advances

One challenge we face in RT education is that it is primarily classroom-focused. While every program provides students with some clinical exposure, the majority of their time is spent in the classroom, leaving less opportunity for hands-on learning in real-world environments. The classroom setting is essential for teaching foundational knowledge, particularly when it comes to preparing for board exams. However, clinical exposure is critical for developing the practical skills that are necessary for success at the bedside.

In clinical settings, students have the chance to apply their theoretical knowledge, but more importantly, it is where they learn to manage real patients. This exposure allows them to practice key skills such as triaging patients, refining their time management, and making quick decisions in high-pressure situations. These experiences also provide a clearer understanding of the full scope of practice for respiratory therapists, including how to collaborate with interdisciplinary teams and navigate complex patient cases.

The limited time spent in clinical settings can make it challenging for students to fully grasp these practical aspects before graduation. Furthermore, clinical experiences vary based on location, meaning some students may not have exposure to certain patient populations or care environments. For example, a student might get a lot of exposure to emergency care but little experience with long-term or home care settings. This variance can leave gaps in their practical experience, which may take time to fill once they enter the workforce.

The challenge, then, is finding the right balance between academic knowledge and clinical experience. Programs must ensure students are not only equipped to pass their exams but also prepared to handle the complexities and unpredictability of patient care in real-life scenarios.

Another layer of complexity is that clinical practices and available resources can vary significantly depending on where you are in the country or even around the world. This variability can affect the kind of experiences students have during their clinical rotations, further contributing to the gap between education and real-world practice.

Additionally, keeping instructors up to date with the latest advancements in technology and care practices is an ongoing challenge. While educators can stay informed through conferences, online forums, and continuing education units (CEUs), including programs like this one, many of us do not have the opportunity to work directly with new equipment or technologies on actual patients. This limits our ability to fully integrate cutting-edge tools and techniques into our teaching.

Without firsthand experience using newer technologies in clinical settings, it becomes harder to share personal stories or offer insights into how these advancements are applied in real life. This gap makes it even more difficult to bridge classroom learning with what students will encounter in hospitals, particularly as healthcare continues to evolve rapidly. Ensuring instructors have access to hands-on experience with the latest technologies is essential for preparing students to handle the realities of modern respiratory therapy.

Focuses of RT Profession Cont'd. 

• Implementation of respiratory-therapy driven protocols
  • Hospital specific
  • Focused on evidence-based medicine and patient centered care
• Emphasis on maintaining certifications, credentials, and licensing

Shifting away from the classroom setting, let’s talk about the clinical side of the RT profession, where a significant focus is on the implementation of respiratory therapy-driven protocols. These protocols guide the care provided by RTs and play a crucial role in how respiratory therapists operate within hospital settings. However, these protocols can vary widely depending on the institution or geographic location, making them highly specific to the hospital or healthcare system in which you work.

For example, one hospital may have a protocol that allows RTs to manage ventilator settings independently based on patient needs, while another facility might require close collaboration with physicians for every change. Similarly, protocols surrounding oxygen therapy, nebulizer treatments, or weaning from mechanical ventilation can differ greatly depending on the hospital’s policies, the patient population they serve, and the resources available.

These differences are often based on a variety of factors, such as the hospital’s culture, regional regulations, and the specific needs of its patient demographic. This makes it important for RTs to adapt quickly when transitioning between facilities or even between departments within the same hospital. What works in one institution may not apply in another, and part of the RT’s skill set involves learning the protocols unique to each clinical environment.

Furthermore, respiratory therapy protocols are often developed and updated based on the latest evidence-based practices, making it essential for therapists to stay informed of new research and advancements in the field. This constant evolution of clinical protocols emphasizes the importance of adaptability and continuing education for RTs, as they must balance standardized practices with the flexibility to adjust to new information and different clinical environments.

This variability in protocols can be particularly challenging for new graduates, especially those who work at multiple hospitals, or even for seasoned professionals transitioning between different facilities. Each hospital may have its own set of protocols, and adapting to these differences can be overwhelming at first. For both new and experienced respiratory therapists, it is essential to remain flexible and quickly learn the specific practices of each institution.

In addition to navigating these varying protocols, there is also a strong emphasis in the RT profession on using evidence-based medicine to provide the highest quality care for patients. While RT schools focus heavily on helping students achieve their certifications, credentials, and licenses, the professional environment shifts the focus to maintaining and building on those qualifications. Respiratory therapists are expected to participate in continuing education (CEUs), in-services, and other professional development opportunities to stay current in the field. This commitment to lifelong learning ensures that RTs are not only keeping their credentials up to date but also growing in their knowledge and advancing in their career ladder.

The specific focus of an RT’s role can also change dramatically depending on the setting in which they work. For example, the skills required for a rehabilitation setting are vastly different from those needed in a pulmonary function testing (PFT) lab or an intensive care unit (ICU). Each environment demands a unique set of competencies, whether working with long-term, recovering patients in rehab or managing critically ill patients on mechanical ventilation in the ICU. This diversity in clinical settings is one of the key aspects of respiratory therapy, making it both challenging and rewarding as therapists continuously adapt their skill sets to meet the needs of various patient populations.

Comprehensive training across hospital areas

• Including but not limited to:
  • Observation units
  • ICUs
  • ER
  • Sleep lab
  • Rehabilitation
  • Home health
  • PFT lab

As new graduates enter the field, their transition can be particularly challenging if they are hired to work in multiple hospitals. I have had several students who secured per diem positions at more than one facility, and this situation can make the adjustment even more difficult. In these cases, they are not only learning different protocols for each hospital, but they are also managing different areas of patient care. For example, they might be working in the emergency room at one hospital and in a PFT lab at another. Juggling these roles can make it hard for new graduates to gain confidence, as they are constantly shifting between protocols, settings, and patient care expectations.

This challenge is not limited to new graduates—seasoned respiratory therapists can also find it difficult to move between hospitals or switch care settings. Even with years of experience, transitioning to a new environment with different protocols and priorities can feel overwhelming. Whether it is a move from one hospital to another or a switch from an ICU setting to rehab, adapting to new practices and expectations can take time and can impact the confidence of even the most experienced RTs.

Variances in RT Professional Practice

• Scope of practice
  • Variances observed across states and hospitals
• Diverse equipment and protocol standards
  • Impacting operational efficiency
• Disparity in workloads
  • Influencing clinical practice and resource allocation

There are several variances in RT practice that contribute to these challenges. Even RTs who have been in the field for a while may feel like they face a gap when moving to a new facility or region. Being a new hire anywhere can be intimidating, and much of that comes from differences in the scope of practice. For example, respiratory therapists in Texas may be performing tasks that are not allowed in California or vice versa. These variations make it difficult for instructors to stay current with what is allowed in each state, and it can be challenging for students to build confidence in their skills before transitioning to the bedside.

The equipment and protocols can vary widely from one facility to another. For instance, one hospital may use a specific model of BiPAP machine, while another hospital uses a completely different brand or model. Learning new equipment with each job change adds another layer of difficulty to the already steep learning curve. This can exacerbate the existing gaps in knowledge, especially when transitioning between facilities that use different technologies or have distinct approaches to patient care.

Moreover, there are disparities in workloads and resources between facilities. Some hospitals may have more staff, allowing for lighter patient loads and more manageable time constraints. Others may have fewer resources, requiring RTs to handle more patients with less support. These differences can impact clinical practice and significantly influence how RTs manage their time and balance their workload. Adapting to a new facility’s workflow and expectations can be challenging for both new graduates and seasoned professionals, as it requires not only mastering new equipment and protocols but also adjusting to different time management strategies.

Merging the 2 Ways of Thinking

• Skills
• Critical thinking
• Time Management
• Empathy
• Compassion

To help students and new graduates feel more confident at the bedside, we need to find a way to merge the clinical setting with the educational side. Bridging these two worlds is essential to preparing students for the realities of patient care. It is not just about ensuring they have the necessary theoretical knowledge; it is also about equipping them with the practical skills and emotional intelligence they will need to succeed.

One key focus should be on helping students develop their critical thinking skills. In the classroom, they learn the basics of decision-making, but in the clinical setting, they need to be able to apply that knowledge in unpredictable, high-pressure situations. By integrating more clinical scenarios and simulations into education, we can help students better prepare for the complex decision-making they will face in real life.

Time management is another critical skill that requires attention. In the classroom, students may have time to work through problems thoroughly, but in clinical practice, they will need to make decisions quickly and prioritize tasks effectively. Incorporating time management training into their education—through case studies, simulations, and clinical rotations—can help them build the skills necessary to manage real-world patient care more efficiently.

Equally important is teaching empathy and compassion, not just for the patient but also for the families present in the room. Clinical care is not just about treatment; it is about communication and emotional support. By emphasizing patient-centered care and teaching students how to engage with families compassionately, we can help them develop soft skills that are just as vital as clinical knowledge.

By merging these aspects of education and clinical practice, we can create a more holistic approach that prepares students not only for their exams but also for the realities of working in the field. This will give new graduates the confidence they need to transition smoothly into bedside care, knowing they are equipped both intellectually and emotionally.

How Do We Bridge This Gap?

How do we bridge this gap? We address this in two different settings—first, how we can bridge the gap in the classroom, and then how to do so on the clinical side.

In the Classroom

Starting with the classroom setting, it is essential to ensure that the curriculum is continuously adapted to meet the evolving demands of the field. This includes integrating new equipment and therapies and incorporating practical, real-world scenarios. In my experience, one of the most frequent requests from students is the inclusion of more patient scenarios. They want the opportunity to think through real-life cases in the safety of the classroom setting so they feel more prepared when they transition to clinical rotations or their first jobs as new graduates.

Incorporating personal experiences is another critical element of making the classroom more relevant to clinical practice. One of the requirements for being an instructor is to have several years of RT experience, and sharing those personal stories helps students understand the depth and importance of the material. When we discuss different therapies or ventilator modes, it is often just theoretical information to them—until we can relate it to real experiences. For example, explaining, "In this situation, I used this ventilator mode, and these were the results I observed," makes the lesson much more tangible. Students tend to engage more actively when we bring these real-world examples into the classroom, and they can better grasp how the knowledge will apply to their future work.

What is interesting is that many students who have worked in hospitals often raise their hands to share their own experiences. They will recount scenarios they encountered but did not fully understand at the time. As they progress through their classes and gain more knowledge, they often have those "lightbulb moments" where everything clicks, and they finally understand the therapies or procedures they observed in action. I encourage this sharing, not only from my end but also from the students. These personal experiences, whether from a clinical setting or elsewhere, enrich the learning environment and help connect theory to practice.

This leads us to the importance of active student engagement. One effective way to foster this is through the use of case studies. We can start by providing printed case studies and allowing students to work through them individually, followed by small group discussions. These discussions give students the opportunity to think critically about different scenarios, share their perspectives, and work together to apply the knowledge they have learned. This kind of active engagement, whether through group work, class participation, or personal storytelling, helps bridge the gap between classroom learning and real-world application.

Of course, we need to incorporate lab activities to further solidify their learning. For example, in a therapeutic lab, students could practice setting up nebulizers, administering medications, or performing other respiratory therapies. In a mechanical ventilation lab, they can get hands-on experience using ventilators and even practice intubating patients. These lab activities provide crucial opportunities for students to apply their knowledge in a controlled environment, allowing them to build confidence and competence before moving into the clinical setting.

One of my favorite approaches to fostering engagement and confidence is making the students the teachers. I have seen this method used in several schools, which is incredibly effective. It forces students to take ownership of the material and gain the confidence they will need when they are the ones explaining treatments to patients, nurses, or family members.

There are a couple of ways I incorporate this into my classes. I assign students to explain complex concepts—either in small groups or as a written exercise. For example, they might need to explain mechanical ventilator modes, specific respiratory therapies, or medications. One of the key elements of this exercise is having them tailor their explanations for different audiences. I ask them to think about how they would explain a medication or therapy to a healthcare professional who already has some understanding, versus a patient or family member who may not be familiar with medical terms.

This exercise is not only a great study technique but also a way to gauge their level of understanding. A technique I was taught when I was in school was, “If you can teach it, you know it well. If you cannot teach it, you need to study it more.” It is a simple but effective way to see what students truly understand and where they might need to focus their study efforts. Teaching forces them to think critically and organize their knowledge in a way that is clear and coherent, which is exactly what they’ll need to do when they are in the field, explaining treatments to patients or collaborating with other healthcare professionals.

Making it clear how language needs to change depending on the audience strengthens students’ abilities at the bedside. Being able to explain complex respiratory concepts in two different ways—one for healthcare professionals and one for patients or family members—makes them more effective communicators and helps them build trust and rapport with their audience. This adaptability is crucial in real-world settings, where clear, concise communication is key.

Another way to turn students into teachers is through skills fairs. These events give students the opportunity to demonstrate therapies or procedures—sometimes to their classmates and sometimes to the community. Skills fairs can be organized as school-wide events, with other programs involved, such as nursing or medical assisting. Inviting other healthcare programs to participate offers a great opportunity for interdisciplinary learning, and it is a fun and interactive way for students to showcase what they’ve learned.

What is especially meaningful about these events is the involvement of family and friends. Inviting them to observe allows students to show off everything they have learned up to that point while also providing a much-needed boost of support from their loved ones. This is particularly important as students juggle the demands of school, work, and personal obligations. Seeing that their hard work is recognized and supported by their family and friends can be a huge motivator and confidence builder as they prepare for the transition to clinical practice.

In the Classroom: Simulations

An exciting way we bridge the gap in the classroom is by using computerized mannequins to create realistic simulations. These mannequins allow us to replicate a true hospital environment right in the lab, offering students hands-on experience in a controlled setting. The three photos here show the mannequins I currently use in my teaching, which provide a wide range of patient assessment skills and scenarios.

Simulations with these mannequins create a safe space for students to practice patient care without the fear of harming anyone. They understand that this is a time to make mistakes and learn from them, which is invaluable in helping them build confidence and skills. The controlled nature of the simulation allows for real-time feedback and the opportunity to repeat procedures until they feel more comfortable.

One of the key areas these mannequins help with is patient assessment. They can simulate breath sounds, vital signs, EKG changes, and more. Some mannequins even allow students to practice drawing arterial blood gases (ABGs), performing CPR, or conducting intubations. For an added level of realism, some mannequins can also "talk," responding to students’ questions based on inputs from a tablet that controls the simulation. This interactive feature gives students the chance to practice communicating with patients, further preparing them for real-world bedside care.

The use of these computerized mannequins has been a game-changer for bridging the gap between the classroom and clinical settings, allowing students to experience a wide range of patient scenarios in a safe and controlled environment.

In the Classroom: Exploring Ethical and Cultural Considerations

• Facilitating thoughtful discussions
  • Encouraging open-ended class discussions in small or large groups
• Addressing complex scenarios
  • Approaches to family interactions during comfort care extubation
  • Effective communication with patients expressing fear of intubation

A key part of bridging the gap in the classroom is addressing ethical and cultural considerations, which can be challenging for some students. These discussions often bring up the more difficult and emotional aspects of our careers—what I like to call the “uncomfortable truths” of the job we have chosen. However, facilitating these conversations is essential for preparing students for the realities they will face in the field.

I usually start these discussions in smaller groups. Students often feel more comfortable talking about sensitive topics with a small group of friends, allowing them to explore these issues in a safer, more supportive environment. Afterward, if anyone feels comfortable sharing their thoughts or experiences with the entire class, I encourage them to do so. This helps foster a deeper understanding of these complex topics while keeping the discussion respectful and empathetic.

One important topic we discuss is family interactions during comfort care extubation. This is something I am personally very grateful for, as my own preceptor handled it with professionalism and empathy when I was a student. Before we entered the room, my preceptor calmly coached me on how to approach the situation, how to show compassion, and how to give the family the appropriate space they needed during such an emotionally charged time. Learning how to navigate these moments with empathy and professionalism is vital, and discussing these situations in class helps prepare students for the emotional realities they may encounter.

We explore other difficult patient scenarios—such as patients who are scared, about to be intubated, struggling with severe shortness of breath, or facing surgery. Understanding how to communicate effectively in these situations is crucial. Students need to learn how to provide reassurance and comfort while navigating the complexity of patient emotions. Additionally, it is important for students to know the resources available to them—whether that is reaching out to a supervisor, a chaplain, or other healthcare professionals for support in these tough moments.

I also like to give a disclaimer before we begin these conversations. If any students have recently experienced loss or trauma, I provide them with the space to step out of the classroom if they feel uncomfortable. Creating a respectful and compassionate environment for these discussions is critical to helping students process the more challenging aspects of our profession.

At the Bedside

• Comprehensive orientation program 
• Gradual introduction to clinical duties
• Providing ongoing education and training opportunities
• Supportive mentorship initiatives

Now, looking at the bedside perspective, one of the most effective ways to bridge the gap for new graduates is through a strong orientation program. A comprehensive orientation helps new grads transition from the classroom to clinical practice with greater confidence and competence. One critical area of focus during orientation should be time management and triage strategies—two essential skills that can be particularly challenging for new graduates to master.

Time management is often something new grads learn as they go, but giving them dedicated time to understand the hospital's preferred methods for triaging treatments, administering medications, or managing patient loads can make a huge difference. Offering guidance on how to prioritize tasks and manage their time efficiently—whether through learning hospital-specific shortcuts or best practices—can prevent them from feeling overwhelmed in those early weeks on the job.

In addition to practical skills, helping new graduates understand the hospital’s organizational structure is key. Knowing who to go to for support, understanding the chain of command, and familiarizing oneself with the roles of other departments all contribute to a smoother transition into clinical practice. These are often overlooked elements of bedside care, but they can have a significant impact on how well new graduates adjust to the demands of the job.

A strong orientation program not only provides new graduates with the tools they need to succeed but also builds their confidence as they integrate into the healthcare team. When they feel supported, they are more likely to thrive in the fast-paced and often stressful environment of bedside care.

An effective orientation program also helps new graduates understand who to report to if they have questions or concerns. It clarifies essential details like who to call if they are running late, sick, or encountering any issues. This takes away some of the added stress that comes with being new—not just to the career but to the hospital and its specific protocols. Clarifying these expectations early on helps new graduates feel more confident and supported as they navigate their new roles.

Although I cannot provide all the specifics of each hospital’s expectations in the classroom, I often have students ask me for clarification before they start their clinical rotations. I always remind them to ask their instructors or preceptors because every hospital operates differently. This is why having these details as part of the orientation is so important—it eases their minds and gives them a clearer understanding of what is expected from the start.

One thing I often told new graduates when I was precepting was, “I understand you are new, and I do not expect you to know everything yet. Nobody knows everything—that’s why continuing education exists.” Reassuring them in this way helps take some of the burden off, allowing them to focus on learning and growing in their new role. It is crucial for them to understand that their responsibilities will gradually increase as they become more familiar with the hospital, its protocols, and their role within the team. By easing their transition through strong orientation programs and clear communication, we set new graduates up for success, helping them gain confidence and competence at the bedside.

On that note, a gradual introduction to clinical duties can be highly beneficial for new graduates. Instead of overwhelming them by throwing them into every responsibility at once, it is helpful to start with a smaller workload, perhaps focusing on just one area of the hospital. This allows them to get acclimated to their new environment, develop their patient assessment skills, and adjust to the reality of working independently. Gradually increasing their responsibilities helps combat imposter syndrome, which is common when they first transition from working under a preceptor to being on their own. By easing them in at a slower pace, you can significantly boost their mental well-being, job satisfaction, career satisfaction, and overall confidence.

A great strategy, similar to what we do in the classroom, is incorporating simulation training into the clinical setting. Simulation-based training is becoming increasingly common in healthcare and is particularly useful for preparing staff for high-stakes scenarios, such as code or rapid response situations. These simulations allow healthcare professionals to practice protocols in a safe environment, identifying areas where they may have missed a step or could improve their decision-making, all without affecting real patients. This hands-on training helps employees refine their skills and build confidence before facing such situations in real life.

Holding regular in-services is another effective way to provide ongoing training, especially when new equipment is introduced to the hospital. Instead of simply integrating new equipment and expecting employees to adapt, having dedicated in-services where experts walk through the ins and outs of the equipment is much more effective. This not only ensures that staff are comfortable with the new tools but also improves patient safety and care quality by minimizing confusion or errors.

By gradually introducing clinical duties, offering simulation training, and providing regular in-services, hospitals can create a more supportive environment for new graduates and seasoned professionals alike, fostering a culture of continuous learning and skill refinement.

In-services also serve an important role in ensuring that employees understand why certain equipment is being introduced or why other equipment is being phased out. Change can be intimidating, and providing clear communication about the reasoning behind these decisions helps reduce uncertainty and fosters more openness to new protocols or tools. In-services create a valuable opportunity for dialogue between leadership, management, and employees, which not only enhances understanding but also encourages feedback from staff who will be using the equipment on the front lines.

An effective initiative is holding skills fairs, which many hospitals and departments already incorporate. Skills fairs can serve multiple purposes. Experienced staff members offer an opportunity to gain teaching experience by demonstrating skills that can help develop their instructional abilities. For new graduates, attending these fairs allows them to observe and learn skills they may not yet have mastered but will need to perform as their training progresses. This exposure can help new RTs better understand the future scope of their role and the additional duties they may take on as their careers develop.

In some cases, these skills fairs can also be extended to the broader community, inviting people outside the healthcare field to learn more about what respiratory therapists and other healthcare professionals do. This not only provides a great learning opportunity but also allows healthcare professionals to engage with the community in a meaningful way, helping raise awareness about the role of RTs in patient care.

By fostering open communication through in-services and providing learning opportunities via skills fairs, hospitals can promote an environment of continuous growth and collaboration, helping both new and experienced RTs feel more connected to their roles and the evolving needs of patient care.

Then, consider a mentorship program, which plays a crucial role in guiding professional growth for both new graduates and seasoned professionals. Mentorship provides a structured system of support where mentees have someone they can turn to for guidance, advice, and encouragement throughout their time at the hospital. These mentors can help new employees navigate career ladders, offering insights into potential career advancements and how to achieve their goals.

One of the key benefits of mentorship is the sense of security it provides. New graduates know they have someone they can go to without fear of judgment, someone who is dedicated to supporting their development. The mentor is there to listen, answer questions, and share personal experiences to help the mentee think through challenging situations more effectively. This kind of supportive relationship can be incredibly valuable in helping new graduates gain confidence and competence in their roles.

Research has shown that mentorship programs have wide-ranging benefits. Not only do they help improve job satisfaction and competence in new graduates, but they also contribute to better employee retention. For seasoned professionals, having a mentor can help reinvigorate their passion for the job, while for new RTs, it can significantly reduce feelings of isolation or imposter syndrome. Additionally, these programs have been shown to enhance compassionate patient care, as having a role model to demonstrate empathy and professionalism encourages mentees to adopt these same qualities.

Ultimately, a strong mentor serves as a role model, showing new graduates what it means to be a skilled and compassionate respiratory therapist. A good mentor's ongoing impact extends far beyond the first few months on the job—it can positively influence the mentee’s entire career, shaping how they approach patient care and professional development for years to come.

Enhancing Well-being

• Provide access to mental health resources
• Enhancing resilience and work-life balance

A critical way to support employees, especially new graduates, is by providing access to mental health resources. This is particularly important for those who may not yet be fully equipped to handle the high-stress and emotionally taxing environments they encounter. Mental health resources can help them manage the pressures of the job and develop healthy coping mechanisms for these challenges.

These resources might include counseling services, stress management workshops, or mindfulness exercises that incorporate breathing techniques and low-impact, low-intensity activities. Peer support groups can also be valuable, as they foster a culture of openness and support. These groups help reduce the stigma surrounding mental health by reinforcing the message that it is okay not to feel 100% all the time. it is human to have tough days in healthcare, and creating a safe space to acknowledge those feelings can go a long way toward promoting emotional well-being.

A significant part of this support is fostering resilience—the ability to bounce back from challenges. Not every day in healthcare will be easy, and being able to recover from the emotional toll of the work is critical for long-term job satisfaction and mental health. New graduates, in particular, look to more experienced staff to see how they handle the emotional demands of the job. They often wonder, "How do they still do this? How do they prevent burnout?"

Encouraging employees to prioritize self-care and use their paid time off (PTO) is a key aspect of building resilience. Adequate PTO allows staff to step away, relax, recharge, and spend time with family. When they return to work, they are rested, refreshed, and better prepared to face the challenges of patient care. Taking these breaks not only prevents burnout but also reinforces emotional resilience, helping employees maintain a healthier work-life balance.

By promoting the use of mental health resources and encouraging breaks, hospitals and healthcare facilities can help their staff build the emotional resilience necessary to thrive in the long term. This will ultimately lead to better patient care and greater overall job satisfaction.

Impact of Bridging the Gap

• Enhanced therapist confidence and competence
  • Benefit for the educational system: positive perception of student experience can lead to a positive reputation in the community, higher placement rates, and higher enrollment rates
  • Benefit to the healthcare institution: enhanced patient care and employee well-being

Bridging the gap between education and clinical settings has a significant and multifaceted impact, benefiting both the educational system and healthcare institutions.

Impact on the Educational System:
For educational institutions, creating a seamless connection between classroom learning and clinical practice can profoundly impact students' perceptions of their experiences. When students feel well-prepared, confident, and supported during their education, they foster a positive view of their program. This positive perception is often shared through word of mouth, leading to a strong reputation within the community.

A good reputation can drive higher enrollment rates, as prospective students are more likely to choose programs that are well-respected and trusted. Additionally, when students graduate feeling competent and ready to enter the field, it boosts the institution’s placement rates, further enhancing its reputation. As these graduates enter the workforce and interact with others—whether it be phlebotomists, CNAs, transporters, or other healthcare professionals—they often share their experiences. If they speak positively about their education and how prepared they feel, this can inspire others to consider a career in RT, helping to address the current shortage of RTs and meet the increasing demand for respiratory care professionals.

Impact on Healthcare Institutions:
The benefits are just as significant for healthcare institutions. When new graduates enter the workforce feeling confident in their skills and knowledge, patient care is enhanced. Competent, well-prepared RTs are better equipped to provide high-quality care, make informed decisions, and collaborate effectively with other healthcare professionals. This directly contributes to improved patient outcomes and overall patient satisfaction.

When employees feel well-supported—through strong orientation programs, mental health resources, mentorship, and opportunities for professional growth—it positively impacts their well-being and job satisfaction. This can reduce turnover rates, improve employee retention, and foster a healthier work environment where staff feel valued and engaged. Ultimately, this contributes to a more stable and efficient healthcare workforce, which benefits both patients and the institution as a whole.

By bridging the gap between education and clinical practice, both sides stand to gain. The educational system builds a strong, trusted reputation, while healthcare institutions benefit from competent, satisfied employees who deliver better patient care.

Summary

Enhanced patient care leads to better outcomes and a more positive patient experience, which is particularly important when patients are at such a vulnerable and often frightening point in their lives. When RTs are well-prepared and confident, they can help patients feel safe, comfortable, and supported during their stay, contributing to their overall health and recovery. This compassionate, competent care not only benefits the patients directly but also enhances the healthcare facility’s reputation.

A healthcare institution known for providing high-quality care and positive patient experiences gains a competitive advantage in the community. Through word of mouth, a reputation of excellence spreads, making the facility more trusted and respected. In turn, this reputation attracts more patients and strengthens the facility’s standing among other healthcare providers.

Furthermore, this improved quality of care and supportive work environment boosts job satisfaction among RTs. When employees feel competent, valued, and part of a supportive team, it leads to higher employee retention. This means more experienced staff are available to participate in mentorship programs, helping to train the next generation of RTs, which in turn reduces burnout and creates a more resilient workforce.

Fostering continuous learning and professional development becomes easier when RTs are confident and passionate about their work. These student-turned-employees are more likely to seek out opportunities to learn and grow, to take on new challenges, and to contribute more actively to their profession. This enthusiasm for growth is exactly what the field of respiratory therapy needs, especially in times of high demand and workforce shortages.

In summary, bridging the gap between education and clinical practice not only leads to enhanced patient care and better outcomes but also strengthens the healthcare institution’s reputation, improves employee satisfaction and retention, and fosters an environment of continuous learning and professional growth. it is a win-win for everyone involved—patients, healthcare providers, and the field of respiratory therapy itself.

Questions and Answers

What are your ideas for how we can better prepare our tests to reflect real-world scenarios?

While everyone is thinking about that, I personally believe that simply being aware of the gap between classroom knowledge and real-world practice is a crucial first step toward bridging it. Acknowledging this gap helps us take intentional steps to create stronger respiratory therapists in the future. By focusing on real-world applications in testing, we can help the RT profession grow, gain more responsibilities, and become an integral part of the healthcare community. This will contribute to the continued development of advanced practice and master’s programs, which are already starting to take hold.

How can we keep instructors up to date with the latest practices?

I really like this idea that someone brought up—having students help bridge the knowledge gap. I have actually seen this happen in my own experience. For example, a student recently pointed out a new method for sending sputum samples that I hadn’t encountered before. It was eye-opening. We looked into it and discovered it was a newer method designed to prevent contamination. I have also had students update me on the transition to new equipment, like the V60 BiPAP. Keeping an open dialogue with students not only helps them feel empowered but also keeps instructors informed about current practices in the field.

How does reflecting on our own experiences as students help us connect with new graduates?

Someone mentioned how important it is to remember how we felt as students, and I couldn’t agree more. Reflecting on those early experiences really gives us perspective. I remember, as someone with no prior healthcare experience, feeling completely intimidated. The scariest part for me was not necessarily the knowledge—it was talking to patients. Even though I felt confident in the material, applying that knowledge in real interactions was daunting. It is important for us to keep these memories fresh because they remind us of the challenges that new graduates face as they transition from student to practitioner.

Can simulations be used for debriefing sessions or for practice talking to families?

That is a great question! Personally, I haven’t used simulations in that specific way yet. However, I’m scheduled to attend training soon to learn how to use mannequins in a more comprehensive way, beyond just patient care. we have done some role-play scenarios where students practice explaining things to us, and I act as the patient. For example, I pretend I have no medical knowledge and ask questions like, “What does inhalation mean?” This forces students to break down complex concepts into simpler terms. I would love to take this a step further and use mannequins for this kind of communication training as well.

What about incorporating equipment troubleshooting or dealing with technology failures into simulation scenarios? Would that better prepare students for real-world challenges?

Absolutely! That is something I have been considering a lot. Equipment troubleshooting, particularly with mechanical ventilation, can be tricky. Students do not always enjoy learning how to troubleshoot waveforms at first, but it is a vital skill. I use mannequins that simulate changes in compliance and resistance, which have been incredibly helpful in demonstrating these challenges. Additionally, there are online tools that simulate ABG (arterial blood gas) changes in response to different ventilation settings, and those have been a big help as well. It is definitely an area where simulation and technology can significantly enhance student preparedness.

How do you see AI being incorporated into learning and the academic side of respiratory therapy?

That has been a huge conversation lately. When I first started teaching, it was relatively easy to assess students through traditional papers. But with the rise of AI tools like ChatGPT, it is become more complex. Instead of fighting against it, we have adapted and started incorporating AI into our assignments. For example, students can give AI a personality, tell it who they are (e.g., “I’m the respiratory therapist treating you today”), and then interact with the AI as if it were a patient in a clinical scenario. The AI responds as a programmed patient, and it has completely changed how we approach assignments. It is a game-changer for practicing patient interactions.

How is AI being incorporated into hospital systems?

I’m curious about that, too! For those in the audience, it would be interesting to hear how AI has been integrated into the hospital systems where you work. AI is evolving so quickly, and its role in healthcare is only going to grow. it is becoming clear that AI will play a significant part in both clinical practice and education moving forward.

You talked about mentorship, which I think is key. How early do you think mentorship should be started—during education or upon entering the workforce?

That is a great question, and I think the timing depends on what both the student and potential mentors are willing to do. I always encourage students to keep in touch with their clinical instructors, provided the instructor is open to it. Clinical instructors can become excellent mentors even after the formal teaching period is over. However, with instructors and preceptors often working with many students, it can be difficult for them to maintain ongoing mentorship for everyone.

In my experience, formal mentorship typically starts once students are hired at a hospital. That is usually when they are assigned an official mentor to help them transition into the workforce. However, having an unofficial mentor—someone you feel comfortable reaching out to during school or clinical rotations—is never a bad thing. I personally leaned on informal mentors a lot when I was a student, and it made a huge difference.

There are different requirements for graduates when it comes to officially working for us, but we have had past students come back and offer mentorship to current students. Some even leave their contact information on a board so that students can reach out if they need help. We also invite former students to come and talk to our newer students, as well as those about to graduate. They give tips on the interviewing process, what to expect when entering the field, and how to feel more confident about the transition. It is really valuable for students to hear from someone who’s just been through it themselves.

Experience is key throughout your presentation, especially in terms of interdisciplinary education. In the real world, we interact with a variety of professionals—medical students, doctors, nurses, phlebotomists, and others. What are your thoughts on incorporating interdisciplinary experiences into the academic setting to better prepare students for these real-world interactions?

I think it is incredibly important. Interdisciplinary education is essential because, in the real world, we are constantly collaborating with professionals from all areas of healthcare. Whether in a hospital setting or post-acute care, you will encounter medical students, doctors, nurses, phlebotomists, and many others. It is vital to prepare students for these interactions early on, whether through simulation or by providing more education in this area.

Personally, it is one of the reasons I love skills fairs so much—they allow students to present their knowledge to other professions. At the school where I work, we have several other medical career degrees and certificates on campus, and we try to team up as much as possible. My department collaborates with other programs, such as occupational therapy assistant and physical therapy assistant programs, to bring our students together. We aim to simulate real-world scenarios where students from different disciplines can work together, just as they would in a hospital or clinical setting. This kind of collaboration helps them understand how to communicate and share knowledge across professions, which is critical for providing comprehensive patient care.

References

American Association for Respiratory Care. (2023, December 18). Why be an RT? www.aarc.org

Hookmani, A. A., Lalani, N., Sultan, N., Zubairi, A., Hussain, A., Hasan, B. S., & Rasheed, M.A. (2021). Development of an on-job mentorship programme to improve nursing experience for enhanced patient experience of compassionate care. BMC Nursing, 20(1), 175.

National Academies of Sciences, Engineering, and Medicine. (2018). Bridging the education-to-practice gap. In Improving health professional education and practice through technology: Proceedings of a workshop. National Academies Press. https://www.ncbi.nlm.nih.gov/books/NBK532784/National Healthcareer Association. (2023). Bridging the classroom-to-practice gap: How to prepare students for the reality of healthcare. 

Opoku, E. N., Jacobs-Nzuzi Khuabi, L.-A., & Van Niekerk, L. (2021). Exploring the factors that affect the transition from student to health professional: An integrative review. BMC Medical Education, 21(1), 535. 

Shoghi, M., Sajadi, M., Oskuie, F., Dehnad, A., & Borimnejad, L. (2019). Strategies for bridging the theory-practice gap from the perspective of nursing experts. Heliyon, 5(9), e02503.

Sreedharan, J. K., Gopalakrishnan, G. K., Jose, A. M., Albalawi, I. A., Alkhathami, M. G., Satheesan, K. N., Alqahtani, A. S., Alonaiziy, M. M., Alsukhayri, A. A., Alqahtani, S. A., & Alqahtani, A. S. (2024). Simulation-based teaching and learning in respiratory care education: A narrative review. Advances in Medical Education and Practice, 15, 473–486.

Editor's Note: This text-based course is a transcript of the webinar, Multiple Generations In The Workplace: Effective Communication To Enhance Diversity, presented by Ingrid Provident, EdD, OTR/L, FAOTA. 

It is recommended that you download the course handout to supplement this text format.

Learning Outcomes

• After this course, participants will be able to recognize the common characteristics of the different generations in the workforce.
• After this course, participants will be able to identify the best ways to manage the various generations to promote satisfaction and harmony.
• After this course, participants will be able to list different communication styles and the strengths/preferences of each.

Introduction

I want to welcome everyone and thank you for being here today. I hope you find the information helpful.

Generational Makeup of the Workforce

• Traditionalists 
  • (born 1928-1945)
• Baby boomers 
  • (born 1946-1964)
• Gen Xers 
  • (born 1965-1980)
• Millennials/Gen Ys 
  • (born 1981-1996)
• Gen Zs /Gen 2020
  • (born 1997-2012) 

I think we would all agree there is a multi-generational workforce currently in most workplaces, with people from all different generations working together across many industries. It is very commonplace to have a mix of Baby Boomers, Generation X, Millennials, and Generation Z coming together.

There are currently 5 generations in the workplace, although Traditionalists are the smallest group.

Traditionalists

Traditionalists were born between 1928 and 1945, so they are often over 70 years old. However, some in this group still work out of financial necessity because their retirement savings took a hit or simply because they want to remain active.

Traditionalists have been influenced most directly by past workplace environments. They have also been the most vulnerable generation to the physical and mental effects of COVID, so you may have noticed older workers struggling to continue working during the pandemic. Traditionalists have been among the most loyal and dedicated yet risk-averse workers. Their values were shaped by the Great Depression, World War II, and the post-war economic boom. This generation possesses a very strong commitment to teamwork and has a high regard for developing interpersonal communication skills.

They are among the most financially stable elderly population in United States history, largely due to their willingness to conserve and save after the economic impacts of the postwar period.

Baby Boomers

Let's shift to discussing the Baby Boomers. This generation was born between 1946 and 1964. Half came of age during the Vietnam War in the 1960s, while the other half grew up during the political change of the 1970s. As a group, Baby Boomers tend to be distrustful of government authorities, given the political climate when they were growing up. 

Generation X

Generation X was born between 1965 and 1980. They are a much more progressive and educated generation compared to previous ones. Gen Xers are typically very independent people. They were among the first to embrace technology for both educational and entertainment purposes.

Generation Y

Looking at the next generation, Millennials, or Gen Y, born between 1981 and 1996, have been considered one of the most misunderstood generations. They are highly technology-oriented and favor a team-driven environment. Millennials are often considered the generation of multitaskers.

Generation Z

Generation Z, born between 1997 and 2012, is the youngest generation currently in the workforce. They often cannot go a day without technology access on their devices. Their smartphones have as much computing power as the bulky desktop computers older generations first embraced. Gen Z is considered highly interconnected, with social circles encircling the globe. They think nothing of having friends in different countries and constantly communicating via various online platforms.

Generational Workforce Statistics 

Let's examine some statistics on the generational makeup of the workforce as shown in Figure 1.

Figure 1. Generational makeup of the workforce.

This chart shows the career drivers, work styles, and percentage of each generation currently in the workforce as of 2020. It also projects the percentages for 2025, which show some shifts occurring mostly with the oldest and youngest generations.

Baby Boomers

Baby Boomers are the first generation to actively prioritize work over personal life. They distrust authority and large organizations. Their values were shaped by the rise of civil rights and the Vietnam War era. Boomers are optimistic yet responsible for the “Me Generation” moniker.

As parents of Gen X, their career drivers are a strong work ethic and company loyalty, hoping for financial stability through pensions and 401Ks. Their work style tends towards delegating and teamwork, believing you should pay your dues and work up the ladder.

In 2020, Boomers comprised 33% of the workforce, but are projected to shrink to just 5% by 2025 due to retirements.

Generation X

Generation X has been called the “slacker” generation but also the “sandwich” generation. They question authority but initiated the concept of work-life balance, unlike their career-driven Boomer parents.

Born into declining population growth, Gen Xers possess strong technical skills and more independence than previous generations. They prioritize work less, leading older Boomer managers to sometimes question their dedication. However, Gen Xers follow rules and are resourceful, innovative, and driven to develop niche skills that allow them to take on challenges. They are perceived as adaptable and less concerned with long-term job stability, changing jobs readily.

In 2020, Gen X was about 32% of workers, remaining steady at around 20% by 2025.

Millennials/Gen Y

Millennials or Gen Y are the first truly global generation, coming of age during rapid internet growth and rising international terrorism. They adapt well to change and deeply value diversity and inclusion. Their educational opportunities expanded significantly due to tech advances during their upbringing.

Millennials are considered the most teamwork-oriented generation today. They grew up heavily programmed by parents with structured activities, while Boomer parents intensely focused on careers. Millennials are our most optimistic generation.

Their percentage in the workplace has remained relatively stable at around 30-35%.

Gen Z

Generation Z is gradually replacing the retiring Veteran Generation. They are our youngest employees, comprising about 5% of the workforce in 2020 but estimated to rise to over 20% by 2025. Gen Z is highly concerned about financial security. They are more pragmatic than Millennials and thrive when given clear direction through step-by-step coaching and frequent face-to-face communication with leadership. Since Gen Z will make up the largest percentage of the 2025 workforce, paying attention to their needs can greatly benefit companies looking to expand.

This chart shows the generation workforce shifts (Figure 2).

Figure 2. Generation workforce shifts.

This chart illustrates the population shifts in the United States over the years 2010, 2015, and 2020. The graphs use different colors to represent each respective year: yellow for 2010, gray for 2015, and darker gray, almost shading towards black, for 2020.

The data indicates that the Baby Boomer generation (born between 1946 and 1964) is experiencing a decline in population percentage due to natural aging. Gen Xers (born between 1965 and 1980) have remained relatively steady but occupy a lower portion of the percentage. Meanwhile, Millennials (born between 1981 and 1996) are gradually increasing in population share, reflecting their growing presence in the US population. Additionally, Generation Z (born between 1997 and 2012) is also witnessing a rise in population percentage.

Please note that this data is specific to the year 2020 and does not project beyond that year. To obtain the latest and most comprehensive population information, it is advisable to refer to up-to-date sources from reputable organizations.

Generational Events

Let's explore some major historical events occurring during each generation's formative years, which helped shape their perspectives (Figure 3).

Figure 3. Major events for each generation.

• Traditionalists - The 1937 Hindenburg explosion, WWII beginning in 1941, and WWII ending in 1945. Overall, many wars and tragedies.
• Baby Boomers - Jackie Robinson breaking baseball's color barrier in 1947, the Korean War in 1950, JFK's assassination in 1963, and the Vietnam War ramping up in 1965.  
• Gen X - The 1969 moon landing, 1969 Woodstock festival, 1970s women's liberation movements, the 1973 global energy crisis, and the 1979 Three Mile Island nuclear accident.
• Millennials - The HIV/AIDS crisis, 1986 Chernobyl disaster, 1987 stock market crash, fall of the Berlin Wall in 1989, Columbine High School shooting in 1999.
• Gen Z - 2000 Y2K scare, 9/11 attacks in 2001, Iraq War starting in 2003, Hurricane Katrina in 2005, Obama elected president in 2008, legalized same-sex marriage in 2015, COVID-19 pandemic beginning in 2019.

You can see how major historical events during these formative years likely shaped societal perspectives to some degree for each generation.

Compelling Generational Messages

What were some of the compelling societal messages dominating during these generations’ upbringings? Figure 4 shows an overview.

Figure 4. Overview of compelling generational messages.

During the formative years of each generation, they experienced significant historical events that shaped their perspectives and beliefs.

Traditionalists

The traditionalists, born before 1946, witnessed events like the Hindenburg tragedy and World War II, which emphasized sacrifice and unity for the common good. They were told to "make do or do without" and to be heroic during challenging times. Their technology was limited to the transistor radio, which provided them with news and information.

Baby Boomers

Baby boomers, born between 1946 and 1964, saw the desegregation shift in major sports like baseball when Jackie Robinson joined the Major leagues. They lived through significant events like the Korean War and the assassination of President Kennedy. They were encouraged with messages that they could change the world and work together for a better future. The introduction of the first transistor radio allowed them to access real-time information.

Generation X

Gen Xers, born between 1965 and 1980, witnessed the moon landing and Woodstock, events that influenced their sense of exploration and questioning authority. They experienced the energy crisis and the advent of personal computers. They were encouraged to be independent, question authority, and were told that heroes don't exist. The introduction of personal computers provided them with a new way to explore information.

Millennials

Millennials, born between 1981 and 1996, lived through events like the fall of the Berlin Wall and the 9/11 terrorist attacks. They received messages that they were special, should achieve now, and be good citizens. The education system became more inclusive, and they were connected 24/7 through the internet. The expansion of technology, particularly the internet, provided them with access to vast information.

Generation Z

Gen Z, born after 1997, grew up in a culturally diverse and globally connected world. They became adept at multitasking and had instant access to information through smartphones and the internet. They received messages of empowerment and inclusivity. Technology, especially smartphones and portable devices, became an integral part of their lives. Each generation's experiences and the messages they received during their formative years contributed to shaping their unique characteristics, perspectives, and attitudes toward the world around them.

These events and messages played a crucial role in molding each generation's values, beliefs, and understanding of the society they grew up in.

Challenges Vs. Opportunities

• Baby boomers or Traditionalists can see younger employees as children and act parental.
• Gen X or Gen Y in management may treat older employees as parents/grandparents.
• Managers not holding them accountable.
• Identifying and addressing these differences can reap the benefit of multi-generational strengths.

These generational differences understandably can pose significant workplace challenges. For example, there is a tendency for older employees to view younger workers almost as their own children, acting in a parental rather than professional manner of accountability.

Conversely, when younger employees step into leadership roles overseeing older staff, they may feel as if they are managing their parents or grandparents. It takes substantial emotional intelligence and communication skills to navigate these multi-generational dynamics. 

For managers and HR professionals especially, it is crucial to understand and appreciate generational differences, along with the influences shaping various age groups. Subtle similarities exist across generations, and healthcare workplaces can benefit greatly when generational diversity is managed effectively, drawing out the unique skills and talents of each age group more fully than a homogenous workforce could. Understanding how to lead different generations and tailor to their needs can foster greater harmony and satisfaction.

Strategies to Effectively Lead and Manage the Various Generations in the Workplace

Understanding the different generations' values and preferences in the workforce can lead to more effective and harmonious interactions.

For Gen Z, active listening and valuing their input are crucial, as they often think outside the box and have unique perspectives. Offering creative work environments can attract them to an organization, especially as they are projected to make up a significant portion of the future workforce.

Veteran/Traditionalists

• Value their experience
• Spend adequate time in orientation and training activities
• Extra time w/ technology
• Respect common norms of courtesy

For veterans or traditionalists, it's crucial to recognize the value of their experience and provide adequate training to adapt to technological changes. Respecting their preferences for face-to-face interactions and common norms of courtesy fosters a positive work environment for them.

Baby Boomers

• Show them how they can be an organizational star
• Provide them with developmental opportunities
• Involve them in operational matters.
• Phased Retirement
• Health / Wellness Programs

Baby boomers appreciate recognition and involvement in operational matters, and offering flexible work options and health and wellness programs can help retain them.

Generation X

• Partner them with mentors that they respect
• Promote work/life balance
• Refrain from giving them too much extended hands-on supervision.
• Reward for productivity

Gen Xers thrive when partnered with respected older colleagues and prefer a work-life balance. Providing clear instructions and allowing them autonomy in their tasks enhances their productivity.

Generation Y/Millennials

• Provide them with structure
• Be generous with training and orientation activities
• Partner them with boomers as mentors

For millennials, structured training and orientation activities are essential, and pairing them with boomer mentors can be beneficial. Listening to their ideas, encouraging creativity, and providing spaces for them to be innovative cater to their preferences.

Generation Z

• Channel their creativity/Listen to their ideas
• Encourage them to communicate outside of technology 
• Provide pleasant working environments
• Projected to make up the largest % of the workforce by 2025

For Gen Z, active listening and valuing their input are crucial, as they often think outside the box and have unique perspectives. Offering creative work environments can attract them to an organization, especially as they are projected to make up a significant portion of the future workforce.

The Generations At Work

• Not everybody in the workplace is motivated by the same things anymore.
• Getting the most out of each generation requires flexibility.
• When companies get it, both the company and the employees win.

It is important to recognize that not all employees are motivated by the same factors. This allows organizations to be flexible and cater to the needs of each generation. When companies understand and meet these needs, it leads to a win-win situation, reducing turnover and fostering a positive and productive work environment. By acknowledging and adapting to the preferences of different generations, organizations can create a more cohesive and successful workforce.

Evidence of Conflicts

• “They have no work ethic. They’re a bunch of slackers.”
• “So I told my boss, if you’re looking for loyalty, buy a dog.”
• “If I hear, ‘We tried that in ‘87 one more time, I’ll hurl.’”
• "I have a new rule. I will not attend meetings that start after 5 PM - I have a life.”
• “Lighten up! Work should be fun.”
• “Many of the interviewers did not understand my windy path through employment, which is, of course, a characteristic of my generation. They didn’t understand I wasn’t looking for one job for the rest of my life and that I wasn’t looking for money and status.”

When encountering statements or attitudes like "they have no work ethic" or "they're a bunch of slackers," especially if they are attributed to specific generational groups, it may indicate a lack of understanding and communication between different generations in the workplace. These perceptions can stem from stereotypes and generalizations that may not accurately represent individuals within those groups. Such sentiments suggest a need for better intergenerational understanding and collaboration.

The expression "if you're looking for loyalty, buy a dog" reflects a desire for a more meaningful and purpose-driven work experience, where employees seek reasons behind tasks and may challenge traditional hierarchical structures. This kind of attitude might arise from the perspective of a younger generation seeking more fulfillment and growth in their careers.

Furthermore, individuals from different generations may have diverse career paths and expectations. Some may prefer stability and loyalty to one employer, while others seek varied experiences and opportunities for personal and professional development. Understanding these differences is essential for organizations to attract and retain the right talent.

It is crucial for employers to be mindful of the language used during interviews and the questions asked to attract individuals who align with the organization's long-term goals and values. Recognizing and valuing diverse career paths and motivations can lead to a more inclusive and harmonious work environment where employees from all generations can thrive. Building bridges of understanding and open communication between generations can foster a culture of respect and collaboration, ultimately benefiting the organization as a whole.

Generational Perspectives: A Quiz 

Let’s explore our own generational perspectives a bit. I will ask some simple poll questions where you can select the choice that best fits you (Poll generated during the live event).

1. Which of the following is your preferred communication style in the office?

A. In person

B. Phone/e-mail

C. E-mail/texting

D. Texting

The majority of respondents prefer in-person communication, followed by phone/email. Only a small percentage favors just texting. This indicates a preference for personal interaction over digital-only contact.

2. How do you define your work-life balance?  

A. I don’t have one: long hours to maintain job security

B. I don’t have one: long hours = identity/sense of contribution

C. I have a balance

D. I’m working on it

Most respondents are working on achieving better balance, implying a desire for greater equilibrium. Very few view work as fully defining their identity. Over a third believe they have attained a good work-life blend, which provides hope it is possible.

3. What is your idea of a reward for a job well done?

A. Pat on the back

B. Money, title, recognition

C. Freedom – day off

D. More meaningful work/projects

The top choice was monetary or title/recognition rewards – extrinsic, tangible forms of appreciation. Almost equal numbers favor more freedom/time off or simply verbal praise. A smaller but meaningful segment finds meaningful work itself the biggest reward. 

4. Why would you change jobs or companies?

A. Wouldn’t - company loyalty

B. To do something different

C. It’s necessary

D. Routine

No one would change jobs routinely as part of strategic career planning. The reasons were evenly split between required moves for more money or different opportunities and loyalty to a current workplace. This conveys both pragmatic and idealistic motivations for leaving a position.

Overall these informal polling questions can provide insights into multigenerational preferences that may inform management approaches for optimal satisfaction. Hearing directly from employees is ideal.

Challenges for Managers

What do members of each generation seek that managers can address?

Figure 5. Challenges for managers for each generation.

Each generation presents unique challenges for managers and supervisors in the workplace. Understanding the different outlooks and characteristics of each generation can help managers tailor their leadership approach and create a harmonious work environment.

Traditionalists

For traditionalists, managers should recognize their dedication to work and value their experience. Providing adequate training and orientation, especially in the face of changing technology, will ensure their success in the evolving workplace.

Baby Boomers

Baby boomers, driven and ambitious, thrive when given opportunities to showcase their skills and be involved in operational matters. Offering phased retirement or flexible work options can help retain their expertise while respecting their desire for work-life balance.

Generation X

Gen Xers appreciate competent leaders and desire a balanced work-life approach. Managers should give them space to excel and avoid excessive supervision, acknowledging their competence and providing clear expectations.

Millennials

Millennials prefer collaborative leadership and a sense of equality within the team. Managers should focus on building strong teams and recognizing individual contributions. Offering flexible work arrangements, wellness programs, and opportunities for personal growth can boost their loyalty and engagement.

Generation Z

Gen Zs seek respect and authenticity in relationships with authority figures. Coaching and mentoring programs, with experienced colleagues rather than direct supervisors, can help them navigate the workplace and develop their potential.

Managers should be mindful of factors that may turn off each generation, such as vulgarity for traditionalists, political incorrectness for baby boomers, cliques for Gen Xers, cynicism for millennials, and inequality for Gen Zs. Being sensitive to these preferences can foster a more inclusive and supportive work environment.

Recruiting and Retaining Talent

• Time off as opposed to increased compensation
• Wellness Programs
• Mentoring
• Opportunities for remote work

To recruit and retain talent, offering time off, wellness programs, and mentoring opportunities can be effective strategies. Providing opportunities for remote work, where feasible, can also cater to the increasing desire for flexibility among different generations.

By understanding and adapting to the diverse needs and perspectives of each generation, managers can create a cohesive and productive workforce, leading to greater job satisfaction and reduced turnover.

To recruit and retain our Gen Xers, millennials, and Gen Zs, there are some specific strategies.

Generation X at Work: Recruit and Retain

• Show them lots of options for their workplace schedule.
• Allow them to work autonomously.
• Tap into their adaptability. Generation Xers are typically flexible, and many are independent operators. Give them an important task that needs to get done; they’ll likely get it handled!
• Give FAST (Frequent, Accurate, Specific, Timely) feedback in order for them to build their skills and improve their resumes.

Gen Xers highly value workplace schedule options and flexibility, allowing them to work autonomously and adapt to different situations effectively. When assigning them important tasks, it's essential to give them the necessary time to accomplish them.

In terms of feedback, the FAST acronym is ideal—providing frequent, accurate, specific, and timely feedback helps them develop their skills and seize greater opportunities for growth.

Millennials / Gen Z at Work: Recruit and Retain

• Tap an outstanding employee from the Millennial or Gen Z Generation to talk to the candidate about the company.
• Provide flexibility to allow them to pursue their many outside interests.
• Get them involved in meaningful volunteer efforts. These workers are community-oriented and are graduates of required community service hours.
• Count them in on benefits like 401(k) plans. Millennials and Gen Z are financially savvy.
• Use their capability to access and share information quickly. This is the most technologically and globally aware generation.
• Pair them up with older mentors.
• Help them learn interpersonal skills for the workplace. They may need to be rescued from difficult situations while they develop these skills.

For millennials and Gen Zs, certain factors can encourage them to stay in the workplace. Ensuring diverse representation during the talent attraction process is crucial; they appreciate having someone from their generation who can relate to them during interviews. Flexibility remains a significant appeal, and incorporating volunteer efforts aligns with their civic-mindedness. Providing opportunities for one paid day to engage in community-oriented projects resonates well with them.

These generations are financially savvy, so discussing 401K plans and other benefits is important, especially since many may have student loans to manage. Utilizing technology for information sharing is essential, given their tech-savviness. Mentoring programs can assist in nurturing their interpersonal skills, as they might excel with technology but require guidance in social situations.

What is in Common? 

• Flexibility is important regarding work-life balance.
• The highest indicator of satisfaction is to feel valued on the job.
• Career development is a high priority.
• A supportive work environment where they are recognized and appreciated with rewards for results.
• And, most importantly, all generations value trust and want respect.

All of our groups share common desires and priorities. They value flexibility and work-life balance, seeking job satisfaction and feeling valued in their roles. Understanding the rewards that motivate each individual is essential for effective management. Career development is particularly significant for the younger generations, as they aspire to progress and achieve their goals within the organization. A supportive work environment, where recognition and rewards align with their values, is crucial. They also appreciate being trusted and respected, and in turn, they reciprocate that trust and respect to their colleagues. Building a workplace that caters to these common needs can enhance employee satisfaction and retention across all generations.

General Strategies

• Provide structure
• Provide leadership/guidance/coaching
• Create Opportunity for “Can do Attitude” – Set up Success
• Reward Team Work
• Provide Work/Life Balance
• Seek Feedback/Listen
• Employee Centered Workplace

General strategies for managing and guiding these generations include providing a structured environment with clear expectations. Adopting a coaching approach to leadership rather than a rigid directive style is beneficial. When giving feedback, it's essential to recognize and highlight their strengths. Creating a culture that allows for learning from mistakes and turning them into valuable lessons is crucial. Rewarding teamwork and recognizing the contributions of the entire team, rather than solely focusing on individuals, aligns well with the collaborative nature of younger generations. By implementing these strategies, managers can foster a positive and productive work environment for Gen Xers, millennials, and Gen Zs.

Professional Communication

• Essential for Working Relationships
• Correlated with Positive Patient Outcomes
• Healthcare Workers Satisfaction or Stress
• Patient Safety
• Public Satisfaction

Effective communication has been linked to positive patient outcomes, increased worker satisfaction, improved safety, and a positive perception of our organizations in the public domain. Various communication style inventories are available to assess and enhance communication skills.

Self Assessment of Personal Communication Style

• When is the last time you took the time to assess your own communication style?
• What color is your brain?
  • Based on the work of Sheila Glazov
  • Brief assessment with no right or wrong answers
  • The outcome provides you with your dominant brain color
• https://www.sheilaglazov.com/brain-quizzes/

You may be familiar with popular communication style assessments like Myers-Briggs, but I would recommend exploring a different one based on the work of Sheila Glaszov. This brief assessment is easy to take, and there are no right or wrong answers. By participating in these free brain quizzes or color brain quizzes, you can discover your dominant communication style outcome.

Four Distinct Brain Colors

• Yellow Brainers are responsible, organized, stressed w/ disorganization, and direct communicators; 30-40% of people
• Blue Brainers are communicative, helpful, tend to over-extend themselves, yet are inspirational; 30-40% of people
• Green Brainers are logical, independent, stressed when they do not have adequate resources and value efficiency; 10-15% of people
• Orange Brainers are dynamic, fun-loving, more informal communication style, and do not like monotony; 10-15% of people

According to this inventory, there are four distinct brain colors, with yellow and blue brains being the most predominant, making up around 30 to 40% of the population each. Yellow brain individuals are known for their responsibility and organizational skills. They prefer direct communication and appreciate receiving factual information.

On the other hand, blue brain individuals are communicative, helpful, and often inspirational. They have a tendency to overextend themselves in their efforts to assist others.

Green brain individuals, comprising about 10 to 15% of the population, are described as logical, independent, and efficient. They value having adequate resources and can experience stress when faced with insufficient support.

The remaining 10 to 15% of the population are orange brains. They are dynamic, fun-loving, and prefer an informal communication style. Orange brains are often creative individuals who enjoy storytelling when sharing information, and they thrive in environments that offer variety and avoid monotony.

It's worth noting that individuals may possess a specific brain color regardless of their generational affiliation, as brain color and work style can differ even within the same generation.

Ideal Conditions in the Workplace

• Once you determine your dominance and the dominance of those on the team, you can create work conditions that play to the strengths of the team members
• Remember People Thrive when their attributes and abilities are acknowledged

Acknowledging and embracing the diversity of communication styles in the workplace can have a significant impact on both effective communication and potential miscommunication. When individuals are aware of their dominant communication style and recognize the dominant styles of their colleagues, leaders, managers, and team members, this can create a work environment that capitalizes on the strengths of each individual.

By understanding and appreciating the unique attributes and abilities of each team member, leaders can tailor work conditions to allow employees to thrive in their roles. This recognition fosters a positive work culture that values and encourages individual styles, leading to improved communication, collaboration, and overall team performance.

When individuals feel acknowledged and supported in their particular communication style, they are more likely to feel engaged and motivated in their work, leading to increased productivity and job satisfaction. Embracing diversity in communication styles can create a cohesive and harmonious workplace that maximizes the potential of all team members.

When Communicating To:

• Yellow Brainers
  • Be Polite and punctual
  • Respect their personal values of organization and rules
  • Stay on track
  • Tell them all the details
  • Encourage them to talk about their achievements
• Blue Brainers
  • Show you are actively Listening
  • Respect their emotions
  • Use stories to explain your point of view
  • Connect with them personally
  • Encourage them to talk about their family
• Green Brainers
  • Do not make small talk
  • Respect their privacy
  • Be brief, but informative
  • Give them lots of data and statistics
  • Encourage them to talk about their knowledge and offer solutions
• Orange Brainers
  • Be direct
  • Respect their spontaneity
  • Make your point quickly
  • Give them the results, not facts and figures
  • Encourage them to talk about their personal lives (hobbies or vacations)

Tailoring communication to the different dominant brain styles can greatly enhance understanding and collaboration in the workplace. When communicating with yellow-brained individuals, it's essential to be polite, punctual, and organized, as they value structure and adherence to rules. Staying on track and providing details while encouraging discussions about their achievements can be effective strategies to engage them.

For those with a dominant blue brain, active listening is crucial, as they often express emotions and appreciate stories. Connecting with them personally and showing interest in their lives outside of work fosters a positive rapport.

Conversely, green-brained individuals prefer brief and informative communication, focusing on data and statistics. Encouraging discussions about their knowledge and proposed solutions aligns well with their style.

Orange-brained individuals prefer direct communication and tend to be spontaneous. Providing quick, results-focused messages without delving into extensive facts and figures is more effective when interacting with them. Engaging in conversations about hobbies, vacations, and personal lives can help build rapport with orange-brained individuals.

By understanding and adapting communication approaches to these dominant brain styles, leaders, managers, and team members can promote a more harmonious and productive work environment where each individual feels acknowledged and valued for their unique attributes and preferences.

How to Stay Motivated

• Yellow Brainers
  • Keeping a positive attitude
  • Scheduling time off to re-charge
  • Taking on a new task: "I know I can do it”
• Blue Brainers:
  • Performing tasks they enjoy doing
  • Developing friendships with other team members
  • Tapping into their creativity
• Green Brainers
  • Taking continuing education classes
  • Being able to research new ideas
  • Scheduling time to read books and articles
• Orange Brainers
  • Doing something new each day
  • Scheduling time for fun and exercise
  • Enjoying social activities with team members outside of work

To effectively motivate individuals with specific dominant brain mindsets, it is essential to understand their preferences and tailor the motivational approach accordingly.

For yellow-brained individuals, creating a positive work environment, acknowledging their organizational skills and adherence to rules, and providing time off for rejuvenation are key factors. Assigning tasks that align with their optimistic outlook and validating their confidence in their abilities will also boost their motivation.

For blue-brained individuals, encouraging them to focus on tasks they enjoy and excel at, fostering positive social interactions within the team, and tapping into their creativity are important strategies. Offering projects that inspire them and allow them to showcase their inspirational abilities will further motivate them.

Green-brained individuals thrive on learning and logical thinking. Providing opportunities for continuing education, encouraging exploration of new ideas, and offering tasks involving data analysis and critical thinking will keep them motivated. Allowing time for them to engage in learning activities that promote growth is equally essential.

For orange-brained individuals, incorporating novelty and new experiences into their daily tasks, scheduling fun and social activities, and involving them in planning and organizing social events are effective ways to keep them motivated. Providing opportunities for them to take on exciting challenges regularly will further fuel their enthusiasm.

By recognizing and catering to the unique preferences and strengths of each dominant brain style, leaders and managers can create a motivational work environment where team members feel valued and engaged, leading to increased job satisfaction and overall performance improvement.

Motivating Others- Often The Way You Are Wired

• Yellow Brain
  • Praise/acknowledge achievements
  • Demonstrate excellence
  • Expect the best from the team
• Green Brain
  • Set reasonable goals
  • Offer incentive or education
  • Fair feedback
• Blue Brain
  • Good job gifts
  • Share inspirational stories
  • Showing interest in life outside work
• Orange Brain
  • Team celebrations
  • Contests w/in department
  • Giving pep talks

Understanding how to motivate others is crucial because people's preferences for motivation can differ significantly. It's a common mistake to assume that what motivates us will work for others. Tailoring motivational approaches to individual brain styles can yield better results.

For yellow-brained individuals, praise and recognition for their achievements are powerful motivators. They appreciate when their excellence is acknowledged and expect the best from their team.

Blue-brained individuals value tangible rewards and gifts as symbols of appreciation. Sharing inspirational stories, both personal and from others, can boost their motivation. Showing interest in their life outside of work also fosters a positive connection.

Green-brained individuals thrive when goals are reasonable and attainable, with incentives to work towards. They value fair and balanced feedback, encompassing both positive recognition and constructive criticism.

Orange-brained individuals excel when team celebrations and fun contests are organized within the department. Pep talks and encouragement make them excellent cheerleaders within the workforce.

By recognizing and catering to these unique preferences, leaders can create a motivating work environment where individuals feel valued, leading to increased engagement and overall productivity.

Takeaways

• Strive to develop empathy and understanding of generational characteristics – ultimately, the organization will be more effective and profitable
• Team diversity can breed great success – this variety of experience provides essential tools to handle challenges faced by an organization
• We do not all communicate the same nor do we see situations from the same point of view.
• Becoming knowledgeable of the differences can allow us to enjoy the rainbow of generational cohorts and brain colors in today’s workplace.

In conclusion, the key takeaways from this presentation emphasize the importance of developing empathy and understanding for the different generations within our organizations. Respecting and embracing the diversity of communication styles and experiences in the workplace can lead to enhanced effectiveness and profitability. By fostering diverse teams with people of different ages and brain colors, we gain valuable tools to overcome various challenges.

Recognizing that we all have unique ways of communicating and perceiving the world, shaped by our experiences and upbringing, enables us to respect and appreciate one another. Becoming knowledgeable about our differences allows us to build stronger connections based on generational and brain dominance attributes, ultimately bringing out the best in our workplace.

For further reference, the sources used in creating this presentation are listed. If you have any questions or concerns, please feel free to email me at the provided address. Thank you for your time and attention.

References

Arrington, G., & Dwyer, R. (2018). Can four generations create harmony within a public-sector environment? International Journal of Applied Management and Technology, 17:1, 1-21.

Baik, D., Blakeney, E. A-R., Willgerodt, M., Woodard, N., Vogel, M., & Zierler, B. (2018). Examining interprofessional team interventions designed to improve nursing and team outcomes in practice: A descriptive and methodological review. Journal of Interprofessional Care, 32, 719-727. https://doi.org/10.1080.13561820.2018.1505714

Christensen, S. S., Wilson, B. L., & Edelman, L. S. (2018). Can I relate? A review and guide for nurse managers in leading generations. J Nurs Manag, 00:1–7. https://doi.org/10.1111/jonm.12601

Clark, K. R. (2017) Managing multiple generations in the workplace. Radiol Technol, 88(4):379-396. PMID: 28298496.

Glazov, S., & Knoblauch, D. (Eds.). (2015). What color Is your brain? When caring for patients: An easy approach for understanding your personality type and your patient’s perspective. SLACK Incorporated.

Hisel, M.E. (2020) Measuring work engagement in a multigenerational nursing workforce. Journal of Nursing Management, 28(2), 294-305.

Lewis, L. F., & Wescott, H. D. (2017). Multi-generational workforce: Four generations united in lean. Journal of Business Studies Quarterly, 8(3), 1.

Editor’s note: This text-based course is an edited transcript of the webinar, Staying Grounded Through Workplace Trauma, presented by Ten'Niquwa "Nikki" Bryan, M.S in I/O Psychology. 

It is recommended that you download the course handout to supplement this text format.

Learning Outcomes

After this course, participants will be able to:

• List strategies to identify workplace trauma, individually and as a team
• Identify the effects of workplace traumas on RTs
• Discuss how to optimize work-life balance during and post workplace trauma

I am an Industrial Organizational Psychologist, commonly known as an I/O Psychology Practitioner. I specialize in various areas within I/O Psychology, but my primary focus lies in partnering with companies and organizations to prioritize their workforce's well-being by fostering a healthy work-life balance and equality.

My expertise extends to leadership development, organizational enhancement, optimizing workplace efficiency, and enhancing employee contentment. Through my company, I am committed to collaborating with leaders across sectors such as healthcare to bridge the gap between management and employees. I achieve this through intuitive coaching and evidence-based consulting practices.

Through extensive research, I have concluded that mindset and emotions play integral roles in our daily endeavors. Moreover, I have observed a reluctance to address workplace trauma despite its prevalent occurrence. It is crucial to acknowledge and tackle these issues to ensure organizational vitality.

Over recent years, there has been a notable shift towards recognizing the significance of human capital within organizations. The maxim, "The organization's most valuable resource is its human resource," has gained widespread acceptance. It is encouraging to witness management increasingly prioritize the human element.

Acknowledging and addressing loss, grief, and trauma in the workplace contributes to overall employee well-being. Failure to do so can impede organizational efficacy. Before delving further, I extend my gratitude to you for joining us and investing in your personal development. Whether you have attended my presentations in the past or not, I commend all frontline workers, particularly those in healthcare, for their resilience during the unprecedented challenges posed by the COVID-19 pandemic.

The Triggers

Allow me to express collective gratitude for your service. As we proceed with today's presentation, I encourage everyone to take notes actively. Alongside the information I will be imparting, I urge you to also introspect on your feelings, thoughts, emotions, and any triggers you may identify. While being trauma-informed is crucial, understanding how to respond when confronted with trauma is paramount. In the event that you find yourself profoundly affected or triggered for any reason, rest assured that professional support is readily accessible. I strongly advise you to seek assistance if such a situation arises. Your well-being is of utmost importance.

What is Workplace Trauma?

Before delving into the intricacies of workplace trauma, let's first establish a clear understanding of what trauma entails. Trauma is a component of a trilogy: loss, grief, and trauma. Loss refers to events such as the loss of life or a sense of security, while grief encapsulates the emotional response to such losses. Trauma, on the other hand, manifests as psychological or physical wounds inflicted by these losses. Psychological trauma can affect anyone, regardless of background or circumstance; no individual is immune to its impact.

In the workplace, the inevitability of trauma looms. Workplace trauma, also known as career trauma or workplace PTSD, manifests as an emotional reaction to adverse events encountered in a professional setting. These events encompass accidents, natural disasters, and exposure to toxic work environments. It is not uncommon for individuals to experience some form of workplace trauma during their careers. Whether enduring a hostile work environment, suffering from bullying or harassment, or witnessing violent acts, the toll on one's mental health can be significant. If any of these scenarios resonate with you, gaining clarity on the concept of workplace trauma is paramount.

Workplace trauma can be defined as the physical or psychological harm inflicted upon employees while on the job. It spans from witnessing traumatic incidents to experiencing violence or abuse firsthand. Its impact should not be underestimated, as it can severely impair job performance and even result in job loss. Now, let's explore the root causes of workplace trauma.

Firstly, it is important to acknowledge that trauma can affect entire communities. For instance, disasters like global pandemics, such as COVID-19, or natural calamities like hurricanes or floods can have widespread traumatic repercussions. Allow me to share a personal experience: I hail from the U.S. Virgin Islands, and in 2019, Hurricanes Irma and Maria wreaked havoc across the Caribbean. On Saint Thomas, one of the Virgin Islands, the local hospital faced dire circumstances. Operating solely on generators, half of the facility lay in ruins with no roof, and the entire structure was condemned. Nurses and doctors turned to social media, desperately pleading for aid. Their anguish was palpable, evident in their heartfelt pleas and the agonizing choices they faced regarding patient care amidst scarce supplies, electricity, and staffing shortages.

The aftermath of such disasters extends beyond the hospital's confines. With homes condemned and transportation hindered by fuel shortages, the entire island community bore the brunt of the catastrophe. Spanning a mere 3,200 square miles, options were limited, with only one hospital serving the entire area. Its condemnation marked a traumatic event for all involved.

Furthermore, trauma encompasses a spectrum of experiences, including technological breakdowns or deliberate acts of violence like mass shootings or perceived threats. It is crucial to recognize that trauma can be induced by threats alone, without the occurrence of an actual event.

Moreover, it is not just the breadth of loss factors that warrants attention; the depth of loss is equally significant. Loss experiences can profoundly impact individuals, groups, or organizations, potentially resulting in life-altering consequences or irreversible turning points. While addressing death-related issues in the workplace is crucial, it is equally vital to acknowledge a wide array of significant losses unrelated to death. These may include divorce, disability, chronic illness, victimization, or layoffs, each capable of shattering confidence and sense of security, plunging individuals into states of trauma.

Causes of Workplace Trauma

• Hostile work environment
• Being the victim of bullying or harassment
• Witnessing a violent act
• Being the victim of violence or abuse
• Non-life-threatening injuries
• Emotional abuse
• Workplace relationships/breakups
• Intimidation
• The experience of being fired
• Microaggressions and misogyny

Facing workplace trauma or any other form of trauma can be deeply distressing. The range of experiences listed—from hostile work environments to emotional abuse and beyond—underscore the multifaceted nature of trauma in professional settings. You may say, "Nikki, I have experienced workplace trauma and other traumas. I do not like it. I do not like how it makes me feel. Why is this even important?' Well, I am glad that you asked, and this is why we are here to talk about the effects of workplace trauma.

Now, let's address why understanding and addressing workplace trauma is paramount. By delving into the effects of workplace trauma, we shed light on its significance. Through this dialogue, we aim to foster awareness and provide strategies for coping and healing. Your willingness to engage in this conversation is commendable, and together, we'll explore the profound impact of workplace trauma and avenues for resilience and recovery.

Importance of Identifying Workplace Trauma

Identifying workplace trauma serves a dual purpose: it acknowledges that something has impacted you as an employee or clinician while reassuring you that you are not alone in facing these challenges. Establishing a trauma-informed workplace culture equips employees like yourself with the tools to comprehend their trauma and encourages them to seek treatment or support confidently. Furthermore, it enlightens managers on how to support their team members better, fostering a culture capable of navigating crises effectively—inevitable challenges we'll all encounter at some point. It is crucial to cultivate a culture that stands by its clinicians during trying times, both present and future. Preparing to address trauma before it occurs is key; being trauma-informed means having a plan of action in place for when challenges arise.

Reflecting on your workplace, are you aware if It is trauma-informed? Has this topic been broached in team meetings or training sessions? In my discussions with various healthcare professionals, it seems that trauma-informed practices are not widely implemented in settings such as doctor's offices, hospitals, or clinics. This highlights the need for broader awareness and adoption of trauma-informed approaches across all sectors of healthcare.

Case Study

• Ashley, Black Female
• Cardiologist office
• Racism
• Fear of being fired/Fired for whistle-blowing

Ashley, a Black female employed as a Certified Medical Assistant (CMA) at a cardiologist's office, endured distressing experiences of racism and feared reprisal for speaking out against injustice. She revealed that the doctor she worked for harbored animosity towards Black and Brown individuals, particularly his own employees. Ashley recounted instances where the doctor blatantly avoided interacting with anyone of Black or Brown descent.

In the workplace, it was customary for employees to inform the doctor of patients awaiting consultation. Shockingly, Ashley observed that her Black and Brown colleagues were consistently ignored by the doctor, who only acknowledged communications from white or Hispanic employees. In one egregious incident, a patient was left waiting for nearly three hours as a result of this discriminatory behavior. Despite repeated notifications from Black and Brown employees, the doctor neglected to attend to the patient promptly.

Furthermore, Ashley detailed a toxic environment where nurses exhibited disdain toward CMAs and Certified Nursing Assistants (CNAs), treating them as inferior. Disturbingly, she revealed instances of negligence, such as administering water instead of insulin to patients, highlighting the grave consequences of such mistreatment.

When Ashley raised her concerns to a Hispanic director within the hospital administration, she faced retaliation and was subsequently terminated for whistleblowing. This unjust dismissal forced her to exit the healthcare field altogether. The trauma inflicted by her experiences was profound, compounded by the realization that such discriminatory practices not only affected her but also impacted vulnerable elderly patients seeking care at the cardiologist's office. Ashley's narrative underscores the urgent need for accountability and systemic change within healthcare institutions to eradicate racism and ensure equitable treatment for all employees and patients.

It is heartbreaking to confront the reality of workplace trauma, but it is a necessary reckoning. Statistics paint a stark picture: 3 in 10 women experience gender-based discrimination, while 1 in 2 Black employees face race-based discrimination in the workplace. Racial trauma, a form of mental and emotional injury resulting from encounters with racial bias and discrimination, further compounds these challenges.

Strategies On How To Identify

• Flashbacks
• Insomnia
• Anxiety
• Depression
• Irritability
• Difficulty concentrating
• Lack of presence of mind
• Ongoing mental health issues
• Ongoing physical health issues
• Increased absenteeism
• Increased reactivity
• Decreased work performance
• Increase in burnout
• Self-isolation
• Substance abuse issues

Considering these statistics, it is evident that the modern workplace harbors potential traumatic situations that often go unrecognized. Yet, the impact of workplace trauma can be profound and wide-ranging, manifesting in various signs and symptoms. Individuals may experience flashbacks, insomnia, anxiety, depression, irritability, difficulty concentrating, and a lack of presence of mind. Ashley's experience, particularly her anxiety surrounding the fear of retaliation after whistleblowing, illustrates the detrimental effects of workplace trauma on mental health.

Moreover, the repercussions of workplace trauma extend beyond mental health, encompassing physical health issues, increased absenteeism, heightened reactivity, decreased work performance, burnout, self-isolation, and substance abuse. Substance abuse, in particular, is a significant concern, often overlooked or difficult to address within the workplace. Colleagues may notice signs of substance abuse in their coworkers, but the private nature of these struggles makes it challenging to intervene effectively.

However, recognizing these signs can provide an opportunity to initiate conversations and offer support to those in need. Building relationships with coworkers outside of work settings enables individuals to pick up on subtle cues and signals of distress. While addressing substance abuse is complex, it is essential to create spaces where colleagues can feel comfortable reaching out for help and support one another through difficult times. Paying attention to these signs and signals can serve as a gateway to offering compassionate support and fostering a culture of care and empathy within the workplace.

Poll Question

I want to hear from you all. Have you experienced workplace trauma?

A. Yes, I have experienced traumatic events or situations in the workplace

B. No, I have not experienced any workplace trauma

C. I am not sure, as I may have encountered challenging situations, but I am unsure if they qualify as workplace trauma

It is incredibly powerful to see such candid participation in the poll. With 75% of respondents indicating that they have experienced workplace trauma, it is evident that these challenges are unfortunately prevalent in many professional settings. Your willingness to share your experiences highlights the importance of acknowledging and addressing workplace trauma.

To those who have experienced workplace trauma, please know that you are not alone, and your experiences are valid. It is essential to seek support and resources to navigate through these difficult situations. For those who have not experienced workplace trauma or are unsure, it is crucial to continue fostering a supportive and empathetic workplace culture where everyone feels safe and valued. Thank you all for your participation and for contributing to this important conversation. Your insights and experiences are invaluable in our collective journey toward creating healthier and more inclusive work environments.

The Effects of Workplace Trauma

Exploring the ramifications of workplace trauma reveals a spectrum of adverse effects on individuals. Unresolved emotional trauma stemming from the workplace can manifest in various detrimental mental health symptoms, such as depression and anxiety, and may ultimately prompt individuals to resign. This was notably observed in the case of Ashley, who opted to depart the industry entirely. Beyond the trauma of racism, there exist additional cultural symptoms, including pervasive gossip and a leadership ethos that neglects to heed employee feedback. Such manifestations serve as telltale signs of a workplace environment fertile for emotional trauma. Consequently, this fosters a cycle of high employee turnover, tarnishes the organization's reputation, and inflicts emotional wounds upon its workforce, thereby engendering a ripple effect.

This impact extends beyond the employees themselves, reaching into the realms of patient care, employee families, friends, and the wider community. Moreover, the repercussions are not limited to social spheres; they also significantly impede productivity. When individuals suffer from these symptoms, it inevitably results in decreased efficiency and an elevated propensity for errors. Within the healthcare sector, where precision is paramount, errors can have dire consequences, potentially costing lives. Such outcomes are unequivocally undesirable.

The recent pandemic exacerbated the trauma experienced by many employees, particularly those on the front lines. This demographic notably includes respiratory therapists, doctors, and nurses. As healthcare professionals, exposure to traumatic incidents is an inherent aspect of daily duties, especially when caring for COVID-19 patients. Notably, the enduring effects associated with workplace trauma encompass sustained mental health challenges.

This is the impact of workplace trauma. It can lead to ongoing mental health issues, depending on the person and the situation. This may include heightened anxiety, both work-related and generalized, increased depression, panic attacks, and challenges with emotional regulation. Furthermore, there are ongoing physical health concerns, such as exhaustion, sleep disturbances, difficulty unwinding, decreased energy, and physical pain.

Additionally, individuals who have experienced traumatic events may suffer from flashbacks. These episodes involve feeling as if they are reliving the trauma, with their nervous system reacting as though the trauma is occurring in the present moment, even if the event has long since passed. This can be particularly distressing, especially in the midst of work responsibilities.

Moreover, workplace trauma can lead to increased absenteeism and diminished employee engagement. For instance, employees experiencing mental and/or physical symptoms may need to take time off to prioritize their health. Similarly, if they encounter triggers at work—such as interactions with a toxic boss—they may feel compelled to avoid the workplace altogether to evade potential distress. Furthermore, trauma responses vary from person to person. Increased reactivity is a common reaction, but it is important to recognize that trauma affects individuals differently.

Employees who experience heightened trauma at work may exhibit hyper-reactivity. This means they are more prone to anger and irritability, often reacting in ways that are disproportionate to the situation at hand. Many of you may be familiar with or have experienced this phenomenon firsthand, as it is quite common. Indeed, hyper-reactivity often arises when individuals' trauma is triggered. For instance, following an interaction with an emotionally abusive boss, they may become more irritable, leading to outbursts such as yelling at a colleague seeking assistance with a project. However, increased reactivity can also persist as an ongoing symptom.

In such instances, individuals may be perceived as having a short fuse. Moreover, trauma-related side effects can significantly impede work performance. The mental, emotional, and physical toll of trauma can result in diminished focus and productivity. Employees may struggle to advance their tasks and projects, causing their performance to decline, even if they have previously excelled in their roles.

Furthermore, increased burnout is a common consequence for many individuals grappling with trauma. They may exhibit avoidant behaviors, seeking to evade thoughts or feelings associated with the trauma's impact. For some employees, immersing themselves in work becomes a coping mechanism—a way to avoid confronting their trauma directly. Many of us have likely experienced throwing ourselves into work as a way to cope, believing that focusing on tasks can help improve our performance. However, this tendency puts us at a heightened risk of burnout. Personally, I have often found myself pouring all my energy into work until my body simply says, "Enough."

Moreover, trauma at work can lead to self-isolation. Individuals may withdraw from both work and personal relationships, spending more time alone. This isolation can exacerbate existing mental health issues, which we'll delve into further shortly. Substance abuse is another coping mechanism for some individuals dealing with trauma. Whether it is alcohol or other drugs, turning to substances to numb the pain can be tempting. This can pose serious risks, whether the substance use occurs at work, outside of work, or both.

While organizations cannot entirely eradicate workplace trauma, there are steps they can take to lessen its impact and provide better support for employees. One crucial aspect is removing the stigma surrounding trauma and related issues. We still encounter some reluctance to discuss these matters openly, but addressing trauma requires acknowledging its presence and fostering an environment where employees feel comfortable seeking help and support.

Absolutely, communicating openly with your employees about workplace trauma is crucial. Letting them know that as an organization, you are committed to supporting them is paramount. Make yourself available to listen to their challenges and address any questions they may have. By fostering an environment where trauma is discussed openly and regularly, you create a sense of psychological safety. This encourages employees to feel comfortable reporting workplace trauma and seeking help when needed.

When a traumatic event occurs in the workplace, it is essential to acknowledge it promptly. Discuss the incident with your employees and outline the steps you plan to take to address it. For example, if there's been a workplace accident, acknowledge the event and then outline the measures you are implementing to enhance workplace safety. it is crucial to reassure employees and let them know how you are working to prevent similar incidents in the future. Similarly, if an employee reports abusive behavior from a supervisor, take action swiftly. Inform the supervisor's direct reports about the situation and any disciplinary actions being taken. Additionally, offer support to employees who may be experiencing trauma as a result of the incident, especially those involved in the specific relationship.

Furthermore, providing workplace trauma training is vital for effectively managing trauma in the workplace. Equipping your team with the necessary knowledge and tools helps create a trauma-informed workplace environment. This ensures that employees are better equipped to recognize and respond to trauma-related issues sensitively and effectively. Prioritizing this aspect underscores your commitment to creating a supportive and understanding workplace culture.

How Leaders Can Handle It

Certainly, workplace trauma training is invaluable for equipping managers with the knowledge and tools needed to support employees effectively. Moreover, it empowers employees to understand their own trauma and feel empowered to seek treatment or support. Offering various trauma-informed training modules can significantly benefit your team. Here are some key areas to consider:

• Understanding the common causes of workplace trauma and strategies for dealing with them.
• Recognizing signs of specific traumas, identifying triggers, and learning how to offer support.
• Facilitating discussions about individual and collective traumatic events sensitively and constructively.
• Identifying and addressing abusive behavior in the workplace, and fostering a supportive work environment.
• Providing guidance on how to report trauma in the workplace and effectively manage and support employees in crisis.

By investing in comprehensive training, you ensure that your team is well-informed and equipped to mitigate trauma's impact. Additionally, it is crucial to offer additional resources to traumatized employees. While key team members like leadership, managers, and HR professionals can offer support and understanding, they are not health professionals. Traumatized individuals often require professional help to manage and heal from trauma. Therefore, it is essential to have additional resources available to provide the necessary support and care for employees dealing with trauma. This ensures that employees have access to the resources and assistance they need to navigate their healing journey effectively.

Providing referrals to trauma specialists and information about available support resources is essential. This may include directing employees to social workers, mental health professionals, or trauma support groups. Additionally, offering a mental health or employee wellness stipend can be highly beneficial. By providing financial resources, employees have the means to access the necessary treatment and support when dealing with trauma.

Furthermore, adopting a zero-tolerance policy toward common drivers of workplace trauma is crucial. While it is impossible to anticipate every event or behavior that may cause trauma, addressing common triggers is feasible and necessary. A zero-tolerance approach sends a clear message that the organization prioritizes employee well-being and is committed to creating a safe and supportive workplace environment.

Key elements to include in this policy are:

• Physical violence: No tolerance for any form of physical aggression or harm towards employees.
• Emotional violence: This includes behaviors such as gaslighting, bullying, and harassment, which can cause emotional harm.
• Emotionally abusive management practices: Leaders must refrain from practices that undermine employees' well-being, such as manipulation or coercion.

It is imperative to document this policy in the employee handbook and ensure that all employees receive and acknowledge it. Having employees sign the document confirms their understanding of the policy and reduces potential issues if disciplinary action is required for policy violations. This proactive approach promotes a culture of accountability and fosters a safer and healthier workplace environment for all.

It is important to recognize that a zero-tolerance approach is not feasible for every situation that may induce workplace trauma. For instance, while excessive gossiping can be distressing for some employees, it is not practical to terminate every employee who engages in such behavior. Instead, it is more effective to discourage it and promote healthier communication practices.

In cases where toxic behaviors persist, employing a "gray rocking" approach can be helpful. This involves refusing to engage with or acknowledge employees who exhibit disruptive behaviors. Over time, this approach can help diminish problematic behaviors. If the behavior persists and disrupts the work environment, it may need to be escalated to HR or the individual's supervisor.

Furthermore, prioritizing employees' health and well-being is paramount for any organization. Taking proactive steps to mitigate workplace trauma and supporting traumatized employees should be ingrained in the organizational culture. When employees feel valued and supported, they are more likely to be less stressed, more engaged with their work, and have stronger relationships with their colleagues and managers. Knowing that the company takes their well-being seriously instills confidence in employees that they will be supported in times of need, fostering resilience and better management of trauma when it occurs.

This proactive approach not only supports individual employees but can also help reduce overall trauma in the workplace. For example, a company that prioritizes employee well-being is less likely to foster a toxic work culture, thus reducing the risk of burnout and associated trauma. Additionally, by cultivating a culture that values well-being, it becomes easier to identify and address behaviors that are not aligned with this culture, such as managers who engage in abusive behaviors. Taking decisive action to address such behaviors, including termination if necessary, sends a clear message that the organization is committed to creating a healthy and supportive work environment for all employees.

Trauma-informed Workplace

Six guiding principles for a trauma-informed approach:

1. Safety
2. Trustworthiness and transparency
3. Peer support
4. Collaboration and mutuality
5. Empowerment, voice, and choice
6. Cultural, historical, and gender issues

Simplification of these three overarching concepts:

• Acknowledgment (“I will be heard”)
• Support (“I can get the help I need”)
• Trust (“I will be treated fairly”)

Incorporating the CDC's six guiding principles for a trauma-informed approach is crucial for creating a supportive workplace environment. Simplifying these principles, acknowledgment stands out as a foundational element. A trauma-informed workplace acknowledges the prevalence and impact of trauma on individuals and strives to create an environment that fosters healing and resilience.

A trauma-informed approach recognizes that trauma can manifest in various forms across different industries. For example, in healthcare settings, trauma may result from high-stress environments, exposure to traumatic events, or abusive behavior from patients or colleagues. In educational institutions, trauma may stem from bullying, academic pressure, or adverse home environments. Similarly, in corporate settings, trauma can arise from workplace harassment, discrimination, or high-pressure workloads.

By acknowledging the diverse forms of workplace trauma across different industries, organizations can tailor their approach to effectively support employees' well-being. This may include implementing trauma-informed policies and practices, providing resources for trauma support and intervention, and fostering a culture of empathy and understanding. Ultimately, a trauma-informed workplace recognizes the importance of acknowledging and addressing trauma to create a safe and supportive environment for all employees.

Case Studies

Marly, Black Female

• SchoolTeacher
• Elementary School
• Sexism

Tabby, Female

• RT
• Hospital
• Sexism, Harassment

Meet Marly, a dedicated Black female educator with seven years of experience teaching elementary school. During a recent job interview at a new school, she encountered an unsettling experience. The assistant principal greeted her with flirtatious behavior, setting an uncomfortable tone from the start.

Marly could not help but notice a gender disparity among the administrative staff, with the majority being male. Her discomfort only escalated when she met the principal, who exuded what she described as "creepy vibes." Despite her reservations, Marly proceeded with the interview process diligently. When offered the position, she requested time to consider it. However, upon declining the offer, the principal crossed a line by texting her with a message that left her feeling deeply unsettled: "I always fight for what I want."

This experience has left Marly apprehensive about working under any male superior. She now actively seeks positions at schools where the administrative staff, including the principal, are predominantly women. The incident has left her feeling traumatized and has eroded her sense of security in the workplace, especially considering the potential for one-on-one interactions with male colleagues in meetings and other professional settings.

In addition to Marly's story, it is important to recognize that such experiences can occur in any industry, including healthcare. Allow me to introduce Tabby, another woman whose experience left a profound impact on me. Tabby is a respiratory therapist who worked at a hospital, and her story truly shook me to the core.

Tabby found herself working alongside another respiratory therapist during the night shift, whom she believed she supervised. However, her colleague's behavior became increasingly concerning as he would inexplicably disappear during their shifts. Despite attempts to reach him on their work phones, Tabby received no response. In a desperate attempt to communicate, she called his personal cell phone.

Days later, Tabby was blindsided when her colleague went to HR and accused her of making sexual advances toward him. He presented text messages and fabricated claims of a sexual relationship outside of work. This false accusation of sexual harassment is a serious matter that requires immediate attention and resolution in any workplace. When summoned to the HR office, Tabby was completely unaware of the allegations made against her.

This disturbing incident highlights the devastating consequences of false accusations and the importance of addressing sexual harassment promptly and effectively. Tabby's experience serves as a stark reminder of the potential risks and trauma that can arise in the workplace, underscoring the need for proactive measures to ensure the safety and well-being of all employees.

However, the HR representative astutely sensed discrepancies in his narrative and took note of the phone number associated with the alleged text messages. Upon scrutiny, it was evident that this number did not match Tabby's. This revelation unequivocally refuted the fabricated accusations. Yet, even in such a scenario, the experience was deeply traumatizing.

Consider the irony: the sole occasion Tabby called him from her personal cell phone, prompted by his neglect of duty, became ammunition for his false claims. This betrayal of trust and misuse of a genuine interaction to construct a false narrative is profoundly distressing. It underscores the vulnerability of individuals in the face of baseless accusations, casting a shadow of doubt and fear over future interactions in the workplace.

Such a situation is undeniably frightening and deeply traumatizing. To diligently perform one's job responsibilities, especially in a position of leadership, only to have a colleague fabricate a malicious scenario of sexual harassment is unimaginable. The emotional toll of such betrayal is profound, leaving scars that may never fully heal.

Following this ordeal, Tabby understandably harbored apprehensions about working with male colleagues. The fear of potential repercussions and the need for added precautions, such as having someone else present during phone calls, highlight the lasting impact of this traumatic experience. Unfortunately, in some instances, the response to such reports hinges on the integrity and discernment of those in positions of authority. Depending on their ethical standards or lack thereof, individuals may face unjust consequences, such as immediate termination, due to false accusations fabricated by others.

This stark reality underscores the importance of fostering environments where integrity, empathy, and fairness prevail, ensuring that all employees feel safe, supported, and heard. Such incidents serve as poignant reminders of the imperative to cultivate workplaces built on trust, accountability, and genuine concern for the well-being of every individual.

I highlighted these two distinct instances as illustrations of how workplace trauma can manifest in diverse ways. By showcasing these narratives, I sought to emphasize that trauma experiences are unique to each individual and may vary widely in their nature and impact. Despite these differences, it is crucial to recognize that the existence of varying experiences does not negate the reality of trauma. Whether overt or subtle, visible or hidden, workplace trauma leaves a lasting imprint on those affected. Acknowledging this diversity underscores the importance of creating supportive and inclusive environments that prioritize the well-being of all employees.

Emotional Intelligence

Emotional intelligence is a recurring theme in my webinars, as it holds significant importance in navigating various aspects of life. Research indicates that over 70% of adults have encountered psychological trauma, with a considerable portion of you having shared similar experiences. Moreover, studies reveal that psychological trauma can impair the brain functions essential for emotional intelligence.

Such trauma induces neural changes that impede individuals' emotional intelligence capabilities. Recognizing and understanding emotions is integral to the recovery process, facilitating the management of emotions and fostering healthy relationships. Emotions wield substantial influence over decision-making processes.

Case Study

• My preterm labor/infant loss story
• 18-year-old
• 22 weeks pregnant
• Law Firm File Clerk

Now, I want to share my personal experience with trauma, the quality of work life, and the importance of work-life balance. I will structure my story around the degrees I have obtained, as each significant trauma coincided with my educational milestones. Unfortunately, each degree I pursued was accompanied by a traumatic event. The lack of support and poor work-life balance led me to quit my jobs during these difficult times. For example, while I was in my second-to-last semester of pursuing an associate's degree, I miscarried my daughter at 21 weeks. This tragic event occurred on Thanksgiving Day. By the following week, after the holiday break, my employer was unsupportive, adding to my distress.

The employer's HR representative contacted me, asking when I planned to return to work. It took me about 24 hours to respond because I was upset and trying to process how she could ask such a question after what I had just experienced. I had been very clear about what had happened to me. One of my friends, who had connected me with the job and still worked there, had experienced something similar just four or five months earlier. The HR person was fully aware of the situation, but it seemed like she did not care. All I could think about was how I had just given birth and watched my daughter take her last breath, and this was how I was being treated.

When I explained everything to the HR person again, her response was, "I am sorry to hear that. I am sorry that this happened to you. You are in my prayers. But please let me know if you are going to be returning to work or if you are going to be putting in your resignation." Of course, I quit. Her response felt incredibly insensitive. While I understand that companies have their due diligence, it was too much for me. I was still trying to process my emotions, and on top of that, I had gotten sick from the job. I worked with older women who had the flu and a stomach virus, which is how I got sick and went into preterm labor. In my mind, I thought, "I am here because of you."

I was only 18 or 19 at the time, and I thought, "I am here because of you." I needed time to process everything, so I quit my job and focused on school. Although I had to repeat some classes, I realized that the best thing for me was to focus on getting my degree so I would not have to work for such people anymore. I needed to keep moving forward.

While pursuing my bachelor's degree, about a year or a year and a half later, I had my son prematurely at 28 weeks. A premature birth was not part of the plan. At the time, my employer told me, "If you do not return, you will be accumulating points, and when you get to a certain amount, it means termination." I had one week to return to work, or I would lose my job.  Given that my son was born at 28 weeks and was in the NICU, I knew he would be there for six to eight weeks. So, I decided to return to work. I went back a week after giving birth, but I soon quit.

As soon as I found another job, I left. The insensitivity of those workplaces deeply bothered me. This experience sparked my passion for employee wellness. When you prioritize your employees and what they are going through, it makes a significant difference. We spend the majority of our time at work, and if I don’t feel safe with my managers or colleagues, I won't be productive or want to stay.

But my challenges did not end there. Ten years after my first traumatic experience, while I was obtaining my master’s degree in 2021, I faced another devastating event. With only six weeks left before graduation, I lost a very good friend and business partner. Not only did I lose her, but I also had to administer CPR and watched her take her last breath. She had COVID-19 and suffered complications from it. Although this was not my first loss of 2021, it was overwhelming. This experience gave me a deep understanding of what healthcare professionals went through during the pandemic. Hats off to them because I could not do that every day. One would think I would take time off to work on myself, but I had to finish school. I thought, "If I don’t finish school now, I won’t have the emotional capacity to repeat a semester."

I had to push through, but thankfully, at the time, I was working for myself. I was not clocking into anyone else's job, which made things a bit easier, though still challenging. Managing my own business meant dealing with people daily and overseeing my employees. It was not easy at all. However, I was able to step back and focus on school. I had built my company to the point where it could essentially run itself, thanks to having the right employees in place. I gave everyone time to grieve, but I took a significant step back to concentrate on finishing school and getting my master’s degree.

During those six weeks, I completed a dissertation and an eight-day coaching intensive. Without my support system—my classmates, professors, community members, and industry peers who stepped in to help with my company—I would not have made it through that traumatic experience.

it is crucial to build companies and organizations that empower others to step up when leaders need to step back. Employees should seek out such organizations because we spend the majority of our day at work, and we need to be in safe, supportive spaces. We need to be in organizational cultures that foster employee wellness and well-being because our work lives inevitably bleed into our personal lives. After experiencing these traumas, I reflected on how I managed the loss thanks to the organization I built for myself. But what about the average working individual? How much time do they get to truly process traumatic events and experiences?

People around me were going through their own traumatic experiences. My friend was not the only person who passed away that year; I experienced six losses back to back. Two of those losses were my friend's spouse and brother. Her job, by the time her brother passed, simply said, "You have time for the funeral, and that's it. You need to get back to work." While I understand that work needs to resume and production must continue, what about the everyday working individual? How are they processing this? What support are their jobs providing to help them navigate such trauma? Or do they end up quitting, as I did 10 years ago? I will quit any job if I am going through something traumatic and not given the space to deal with it properly.

I advocate for this concept every single time because if your mental health is not at its best, it leads to numerous triggers, which we'll discuss in the upcoming slides. As an I/O Psychologist, my goal is to help companies and organizations prioritize their people by fostering a healthy quality of life and work-life balance. When you prioritize people over profit as a team, you increase productivity and, of course, profitability—after all, that is why we are in business

What Is Work-Life Balance?

Some argue that there is no such thing as work-life balance—you cannot acquire it, you cannot obtain it. But, as you might expect, I beg to differ. Before I delve into my philosophy of work-life balance, let's explore a few definitions of what it entails. Typically, work-life balance is defined as the proportion of time spent on your job compared to the time spent with loved ones or pursuing personal interests and hobbies. Healthy work-life balance refers to maintaining a harmonious relationship between your work and personal life. It involves consciously managing your time and energy to meet both professional and personal commitments while prioritizing self-care and well-being.

Naysayers argue that work-life balance is unattainable because there will always be a part of your life—work or home—that requires more attention than the other. Instead of chasing work-life balance, they suggest letting it go altogether. In short, they are saying you cannot really achieve work-life balance because one aspect will always take priority over the other. They advise against pursuing it at all. However, I disagree. I believe we need to shift our perspective or understanding of work-life balance, but we should not dismiss it altogether. I love the perspective that "Work-Life Balance Is a Cycle, Not an Achievement." Creating work-life balance involves finding harmony between your work life and your home life. There will be times when one demands more of your time and attention, but that does not diminish the importance of the other.

If we spend more time understanding and respecting where we are within the cycle, that creates balance. It is also important to recognize that work-life balance will look different for everyone, depending on their roles or where they are in their life journey.

Poll Question

Do you have a healthy work-life balance?

A. Yes, I consistently make time for both work and personal life, maintaining a balanced approach.

B. No, I often find myself overwhelmed with work, leaving little time for personal activities and relaxation.

C. Sometimes, I manage to strike a balance, but there are periods when work takes precedence over personal life.

D. I'm not sure, as I haven't really assessed or thought about my work-life balance.

Let's see where everyone stands on their work-life balance. Sometimes, or you are not sure, as you have recently assessed or thought about your work-life balance, go ahead and answer the poll. Let us know where you are. For me, achieving work-life balance took a while because, as I mentioned earlier, I would throw myself into work, especially during traumatic events. I would avoid dealing with issues and just immerse myself in work, pushing myself until my body eventually shut down. In my last corporate job, my body completely gave out—hardwired, it was like, "Nope, nope, nope." This forced me to quit that job. It is great to see that 88% of you feel you have a healthy work-life balance, with only 12% saying no. That's amazing! I'd love to hear how you maintain your work-life balance. Feel free to share in the chat.

Optimizing work-life balance during a traumatic experience is crucial. If you are struggling with workplace trauma, know that you are not alone. We all go through it in different ways, and many people experience exposure to traumatic events at some point in their careers. Fortunately, there are helpful resources available to help you cope with your experiences and move forward. Workplace trauma can be debilitating, but with proper support, you can begin to heal.

Optimizing Work-Life Balance (During)

Now that we have discussed what work-life balance is let's focus on how to optimize it during a traumatic experience. As I mentioned earlier, part of work-life balance involves understanding and respecting where you are in the cycle. When a traumatic experience occurs, it is essential to acknowledge what has happened, how you feel, and what you need before making any effective moves. Taking the time to take inventory of your emotional and mental state is crucial for understanding where you are and where you need to go. This self-awareness lays the foundation for effectively managing your work-life balance during difficult times.

Once you have taken this inventory, you can prioritize your to-do list accordingly. For instance, if you are in a state of emergency like during the COVID-19 pandemic, the first item on your list might be to check in with your clinical supervisors to see if you are needed to report to duty that day.

Next, it is crucial to alert your support system about your trauma so they are aware. My favorite quote to share is, "You do not have to do life alone, and you should not do life alone." If you have already identified your support system, let them know exactly what you need. This emphasizes the importance of the first step I mentioned earlier: acknowledging what happened, how you are feeling, and what you may need. By completing this inventory first, when you alert your support system, you'll already have a clear idea of what you are asking for. For example, "I might need someone to pick up my kids" or "I cannot drive." For me, after experiencing the situation with my friend, I'm thankful I did not read the text message from her sister because they had already taken her to the hospital, even though I already knew what had happened.

When you are in shock, your brain still holds onto hope. After making it home and taking a shower to sanitize due to COVID-19 concerns, I finally read the message and felt unable to walk. My son was at school, and I had to assess what I needed at that moment as my brain processed the trauma. It was still a traumatic experience because I was in the midst of it all, with a lot happening. My mom had to drive to my house to pick me up, and I had to ask my son's other godmother to pick him up from school. Eating was the last thing on my mind, but he still needed to eat. I had to start delegating tasks to my support system in order to make it through.

Responding to the question about work-life balance, switching from being a floor RT for 21 years to becoming an RT educator has been a significant change. This switch has allowed for a better work-life balance, as it enables more flexibility to be there for her five kids with weekend and evening schedules, compared to the demanding 12-hour shifts for four days, four times a week as a floor therapist.

it is truly amazing that the change in roles has allowed her to spend more quality time with her kids on weekends. Working while the kids are home can indeed be challenging. Melissa's approach to maintaining work-life balance by prioritizing "me-time" when stressed and ensuring to spend time with family and friends is crucial. Leaving work at work is vital, regardless of whether you are self-employed or not. Establishing separate boundaries, such as having a dedicated phone for work and setting specific business hours, helps maintain a healthy balance. Respecting these boundaries is key to preventing work from encroaching on personal time.

Absolutely, maintaining strict boundaries around work hours is crucial for preserving work-life balance. Not responding to emails or clients outside of designated hours is a great practice to ensure that work stays at work and does not intrude on personal time. Blurring the lines between work and personal life can lead to burnout and decreased well-being, so it is essential to establish clear boundaries and stick to them.

In addition to setting boundaries around work communication, regulating your schedule is also important. This might involve reducing your workload or adjusting your working hours to accommodate a traumatic experience or event. Understanding and respecting where you are in the cycle of life and work allows you to make necessary adjustments to prioritize your well-being. If you are going through a difficult time, it is crucial to recognize that you may not be able to maintain the same level of work intensity as usual, and that's okay. Taking the time to care for yourself and address your needs is essential for long-term well-being.

Respecting your body and acknowledging everything happening holistically is crucial. it is also important to minimize exposure to triggers, especially if you haven't had the opportunity to address your psychological state in depth. Actively subjecting yourself to triggers can have unforeseen consequences, so it is essential to be mindful of that. However, isolation should be avoided if possible. Surrounding yourself with others who are not triggering can help keep you grounded and focused. In my experience, the support of classmates and peers made a significant difference in my journey, even though I attended school online. Their connection and emotional support played a crucial role in my mental well-being.

As much as I felt the urge to shut down, I knew I could not afford to do so. Otherwise, I risked slipping into depression. Isolation has a way of exacerbating emotional struggles because you are left alone with your thoughts. Being connected to others was crucial for me; it allowed me to release my emotions. However, I made sure not to overwhelm my support system with everything I was going through. Instead, I actively sought out therapy. By the fourth week after my friend's passing, I had already started therapy. It was a critical step because it took our family quite some time to bury her. She passed away on October 4th, and her funeral was not until Halloween, October 31st. That gap of almost a month was where the traumatic experience unfolded.

The delay in the funeral prolonged the feeling of being trapped in the trauma. Despite the ongoing turmoil, I found myself blocking out my emotions so I could focus on finishing school. However, as the week of her funeral approached, I started experiencing anxiety and panic attacks. The memories of that day kept replaying in my head relentlessly. Realizing I needed help, I made the decision to seek therapy. It was not easy—I struggled to find the words to explain what I was going through, and I did not want to burden someone else with my trauma. In fact, I did not even want to confront it myself. But I knew I could not continue to suffer in silence, so I reached out for professional support.

it is understandable to feel hesitant about burdening someone else with your own trauma. Seeking therapy and journaling were essential tools for me during that time. I have always found solace in journaling—it is a way to release pent-up emotions and thoughts. While journaling does not make the emotions disappear entirely, it loosens their grip on you. Releasing your emotions, especially when you are in the midst of trauma, is crucial. It allows you to identify and understand those emotions and where they are coming from. Eventually, you reach a point where you can let them go, freeing yourself from their hold. I highly recommend journaling to anyone going through a challenging time—it's a powerful tool for emotional release and self-reflection.

Optimizing Work-Life Balance (Post)

Optimizing work-life balance post-trauma can be challenging, as your work environment might be one of the most difficult places for interactions. This is essentially where PTSD can originate. For example, if you work in a loud environment and have experienced PTSD from your time in the military, you are likely to encounter triggers frequently. On the other hand, your anxiety may be heightened by being alone in a room with another individual, such as a toxic supervisor. Regardless of your specific triggers, it may not be feasible to completely change career paths to reduce your hypersensitivity to your surroundings. Instead, you can make adjustments to your workload to lessen your stress. Maintaining a clean work area and avoiding clutter, as well as reducing time spent in crowded break rooms or cramped meetings, can help manage your stress levels.

In addition to adjusting to your workplace, you may find social events challenging due to increased anxiety. However, avoiding triggers by drastically reducing time with friends, family, and loved ones can be very detrimental to your mental health. Instead, take the initiative by implementing preventative measures and improving your environment. Spend time in places that bring you peace, such as the beach, on walks, or hiking. Engage in activities that ground you and surround yourself with supportive, non-toxic people who uplift you.

Furthermore, counseling and therapy can help improve your reactions to triggers and reduce your stress. These strategies can collectively enhance your overall well-being and help you manage post-trauma challenges more effectively. I am pro-counseling and therapy. A mental health care provider can provide you with coping skills and tips to gradually grant you closure from traumatic events. It does not happen instantly or on your desired timeline, but they guide you there. This support can also help you navigate social situations more effectively.

Focus on what you can control: the places you visit and the number of people you are around. Stick to safe zones, like familiar shops, restaurants, and hangout spots where you feel comfortable. Depending on the type of trauma you have experienced, you might also consider traveling and exploring new places. Just be sure to do your research to avoid putting yourself in potentially triggering situations.

I love the idea of creating a stress plan. It does not mean that when the time comes, we will stick to that plan exactly or that it will play out the way we want. However, it gives you an idea of what to do if something traumatic happens. Even when you carefully adjust your surroundings at home or work, there may be moments when you cannot anticipate stress or triggers to your PTSD. In these cases, having a stress plan can help you navigate through those difficult moments. Find a quiet place, or try stepping away if you begin to feel overwhelmed. This could be as simple as closing the office door, taking a trip to the restroom, or taking a quick walk around the hallways or stairwell when you experience heightened anxiety. The presence of other people may sometimes make you feel trapped or closed off, but remember, this is only for a brief moment. We are not isolating ourselves; we are stepping away temporarily to regain our composure and ground ourselves. Everyone's triggers are different depending on the root of their PTSD, so personalize your plan to what works best for you.

Someone who has PTSD from the military will have different triggers than I do, as I have never been in the military but have experienced my own forms of trauma. For some people, being alone may worsen their triggers, increasing the risk of a panic attack. In this case, try to find a comfortable environment with a bit of background noise and enough people around so you don't feel isolated. Practice anxiety-reducing exercises to manage your stress.

Unfortunately, there may be times when finding a quiet spot to be alone is difficult, such as during a meeting. Several exercises can help reduce stress and bring your breathing and heart rate under control to lessen the effects of a panic attack. Breathing exercises are some of the most common and simple methods to reduce rising anxiety. By controlling your breathing, you can regulate your heart rate and ease the feeling of panic. You can also try muscle relaxation techniques, depending on your environment, to relieve any tension in your body. Each technique works differently for everyone, so it is important to try various methods to find what makes you feel comfortable. Additionally, remember to alert your support system when needed.

It is important, both during and after trauma, to let your support system know where you are. Contact them if you need assistance during a panic attack caused by PTSD. By definition, a support system is a group of trusted individuals with whom you feel comfortable expressing yourself without fear of judgment or ridicule. Ensure these are solid people who understand trauma, know your situation, and can provide the support you need. Remember, your support system may change over time, with different people helping you during various stages of the process.

Having the right people in your support system is crucial because the wrong individuals can be triggering and counterproductive. Be patient with yourself; the healing process takes time, and there will be good days and bad days. Remember that you are strong and will get through it.

It is also important to recognize the telltale signs that you may need to seek professional help. These signs include experiencing flashbacks, nightmares, or intrusive thoughts about the event; avoiding people or places that remind you of the trauma; feeling hopeless, helpless, or worthless; and struggling with substance abuse or other destructive behaviors. There is nothing wrong with seeking professional help. Mental health professionals are there to support you and provide resources to heal from your experience, helping you get back on track with your goals and everyday life.

Learning in Different Ways: Books, Movies, Shows

l always like to include books and shows because people learn in different ways. I love to read, so if you are a reader, I recommend "The Empathetic Workplace" by Katherine Manning. This book is crucial for every manager and HR representative. It does not just prepare them to face reports of traumatic experiences at work; it helps them plan for it. Manning includes a five-step method that helps managers make survivors feel supported and understood.

"The Empathetic Workplace" guides supervisors of any level in understanding how stories of trauma impact the brains of both the survivor and the listener. It provides tools to handle these interactions appropriately, benefiting the listener, the organization, and, most importantly, the survivor. Another great book is "Rising Above a Toxic Workplace" by Gary Chapman. This book discusses how to cope with and overcome toxic work environments.

Additionally, "Surrounded by Idiots" is an insightful book that teaches you how people function and why we struggle to connect with certain individuals. It offers methods for assessing the personalities of those we communicate with and provides insights on how we can adjust our interactions. These books offer valuable perspectives and strategies for navigating and improving workplace environments, making them essential reads for anyone looking to enhance their understanding and management of workplace dynamics.

In "The Empathetic Workplace," Katherine Manning shares authentic stories from today's workers who explain how they cope, change, or quit. They candidly discuss what they learned, what they wish they had done, and how to gain resilience. As for movies and shows, here are some great options that many people have probably watched, such as "Criminal Minds." This is one of my favorite shows. It follows FBI profilers in the Behavioral Analysis Unit (BAU) who capture criminals. The show delves into the minds of serial killers, annihilators, bombers, and more. Including these books and shows provides a variety of resources for different learning preferences, helping individuals understand and navigate trauma and workplace challenges.

In addition to each case they take on, "Criminal Minds" also shows how the job affects the personal lives of the FBI profilers and traumatizes them. For example, Unit Chief Hotchner's wife becomes a casualty of his job. One of the serial killers they were hunting warned Hotchner to stop pursuing him, threatening that he would "pay" if he did not. The payment turned out to be the killer targeting Hotchner's wife. The entire team, including Hotch, was subjected to the trauma of hearing this event unfold, leaving a lasting impact on them. You can only imagine the profound effect this had on their mental and emotional well-being.

These elements in "Criminal Minds" provide a stark illustration of how high-stress jobs can bleed into and disrupt personal lives, underscoring the importance of addressing and managing trauma effectively. I think every single one of the BAU profilers in "Criminal Minds" had something traumatic happen to them because of the job. Watching that show gives you a visual understanding of how workplace trauma takes place. Though these events are traumatic, it is not intentionally their fault—they're simply doing their job.

Similarly, workplace trauma is a constant theme in healthcare shows like House and Grey's Anatomy. We watch characters lose patience, go through various transitions, and face daily challenges. These shows illustrate the realities of working in the healthcare industry. In "How to Get Away with Murder," we see the impact of traumatic events such as sexual harassment, miscarriages, and loss of babies due to the stress of the cases they handle. These traumatic events stay with the main characters as they try to navigate their work lives. Some handle it better than others, while some simply avoid dealing with it.

I recommend these shows because they provide a glimpse into the pros and cons of the choices you make in response to trauma. If you choose not to properly deal with your trauma, you can see the potential decline in your life, highlighting the importance of addressing and managing traumatic experiences effectively.

Summary

I always like to give real-life scenarios of what can happen in different ways because we relate to things differently. For example, in "Criminal Minds," one of the seasons shows Morgan dating a doctor, and her life becomes traumatized by his work. Trauma does not always have to take place at work, but it can still affect your work.

To summarize, workplace trauma is an emotional response to negative events at work. It can be defined as the physical or psychological harm caused to employees when they are at work. This can include hostile work environments, microaggressions, and other detrimental factors. It is important to identify workplace trauma to give employees the space to recognize that they are not at their best and that their job is there to assist them in understanding the trauma and finding tools and resources to deal with it. Managers also need to be aware of the traumas taking place and provide support along with a culture that can help employees through these traumas.

As someone who may be experiencing traumatic events at work or elsewhere, pay attention to your body and mind for changes that affect your work performance. These are often the first signs of workplace trauma. If you are a manager, the best tool or resource you can provide is workplace trauma training.

Becoming a trauma-informed workplace makes a significant difference for everyone involved. Remember, work-life balance is a cycle, not an achievement. We may all be in different parts of that cycle, but each part is equally important. A healthy work-life balance means maintaining a harmonious relationship between your professional and personal life.

When experiencing trauma, the most important step is acknowledging that something is happening. Don’t do life alone. Alerting your support system and releasing your emotions can greatly impact how trauma affects your life. Stress and trauma are inevitable, but creating a stress plan for the future can make a difference in how trauma affects you. That’s all I have for you today. Thank you for tuning in, and I hope you found this webinar beneficial.

References

Chapman, G., & White, P. (2014). Rising above a toxic workplace: Taking Care of Yourself in an Unhealthy Environment. Moody Publishers.

Erikson, T. (2019). Surrounded by idiots: The Four Types of Human Behaviour (or, How to Understand Those Who Cannot Be Understood). Random House.

Manning, K. (2021, February 16). The Empathetic Workplace: 5 Steps to a Compassionate, Calm, and Confident Response to Trauma On the Job.

Thompson, Neil, and Dale A. Lund. Loss, Grief, and Trauma in the Workplace, Taylor & Francis Group, 2009. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/waldenu/detail.action?docID=3117896.

Editor’s note: This text-based course is an edited transcript of the webinar, Respiratory Management of Patients With Neuromuscular Weakness Series: Review Recommendations Best Practice, presented by Dr. Duane Reed, EdD RRT, RCP. Any errors in transcription or editing are the responsibility of Continued.com and not the course presenter. It is recommended to download the course handout to supplement this text format.

Learning Outcomes

After this course, participants will be able to:

• Identify neuromuscular diseases that affect the respiratory system.
• Identify evidence-based recommendations for patients with neuromuscular diseases.
• Discuss best practice management for patients with neuromuscular diseases.

Overview of Neuromuscular Diseases (NMD)

Many forms of neuromuscular disease exist:

• Amyotrophic Lateral Sclerosis (ALS)
• Charcot Marie Tooth Disease (CMT)
• Multiple Sclerosis (MS)+
• Muscular Dystrophy
• Myasthenia Gravis
• Myopathy
• Myositis
• Guillain Barre Syndrome (not a disease, but when the immune system attacks the neuro system)

The foundation for our discussion comes from a panel discussion centered around 128 studies presented in the Journal of Chest. This panel has yielded 15 graded recommendations and a good practice and consensus-based statement. Our primary aim is to uncover evidence-based best practices for effectively managing the respiratory aspects of neuromuscular diseases.

Neuromuscular diseases manifest when the nerves governing movement are negatively impacted. This brings our attention to the nervous system. The resulting muscle weakness, a notable complication stemming from neuromuscular diseases, significantly affects the respiratory system. This connection becomes evident when considering the role of the diaphragm, a pivotal component of the respiratory system. The diaphragm relies on nerve impulses for stimulation. Thus, any damage to the nerves jeopardizes the function of the respiratory system. This is where the link between nerve damage and respiratory system vulnerability emerges. Respiratory failure is a prevalent complication closely linked to neuromuscular diseases.

This serves as a pivotal reason for us to delve into a discussion about various neuromuscular diseases. When nerve functionality is compromised, complexities can emerge, especially concerning respiratory function. This can lead to disruptions in the processes necessary for breathing and lung function. While you might be familiar with some of these conditions, others may be less known, yet all are intrinsically tied to the risk of respiratory failure. Understanding neuromuscular diseases' influence on the respiratory system is crucial because they often lead to respiratory complications due to their impact on nerves and muscles involved in breathing.

Figure 1. Diagram illustrating motor neuron of ALS (Continued Getty Images). 

Many forms of neuromuscular diseases exist, with some being more familiar to us than others. One well-known example is ALS or amyotrophic lateral sclerosis in Figure 1. This disease primarily affects the nervous system, leading to a gradual weakening of the muscles. You may recognize it by its former name, Lou Gehrig's disease. It leads to muscle cell degeneration, resulting in a decline in muscle functionality and overall mobility.

Figure 2. The foot of a person with Charcot-Marie-Tooth. (Benefros at English Wikipedia, CC BY-SA 3.0 via Wikimedia Commons). 

Another example is Charcot-Marie-Tooth disease, commonly referred to as CMT. This condition is essentially a hereditary disorder that primarily induces nerve damage in the arms and legs seen in Figure 2. CMT disease leads to reduced muscle size and strength, accompanied by potential sensory loss, muscle contractions, and challenges in walking. Commonly observed are foot deformities like hammertoes and high arches. While symptoms often initiate in the lower extremities, progression to the hands and arms can occur over time. The manifestations of CMT disease generally emerge during adolescence or early adulthood, although they can also manifest in midlife.

Figure 3. Damage myeline sheath of Multiple Sclerosis. (Continued Getty Images). 

Multiple sclerosis in Figure 3, often referred to as MS, is a widely recognized condition. It is a potentially disabling disease affecting the brain, spinal cord, and central nervous system (CNS). In this disease, the immune system erroneously targets the protective sheath, known as myelin, covering nerve fibers. This leads to various issues, as the degradation of myelin disrupts the proper functioning of nerves, resulting in communication problems within the body. This condition can cause various symptoms and challenges, and we will provide an illustrative image to convey its effects better.

Muscular dystrophy is a widely recognized condition known for inducing muscle-related issues. This disorder also intricately affects the surrounding protective sheath of nerves. Over time, these issues inevitably extend their reach to the respiratory system, raising a pivotal concern. Delving into the context of ALS, a compelling image illustrates the contrast between a healthy motor neuron and one that is emblematic of ALS. These distinctions become apparent in the cell bodies and axons, both crucial for maintaining optimal nerve function. These transformations culminate in muscle atrophy, setting apart ALS-affected motor neurons from their healthy counterparts within the spinal cord. ALS is unquestionably a profoundly debilitating condition.

Moreover, we have previously explored Charcot-Marie-Tooth disease. A comparison between unaffected and affected nerves visually portrays the scarring of the myelin sheath, a distinctive feature of this hereditary disorder. The damage predominantly manifests in the arms and legs, impairing nerve and myelin sheath. This disease can significantly impair affected individuals, and its impact may even extend to lung function. It is important to note that while these diseases, such as multiple sclerosis, exhibit distinct origins, they share commonalities in terms of their repercussions.

Regarding multiple sclerosis, a parallel arises concerning the damage inflicted upon the myelin sheath. A visualization on the right effectively underscores the compromised state of the myelin, underscoring its pivotal role in safeguarding nerves. This assumes particular significance when considering nerves stemming from the cervical spine, which extend to the diaphragm. Any compromise in these nerves disrupts the necessary transmission for stimulating impulses, posing a considerable challenge to respiratory function. This emphasizes the significance of delving into neuromuscular diseases, given their substantial influence on the respiratory system, particularly within the realm of inherited disorders.

Among the array of disorders highlighted, myasthenia gravis emerges as a notable case. This condition typically initiates in the brain and progresses downward, impacting muscles and culminating in rapid fatigue. This importance cannot be understated, as it targets voluntary muscle groups, including those implicated in respiration. Conversely, while Guillain-Barre syndrome is classified as a syndrome rather than a disease, its effects on muscle function are noteworthy. Additionally, it is essential to distinguish myositis, characterized by inflammation of muscles, as a rare disorder. Both Guillain-Barre syndrome and myositis present substantial challenges.

All these diseases collectively manipulate nerve function. Once nerve integrity is compromised, the essential nerve impulses the diaphragm relies upon to generate pressure changes are disrupted. This underscores the potential complexities that can arise when nerve functionality is compromised, particularly concerning respiratory function.

Advancing Research on Respiratory Management of Patients with Neuromuscular Weakness

An expert panel conducted a systematic review focusing on the respiratory management of neuromuscular diseases (NMD). They employed the Grading of Recommendations, Assessment, Development, and Evaluations approach to assess the certainty of evidence, formulate recommendations, and assign grades. The consensus was reached through a modified Delphi technique.

Drawing insights from 128 studies, the panel established 15 graded recommendations, one good practice statement, and one consensus-based statement. It is important to note that the evidence supporting best practices for NMD respiratory management is limited, primarily relying on observational data from amyotrophic lateral sclerosis.

The guidelines offered an understanding of areas such as mouthpiece ventilation, the transition to home mechanical ventilation, salivary secretion management, and airway clearance therapies. It's emphasized that the pathologic features of NMD encompass a wide spectrum of disorders, each with varying rates of lung function decline. In clinical practice, the role of clinicians extends beyond medical evaluation to shared decision-making with patients and families. This involves respecting patient preferences and treatment goals, considering the quality of life, and judiciously utilizing available resources in decision-making processes.

Panel Recommendation 1: Use and Timing of Pulmonary Function Test (PFT)

In the context of patients with neuromuscular diseases at risk of respiratory complications, experts advise incorporating the timing of Pulmonary Function Testing (PFT) as a valuable tool for management. The panel strongly recommends the integration of PFT into the management process. These recommendations aim to serve as a basis for developing protocols and guidelines. 

Panel Suggestions:

The panel proposes PFT as a cost-effective intervention. They recommend spirometry, focusing on FVC (forced vital capacity) and SVC (slow vital capacity), along with MIP (maximum inspiratory pressure), MEP (maximum expiratory pressure), and SNIP (nasal inspiratory pressure) measurements for patients with neuromuscular conditions. Additionally, peak cough flow should be considered. FVC and SVC techniques should be employed to assess respiratory health comprehensively. A slower version like SVC is crucial for patients with COPD who may experience prolonged air trapping. Evaluating respiratory reserve and muscle strength involves measuring MIP and SNIP. These parameters are indispensable when managing neuromuscular patients, expanding our toolkit. Panel recommendation two emphasizes utilizing PFTs and understanding their optimal timing.

Panel Recommendation 2: Use and Timing of PFT for Patients with NMD at Risk of Respiratory Failure

For patients with neuromuscular disease prone to respiratory complications. The panel advises conducting PFTs at least every six months, as deemed suitable. This recurring six-month interval aligns with the recommended frequency.

Panel Suggestions: 

Employing a consensus-based approach, the panel arrived at a six-month testing interval. While recognizing that the progression rates vary among NMDs, particularly evident in cases like ALS, where significant respiratory parameter changes could manifest in 3 to 6 months, the panel acknowledged that for more stable or slowly progressing conditions like Duchenne muscular dystrophy, PFTs could be conducted at less frequent intervals, such as every 12 months. The panel proposes considering one or more of the following assessments within this timeframe. While not mandatory to perform all, options include measuring vital capacity, slow vital capacity, MIP, MEP, SNIP, and cough.

Panel Recommendation 3: Screening for Respiratory Failure and Sleep-Related Breathing Disorders

Let's delve into recommendation three, which revolves around sleep-related disorders in the context of neuromuscular diseases. When working with patients with symptomatic patients with NMD who have normal PFT, the panel proposes employing overnight oximetry, often referred to as ONO. Additionally, the suggestion involves utilizing polysomnography to evaluate the necessity for non-invasive ventilation. This step relates to the consideration of sleep studies as well.

Panel Suggestions:

The panel highlights polysomnography as a valuable tool for determining non-invasive ventilation's appropriateness. Clinicians, consider polysomnography to assess whether noninvasive ventilation (NIV) is clinically indicated. This particular ventilation approach includes methods like BiPap. 

Panel Recommendation 4: Noninvasive Ventilation (NIV)

Moving on to recommendation four primarily centers around patients with neuromuscular diseases experiencing chronic respiratory failure. This scenario necessitates a closer look at non-invasive ventilation strategies. When discussing chronic respiratory failure, it is important to note that this often pertains to COPD patients.

Panel Suggestions:

The panel's recommendation of employing non-invasive ventilation aligns logically with this context. However, it is worth highlighting that while clinical indications for non-invasive ventilation are present, they can vary based on factors such as the specific neuromuscular disease, patient age, and the pace of disease progression. In essence, these multifaceted variables influence the suitability of non-invasive ventilation.

The evidence was primarily derived from adults with ALS, given its prevalence as the most common NMD. However, its application should be approached thoughtfully when considering younger children, adolescents, and adults with non-ALS diagnoses. The panel further suggests that its applicability remains subject to these diverse factors even with established indications for non-invasive ventilation. The panel highlights key indicators, such as a decrease in forced vital capacity (FVC) to less than 80% of predicted accompanied by symptoms or an FVC below 50% of predicted symptoms. Similarly, a SNIP or MIP measurement indicative of a reserve of -40 centimeters of water can signify the need for non-invasive ventilation.

The guidelines have transitioned from recommendations and marked a significant development in 2023. Specifically, if a patient's FVC falls below 80% with symptoms or below 50% without symptoms, the situation warrants the implementation of non-invasive ventilation.

Panel Recommendation 5: Sleep-related Breathing Disorders

Panel recommendation number five pertains to the intersection of neuromuscular diseases and sleep-related breathing disorders. The panel highlights the utilization of non-invasive ventilation as a treatment approach for individuals with neuromuscular diseases facing sleep-related breathing disorders. 

Panel Suggestions:

Based on limited available data, transcutaneous and end-tidal CO2 measurements exhibited potential in identifying hypoventilation and initiating as well as managing NIV. Home-based overnight capnography emerged as a practical option and criterion for initiating respiratory support. Furthermore, the panel advises referencing the criteria outlined by the American Academy of Sleep Medicine (AASM). Familiarity with these criteria is valuable, and considering a sleep course might be beneficial if you are not already acquainted. The AASM criteria pertain to sleep disorder-related hypoventilation in adults. It is also important to note that the European Respiratory Society (ERS) offers its own guidelines and recommendations tailored specifically for pediatric patients. While the panel endorses the use of non-invasive ventilation, they emphasize the significance of aligning with the appropriate guidelines for comprehensive and effective treatment.

Panel Recommendation 6: Respiratory Parameters for NIV

When it comes to determining the parameters for non-invasive ventilation in patients with neuromuscular diseases, the panel suggests employing diagnostic tests such as FVC, MIP/MEP, ONO, or evidence of sleep-disordered breathing or hypoventilation on polysomnography to predict the timing of NIV initiation. Additionally, the panel proposes using parameters observed on the polygraph to predict the appropriate timing for initiating non-invasive ventilation in sleep-related breathing disorders or hyperventilation cases. Polysomnography is not deemed obligatory for adult NMD patients under NIV management if PFT or ONO criteria validate its use. In situations where concerns linger regarding whether PFT and clinical assessments adequately address potential complications like hypoventilation, sleep testing can prove beneficial.

Panel Suggestions:

The panel emphasizes that initiating non-invasive ventilation does not necessarily require polysomnography for adults. Instead, relying on the criteria established through pulmonary function tests (PFT) alone can be sufficient for guiding the decision. Notably, ONO presents distinct advantages of being cost-effective and easy to repeat. ONO serves dual roles: evaluating nocturnal desaturation to levels below 88% for a 5-minute interval, potentially qualifying NMD patients for NIV devoid of OSA indications, and monitoring NIV effectiveness by ensuring oxygen saturations exceed 90% during over 90% of the NIV recording. This shift in focus minimizes the necessity for polysomnography in the initiation process.

Panel Recommendation 7: Individualizing NIV Treatment 

Recommendation number seven addresses the treatment approach for patients with neuromuscular disease necessitating non-invasive ventilation. The panel highlights the importance of tailoring the non-invasive ventilation treatment to align with individual ventilation goals, as It is not a one-size-fits-all solution.

Panel Suggestions:

The panel recommends adjusting variables like mode selection, inspiratory time, and inspiratory/expiratory pressures. While no specific mode is favored over others, It is crucial to select a mode and then fine-tune parameters like inspiratory time and pressures to meet the patient's unique ventilation objectives. This adaptation process varies on an individual basis, taking into account the broader hospital context, yet each patient's distinct needs must be prioritized when making these determinations.

The panel also suggests that implementing a backup respiratory rate could enhance patient-ventilator synchrony and improve gas exchange. It is important to note that patients with bulbar impairment might face challenges in tolerating non-invasive ventilation. Furthermore, the panel advocates for ongoing assessment encompassing factors such as sleep quality, digital data analysis, leak management, oximetry, and capnography. This comprehensive approach ensures an effective treatment strategy and encompasses the multifaceted aspects of patient care.

Figure 4. Diagram of bulbar neuron impairment (Rcchang16, CC BY-SA 4.0 via Wikimedia Commons).

The topic of bulbar impairment is a crucial consideration in non-invasive ventilation. Bulbar impairment in Figure 4, often referred to as bulbar palsy, results from conditions affecting the lower cranial nerves, typically the seventh and eighth nerves. This condition can lead to speech deficits due to paralysis affecting these nerves.

In the accompanying visual in Figure 4, you can observe the damage to the lower motor neuron, which stems from the primary motor cortex of the brain. This damage can significantly impact speech functions. It is important to understand that non-invasive ventilation might not be a suitable solution when we refer to bulbar impairment due to the nature of the impairment itself. Certain populations, particularly individuals with bulbar dysfunction, may face challenges in performing PFTs. Additionally, daytime PFTs can serve as a valuable indicator of sleep-related hypoventilation, exhibiting a correlation with durations of oxygen saturation ≤ 90% and arterial blood gas Pco2 levels ≥ 45 mm Hg. 

Diagnosing bulbar impairment is the realm of medical professionals, but It is essential for us to comprehend that non-invasive ventilation would not effectively address this condition. This understanding is pivotal for making informed decisions about the appropriate course of action in such cases. 

Panel Recommendation 8: Bulbar Function

Recommendation number eight addresses the use of non-invasive ventilation in patients with preserved bulbar function who are affected by neuromuscular diseases. In such cases, the panel advises considering the utilization of mouthpiece ventilation (MPV) during daytime hours, serving as an adjunct to the traditional nocturnal mask ventilation. 

Panel Suggestions:

While mouthpiece ventilation has been employed to delay the need for mechanical ventilation in neuromuscular diseases, it is important to acknowledge that its effectiveness could be limited by bulbar symptoms in some cases. If non-invasive ventilation is necessary, opting for mouthpiece ventilation is recommended. Various designs exist for mouthpiece ventilation, which is distinct from conventional ventilation due to the absence of intubation. Patients are fitted with a mouthpiece instead. This method is endorsed as a viable approach in cases where preserved bulbar function exists.

Panel Recommendation 9: Mechanical Ventilation

In cases where patients with neuromuscular diseases experience non-responsive non-invasive ventilation and their bulbar function deteriorates, leading to issues like aspiration, inadequate cough, and declining lung function, adopting home mechanical ventilation via tracheostomy becomes a viable alternative. The panel strongly recommends initiating mechanical ventilation as early as feasible, alongside careful consideration of care objectives. This move is particularly pertinent if non-invasive ventilation proves ineffective.

Panel Suggestions:

The positive impacts of MPV remain uncertain, yet they might encompass postponing or circumventing tracheostomy, enhancing speech, augmenting cough efficacy, and refining the synchronization of breathing and swallowing.  Given the limited evidence, the equilibrium between risks and advantages likely tips in favor of the intervention, although the certainty of evidence remains very low. Even when confronted with worsening bulbar function, aspiration, ineffective cough, and declining lung function, the panel suggests transitioning to regular mechanical ventilation. The key is to ensure appropriate ventilation and care despite these challenges.

Furthermore, the panel advocates for optimizing secretion management and airway clearance, tailoring these approaches according to patient preferences, treatment objectives, quality of life factors, and available resources. This comprehensive strategy assists in making informed decisions regarding patient care. This emphasis on personalized care accounts for various facets and aligns with the overall care approach.

Panel Recommendation 10: Sialorrhea Management

Moving on to panel recommendation number ten, which addresses sialorrhea in patients with neuromuscular diseases. In such cases, the panel suggests commencing with a therapeutic trial of an anticholinergic medication as the initial treatment option. This approach serves as the primary line of therapy for managing sialorrhea in these patients. Sialorrhea is a prevalent issue in NMD, especially notable in ALS, and can elicit significant distress, leading to a diminished quality of life. It also amplifies the risk of aspiration and pneumonia due to challenges in swallowing, safeguarding the airway, and fostering effective coughing. Consequently, the panel strongly recommends initiating treatment with a trial of anticholinergic agents, which offer affordability and accessibility. 

Panel Suggestion:

The panel recommends starting with a trial of oral anticholinergic medication. We are familiar with anticholinergic medicines like DuoNeb and Atrovent, which block cholinergic responses. This action not only addresses their intended effects but also has a secondary effect of reducing secretions. This dual function is important to grasp when considering their use for conditions like sialorrhea.

Sialorrhea

Figure 5. Diagram of salivary glands. (Blausen Medical WikiJournal of Medicine, CC BY 3.0). 

Sialorrhea, also known as drooling, is characterized by the presence of excessive saliva beyond the lip margin seen in Figure 5. This condition can manifest due to various neurologic disorders, including ALS, cerebral palsy, Parkinson's disease, and medication side effects. In children, cerebral palsy is the most frequent cause of sialorrhea. Anticholinergic medications can be beneficial for managing excessive drooling in children as they offer a drying effect. Beyond its role in this context, anticholinergics are known to block acetylcholine, which can affect bodily functions, including heart rate regulation.

In the accompanying image (Figure 5), you can observe the various affected areas when someone experiences sialorrhea. The buildup of excessive secretions can pose significant challenges. While anticholinergic drugs are a valuable option, they aren't the sole approach available for addressing this issue.

Panel Recommendation 11: Botulinum toxin (BT) Therapy for Salivary Glands 

For patients with NMB and sialorrhea who have an inadequate response or are intolerant of the side effects of anticholinergic therapy, the panel suggests using Botulinum toxin (BT) or Botox.

Panel Suggestion:

A potential alternative for individuals facing challenges with anticholinergic therapy due to side effects is Botulinum Toxin (BT) treatment targeted at the salivary glands. Some individuals find it difficult to tolerate anticholinergic agents because they can impact heart rate regulation, accelerating the heart rate by blocking the slower processes. In cases where anticholinergic therapy is not suitable, the panel also suggests considering the use of Botox injections for the salivary glands. This option stands as a valid panel recommendation for addressing sialorrhea.

Panel Recommendation 12: Salivary Gland Radiation

Panel recommendation number 12 addresses the same concern with sialorrhea. It pertains to patients with neuromuscular disease and sialorrhea who face an inadequate response to or cannot tolerate the side effects of anticholinergic therapy. Alongside the option of using Botox injections, the panel recommends considering salivary gland radiation as an alternative. This treatment approach is more comprehensive and specific to the disease context.

Neuromuscular diseases can present significant challenges, particularly when accompanied by uncontrollable drooling due to sialorrhea. In such cases, exploring advanced options like salivary gland radiation underscores the gravity of the issue and the need for tailored interventions to enhance the patient's quality of life.

Panel Suggestion:

The panel suggests using salivary gland radiation as an option when anticholinergic therapy or Botox injections do not yield the desired results. This approach serves as an additional avenue for managing sialorrhea in patients with neuromuscular disease, particularly when other interventions prove ineffective. The aim is to provide a comprehensive range of options to address this challenging condition and improve patients' well-being.

Panel Recommendation 13: Glossopharyngeal Breathing for Lung Volume Recruitment (LVR) and Airway Clearance 

For patients with NMB and hypoventilation, the panel recommends Glossopharyngeal Breathing (GPB) for lung volume recruitment (LVR). This technique is preferred due to its low cost and the patient's ability to perform it independently. The technique requires minimal training or assistance. 

Panel Suggestion:

For patients experiencing hypoventilation, an approach to consider is glossopharyngeal breathing (GPB) for lung volume recruitment. This technique aims to counter the development of atelectasis by recruiting alveoli. In essence, GPB is a positive pressure breathing technique suggested by the panel to aid failing respiratory muscles, keeping in mind the context of muscle weakness.

The glottis plays a key role in this method, trapping air in the lungs while a gulp of air is drawn in. While numerous breathing techniques exist, GPB emerges as a valuable option highlighted by the panel for its potential to enhance lung function and counter the challenges associated with muscle weakness and hypoventilation.

Glossopharyngeal Breathing (GPB)

Glossopharyngeal breathing offers a distinct approach to enhance voice and cough effectiveness. This technique focuses on trapping air within the lungs through a stepwise process. Beginning in a relaxed position, the patient sequentially employs the glottis to retain air while taking a gulp of air, followed by a passive exhalation. This method effectively maintains lung expansion and function by harnessing the glottis to hold air, ensuring optimal lung capacity and assisting in voice and cough improvement. This recommendation presents an alternative breathing technique to optimize lung function and address issues like muscle weakness.

Panel Recommendation 14: Reduced Cough

Panel recommendation number 14 addresses patients with neuromuscular diseases who experience diminished cough. Recognizing the critical significance of effective coughing, the panel suggests the adoption of manually assisted cough techniques independently or added to other modalities such as LVR. These techniques encompass various approaches to aid patients in achieving a productive cough.

Panel Suggestion:

The panel recommends employing these cough techniques independently or integrating them with other modalities, like lung volume recruitment (LVR). Essentially, any effective cough technique that can be utilized is encouraged. The panel emphasizes the value of attempting various assisted cough techniques, including those previously employed, to enhance the patient's ability to clear their airways effectively.

Panel Recommendation 15: Reduced LVR

Panel recommendation number 15 pertains to patients with neuromuscular disease experiencing diminished lung volume recruitment (LVR) and cough capabilities. In such cases, the panel advises the utilization of standard LVR techniques employing a handheld resuscitation bag or a mouthpiece.

Panel Suggestion:

The technique itself is cost-effective, yet it does require training and assistance. Notably, manual-assisted coughing proves more effective when combined with volume recruitment or expiratory cough assist. The essence of this technique lies in utilizing a handheld resuscitation bag or a mouthpiece to facilitate coughing. However, it's essential to provide patient training for proficient execution. This recommendation emphasizes a comprehensive approach to enhance lung function and cough effectiveness.

Panel Recommendation 16: Reduced Cough Effectiveness

For patients with neuromuscular disease experiencing compromised cough effectiveness that is not responsive to alternative techniques, the panel recommends integrating a regular mechanical insufflation-exsufflation (MI-E) cough assist device. You might be familiar with these devices, which aid in clearing secretions.

Panel Suggestion:

The panel's suggestion to employ MI-E devices underscores their importance in addressing excessive secretions and the associated risks posed by muscle weakness. The accumulation of excess secretions can lead to serious issues, including atelectasis. Consequently, the recommendation urges the use of cough assist devices like MI-E to mitigate these concerns. While various types of devices are available, the one shown here represents the approach. Assisting individuals with coughing is vital for maintaining respiratory health, whether they have neuromuscular diseases or not. However, providing assistance becomes even more critical for those with neuromuscular conditions due to the challenges they face. Handheld devices play a significant role in aiding individuals in effectively clearing their airways and managing secretions. The goal is to ensure optimal lung function and minimize the potential complications associated with muscle weakness and compromised cough effectiveness.

Panel Recommendation 17: Secretions

Panel recommendation number 17 focuses on secretion management, introducing various devices. For patients experiencing challenges in clearing secretions due to neuromuscular diseases, the panel suggests the utilization of High-Frequency Chest Wall Oscillation (HFCWO), commonly known as vest therapy, for secretion mobilization. In addition, HFCWO is suggested to be combined with airway clearance therapies such as cough assistance or LVR.

Panel Suggestion:

This approach is recommended and can be combined with other airway clearance devices like the cough assist or lung volume recruitment (LVR). These familiar devices, commonly used in our practice, gain enhanced significance in the context of neuromuscular diseases. Notably, the panel recommends using the vest as part of a comprehensive strategy to ensure effective coughing and secretion management. The primary objective is to prevent potential complications that may arise when patients struggle to clear their secretions effectively.

The panel has devised a flowchart (click on the link to access or refer to the course handout) for initiating non-invasive ventilation (NIV) in patients with NMD who exhibit respiratory failure symptoms. Beginning at the top left with the neuromuscular disease, the flowchart outlines a structured process. This includes recommendations for performing PFTs every six months. If criteria are met, progression to the next phase occurs. In instances where criteria are not met, scheduling a follow-up PFT in six months is suggested. Monitoring for current symptoms is essential. If the criteria are met, NIV initiation can be considered. Additionally, ABG and sleep study results are considered, demonstrated in the flowchart.

This flowchart effectively breaks down the discussed criteria, including forced vital capacity thresholds and symptoms, providing a visual representation that aids in understanding and retention. Consider utilizing this informative slide as a resource to reinforce the concepts discussed in our conversation. While not mandatory, this new research offers valuable insights into managing patients with neuromuscular diseases.

Clinical Scenarios

Question 1:

When caring for a patient with an NMD, the panel suggested that a PFT be done at least how often?
A. Once a year
B. Every 3 months
C. Every 6 months
D. PFTs are not recommended for NMD patients

Rationale:

For patients with neuromuscular diseases prone to respiratory failure, the recommendation is to schedule evaluations at least every six months, aligned with the progression of the particular neuromuscular condition. When discussing Pulmonary Function Tests (PFT), it is crucial to focus on Forced Vital Capacity, Slow Vital Capacity, as well as assessing respiratory muscle strength through Maximum Inspiratory Pressure (MIP) and Maximum Expiratory Pressure (MEP). Clear comprehension of these elements is essential as they form an integral aspect of the treatment protocol for patients afflicted by neuromuscular disorders.

Question 2:

For patients with systemic NMD who have a normal PFT and overnight oximetry (ONO), what is suggested by the panel to assess whether noninvasive ventilation (NIV) is needed?
A. Polysomnography
B. Chest X-Ray
C. ECG
D. EEG

Rationale:

In the case of patients affected by systemic neuromuscular diseases who exhibit normal overnight oximetry results but require assessment for the necessity of non-invasive ventilation, the recommended approach by the panel involves polysomnography. Polysomnography serves as a diagnostic tool to determine the suitability of non-invasive ventilation for systemic patients with normal Pulmonary Function Test (PFT) results. Therefore, when patients present with normal overnight oximetry data, the appropriate course of action involves conducting a polysomnography, commonly referred to as a sleep study, to ascertain the potential requirement for non-invasive ventilation.

Question 3:

For the treatment of patients with NMD and sleep-related breathing disorders, the panel suggests which of the following?

• Tracheostomy
• Bronchodilator therapy
• PFT
• Noninvasive Ventilation (NIV)

Rationale:

When addressing the treatment approach for patients with neuromuscular diseases who exhibit sleep-related disorders, and considering options such as tracheostomy, bronchodilator therapy, Pulmonary Function Tests (PFT), or non-invasive ventilation, the recommended course of action is to opt for non-invasive ventilation.

This decision aligns with the criteria established by the American Academy of Sleep Medicine (AASM) for adults and the European Respiratory Society's guidelines for pediatric patients experiencing sleep-related breathing hypoventilation. As per these guidelines, once patients meet the specified criteria during evaluations, it becomes appropriate to initiate non-invasive ventilation. It is noteworthy that the decision to employ non-invasive ventilation applies to both adult and pediatric patients, depending on which set of guidelines is applicable to the specific case.

Question 4:

For patients with NMD and sialorrhea, the panel suggests the use of which treatment?

• Sympathomimetic bronchodilator medication
• Anticholinergic medications
• Steroidal medications
• Nonsteroidal anti-inflammatory drug

Rationale:

In the scenario where a patient with a neuromuscular disorder is experiencing issues with excessive drooling and impaired fluid control, the recommended solution is the utilization of anticholinergic medication. The panel suggests an initial trial of a cost-effective oral anticholinergic medication as a suitable intervention.

When considering anticholinergic drugs, examples such as Atrovent and Spiriva are relevant. These medications work to address the symptoms associated with excessive drooling and inadequate fluid control caused by neuromuscular disease.

Question 5:

After evaluating patients with NMD and difficulties with secretion clearance, the panel recommends using which for secretion mobilization?

• Suctioning with a large catheter
• High-Frequency Chest Wall Oscillation (HFCWO)
• Incentive spirometer
• Tracheostomy

Rationale:

To facilitate the movement and clearance of secretions, a strategy often employed is secretion mobilization. The term "mobilization" signifies movement in this context. An effective solution, as recommended by the panel, is the utilization of high-frequency chest wall oscillation, commonly known as the vest. This approach has been suggested by the panel for enhancing secretion mobilization.

Furthermore, it is worth noting that incorporating vests, like the high-frequency chest wall oscillation device, can be enhanced by combining them with other airway clearance devices. This combined approach aligns with the panel's suggestions for optimizing the effectiveness of secretion mobilization techniques.

Summary

 Our discussion has revolved around neuromuscular diseases and their respiratory management. The panel's recommendations have been formed based on an amalgamation of 128 studies. These recommendations are categorized as graded and consensus-based statements.

These guidelines underscore the challenges posed by limited research, largely reliant on observational data from ALS patients. Our primary focus has been on pulmonary function assessment. Low-cost interventions have been highlighted, particularly forced vital capacity (FVC), slow vital capacity, maximum inspiratory and expiratory pressures, including SNIP (nasal inspiratory pressure), and peak cough flow. These parameters should be considered in patients with neuromuscular diseases, bearing in mind clinical practice variances.

Furthermore, the panel endorsed the utilization of pulmonary function tests (PFTs) at least every six months, based on the specific neuromuscular disease progression. The essentials include FVC, MIP, and SNIP. For those with normal PFTs but sleep-related disorders, polysomnography is recommended to assess the need for non-invasive ventilation.

In the context of chronic respiratory failure in neuromuscular disease patients, non-invasive ventilation is advocated. The criteria include FVC dropping below 80% of predicted with symptoms or below 50% without symptoms, as well as SNIP/MIP falling below 40 cmH2O or the presence of hypercapnia.

Polysomnography aids in predicting the timing of non-invasive ventilation. In specific cases, PFT criteria alone suffice. Non-invasive treatment aligns with hospital goals, emphasizing an individualized approach. For patients with bulbar impairment, toleration of non-invasive ventilation can be challenging. Mouthpiece ventilation is considered, along with nocturnal mechanical ventilation for those with preserved bulbar function. Management includes anticholinergic medication or Botox for sialorrhea. In severe cases, salivary gland radiation might be necessary.

For lung recruitment, glossopharyngeal breathing can be explored. Reduced cough capacity necessitates assisted cough techniques, potentially utilizing insufflation-exsufflation devices. Secretion mobilization is vital, with options including vests and PEP devices to aid in preventing complications from impaired cough reflexes. This comprehensive approach, from PFTs to non-invasive ventilation, underscores the commitment to aiding patients facing neuromuscular diseases.

References

Berry, R. B., Chediak, A., Brown, L. K., Finder, J., Gozal, D., Iber, C., Kushida, C. A., Morgenthaler, T., Rowley, J. A., Davidson-Ward, S. L., & NPPV Titration Task Force of the American Academy of Sleep Medicine (2010). Best clinical practices for the sleep center adjustment of noninvasive positive pressure ventilation (NPPV) in stable chronic alveolar hypoventilation syndromes. Journal of clinical sleep medicine: JCSM : official publication of the American Academy of Sleep Medicine, 6(5), 491–509.

Khan, A., Frazer-Green, L., Amin, R., Wolfe, L., Faulkner, G., Casey, K., Sharma, G., Selim, B., Zielinski, D., Aboussouan, L. S., McKim, D., & Gay, P. (2023). Respiratory Management of Patients With Neuromuscular Weakness: An American College of Chest Physicians Clinical Practice Guideline and Expert Panel Report. Chest, S0012- 3692(23)00353-7. Advanced online publication.

Silva, I. S., Pedrosa, R., Azevedo, I. G., Forbes, A. M., Fregonezi, G. A., Dourado Junior, M. E., Lima, S. R., & Ferreira, G. M. (2019). Respiratory muscle training in children and adults with neuromuscular disease. The Cochrane database of systematic reviews, 9(9), CD011711. 

Warren, V.C. (2002). Glossopharyngeal and neck accessory muscle breathing in a young adult with C2 complete tetraplegia resulting in ventilator dependency. Physical
therapy, 82 6, 590-600.

Editor’s note: This text-based course is an edited transcript of the webinar, Oscillating Between Dysfunction Function in Healthcare, presented by Tabitha Ogle, MS, BCC, RRT. 

It is recommended that you download the course handout to supplement this text format.

Learning Outcomes

• Describe leadership the necessary skill set for individual team success
• Recognize strategies for improving RT retention value long term
• Discuss focused areas for growth advancement in the RT profession

Introduction

In this course, we aim to provide awareness and understanding of the multitude of factors that impact functionality within healthcare, particularly for respiratory therapists and other clinical care team workers. By increasing awareness, we create an opportunity for individuals to take control of their reactions, responses, and preparedness in the face of these factors. I have a unique background as an Army-trained respiratory therapist, and I am passionate about advocating for others. With over 15 years of diverse clinical care experience, I have observed various trends within different clinical teams and organizations, which has fueled my curiosity about what truly creates functionality in healthcare.

My employee-first mindset has led me to pursue a degree in industrial organizational psychology. My Master of Science program focuses on analyzing the human aspect within organizations, specifically exploring what enables employees to thrive and what factors contribute to their failure. This academic focus, coupled with my personal experience and observations, has shaped my career goal of advocating for and empowering all of you—the individuals who truly matter in the healthcare system. By sharing this information and knowledge with you, I aim to equip you with the awareness and understanding needed to take control of your reactions, responses, and preparedness within your healthcare roles. Together, we can work towards creating a more functional and supportive healthcare environment for everyone involved.

Oscillating Principle

• Defined as the fluctuation between two things
• Even with ideal working environments empowering mindsets, we must honor that some shifts will be more dysfunctional than others despite external influences from the organization

We all know as respiratory therapists that the oscillating principle is the fluctuation between two things, so how fitting for it to be an oscillation between functionality and dysfunctionality in healthcare. Even with an empowering working environment mindset, we must honor that some clinical shifts will be intensely more dysfunctional than others. By honoring that, we can actively prepare to improve the quality of the area environment in which we work. I will navigate this information to highlight the complexities and the dysfunction and touch on the functionality inside the organization's clinical leadership. After I provide that information, I will give you tools and tips on enhancing your functionality within different clinical teams and supportive work environments.

Oscillating in Healthcare 

• Healthcare is a challenging organization to work in due to a multitude of factors:
  • High emotional cost occupation 
  • Human exchange   
  • Complex working environments
  • Complex working matrix
  • High workloads
  • Lack of or limited resources 

Working in healthcare can be a challenging occupation for various reasons, including the high emotional cost associated with it. Healthcare professionals often find themselves in life-threatening situations where quick and decisive action is required. Dealing with such situations repeatedly over a prolonged period can take a toll on their emotional well-being. The nature of healthcare work involves intense human emotional regulation, control, and interaction. Healthcare providers need to maintain composure and empathy while handling patients who may be in distress or facing serious health issues. This constant emotional exchange can be draining and impact the well-being of healthcare professionals. To address these challenges, there has been a growing focus on patient psychological safety factors in recent years. The advocacy for patient psychological safety aims to create a supportive environment that not only benefits patients but also recognizes the emotional needs of healthcare professionals. By prioritizing psychological safety, healthcare organizations strive to reduce emotional stress and create a more sustainable work environment. High emotional cost occupations typically refer to roles that involve significant face-to-face or voice-to-voice human interaction, such as healthcare, social work, counseling, emergency services, and similar fields. These professions require individuals to navigate complex emotional situations, making self-care and emotional support crucial for those working in these areas. Couple that with the intensity of life or death or medical issues.

We also work in a complex working environment, I am going to touch more on that psychological safety factor aspect. Inside healthcare, we are operating under some really interesting psychological phenomenons, which sounds super cool, but when you look at it, it creates a very complex working environment, the ability for us to function. In the context of a complex working environment, such as healthcare, the status quo bias can indeed contribute to the acceptance of abnormal or abusive working situations. In healthcare, where the focus is primarily on patient care and well-being, it is crucial to address and rectify any issues related to abusive work environments, bullying, operating with a lack of limited resources, working in unhealthy or unregulated working conditions, not being able to get our breaks and other challenges. However, the status quo bias can hinder the willingness or motivation to challenge these norms and bring about necessary changes.

Then that falls with another concept called "group think." Groupthink refers to the phenomenon where a group of people prioritizes consensus and harmony over critical thinking and objective analysis, leading to faulty decision-making. This concept has been observed in various fields, including healthcare. In clinical rounds, it's not uncommon for groupthink to occur, where individuals may hesitate to challenge a statement or decision made by a more authoritative figure. This can happen even if there are concerns about the accuracy or appropriateness of the suggestion. The fear of speaking up or going against the consensus can contribute to the perpetuation of potentially incorrect or suboptimal practices. For example, an advanced care provider states, "Albuterol for CHF," everyone kind of nods along, even though we know that that is not the most appropriate first choice. That falls into a "blame culture." I know a lot of respiratory therapists can resonate with this blame culture inside healthcare. "It is everyone else's fault," instead of sitting back and looking at the problem, trying to find the root cause analysis, "Why did it happen? What can we do to move forward to find a more functional solution?" Instead of doing that, a lot of times, we point fingers, "Well, the nurse never called, or respiratory never showed up." Blame culture can exacerbate the problem of groupthink. When individuals fear blame or retribution for voicing their opinions or suggesting alternative solutions, they may be more inclined to go along with the majority, even if they have reservations. This can hinder the identification of the root causes of issues and impede progress toward finding more effective solutions.

On top of that, we have a complex working matrix inside healthcare. As respiratory therapists, we tend to be a little bit more nomadic. We jump around throughout the hospital, and with that, we get to see these various working matrices. This mobility allows you to interact with various care teams and gain exposure to different working matrices. It can provide you with a broader perspective and a deeper understanding of how different healthcare professionals collaborate to meet the diverse needs of patients. For example, one patient could have a primary physician, a cardiologist, a post-op, and so forth. Each one of those individuals on that care team creates a complex working matrix because everyone has a say in what is going to transpire for this patient. As a result, creates a lot of frustration when you need to communicate something like an arterial blood gas report. You call one physician, they tell you to call another, and you place the note in the chart. The situation where you need to communicate important information but encounter obstacles, such as having to contact multiple physicians or deal with complex care models, is unfortunately common in many hospitals. The high-volume care models in place in most US hospitals can indeed contribute to increased complexity and inefficiency in communication. This can lead to additional tasks and responsibilities for healthcare professionals, further burdening their already busy schedules.

This complex and challenging working environment, particularly in the healthcare industry, creates issues that include high-volume care models, difficulty in interacting and engaging with others, nomadic behaviors such as status quo and groupthink, a blame culture, and a lack of or limited resources. Moreover, the emotional toll of this environment, coupled with a lack of support from the organization, can intensify the challenges faced by healthcare professionals. When time is limited, and there are numerous tasks to be accomplished, it becomes difficult to maintain a high level of compassion and empathy towards patients and colleagues. 

Now when I say resources, that can be a gamut of things. It encompasses various aspects, including human capital (having enough trained and skilled personnel), equipment, education, training, and effective communication channels. These resources are crucial for maintaining a cohesive and collective approach to the job.

In many healthcare organizations, there is often a mission statement that emphasizes innovation and patient care. This mission statement is meant to provide employees with a sense of purpose and connection to something greater than themselves. However, when the organization operates with limited resources and fosters negative emotional exchanges and leadership or employee relationships, it can create mistrust among employees. This mistrust leads to disengagement, which is detrimental in a healthcare setting where active engagement is vital. Conflicting organizational behaviors can also contribute to a toxic work culture. For example, if a hospital promotes itself as the "greatest place to work" while its clinical teams are facing crisis staffing or a massive staffing deficit, it can come across as tone-deaf and lacking awareness of the challenges and conflicts experienced by the clinical teams.

Addressing these issues requires a multi-faceted approach. Organizations should prioritize providing sufficient resources, including staffing, equipment, education, and training, to ensure employees can perform their roles effectively. Open and transparent communication channels should be established to foster understanding and trust within the organization. It's important for leaders to actively address and resolve conflicts, promote a positive work culture, and align their actions with the mission statement to create an environment where employees feel valued and supported.

Organization Complexity 

• Healthcare is in a current life-cycle of growth. 
• The palpable divide between organizational operations clinical care practices. Demonstration of this divide is reflected in high-volume care models. 
• Outdated care models practices.
• Counterintuitive staffing retention practices ultimately cause a decrease in profitability. 
• When we participate in interpersonal conflict or engage in dysfunctional work behavior, the organization ultimately wins.

Organizational complexity inside healthcare, every organization throughout the world goes through what we call business life cycles. Healthcare is currently going through a life cycle of growth. There is a lot of push and pull for different regulations and different requirements. It is in that, like puberty, midlife crisis kind of realm. No one really knows which step to take, adding to that mistrust within the organization. For all of us on the clinical side, we have to honor there is a palpable divide between the organizations' operation and clinical care practice. This is demonstrated and reflected in those high-volume care models, which are not only devastating for employees and patients but are financially counterproductive. On top of that, we have our outdated care model practices. If we know what the best care practice states, but we are not following that, it creates animosity and frustration. Our counterintuitive staffing retention practices ultimately add to that decrease in profitability.

When we as employees participate in those interpersonal conflicts or engage in dysfunctional work behavior, the organization ultimately wins, which sounds crazy when I say it, but here is some information to back up that statement. When we are actively fighting amongst ourselves, creating conflict between ICU and OR, or ICU and ER, or the respiratory day shift, versus respiratory night shift, we become distracted. We are at each other for the issues, it is a lack of support from the organizational structure. If we do not have enough people to do the job, of course, we are going to be at odds with each other because we are all stretched incredibly thin. What is more empowering is to work together and ask for systematic change.

When we are fighting amongst ourselves, the organization wins because it can say, "Listen, healthcare is dysfunctional. That is the way it is." I cannot tell you how many times I have heard that statement out of CEOs CFO, 's and CMOs' mouths. When I say, "We have palpable problems within healthcare," it is okay to admit as long as we focus on the solution-driven efforts to improve it. I always get the rebuttal, "But healthcare's dysfunctional." Well, it is at this time, but like any problem, there is a palpable solution.

Complexity in Leadership 

It is true that clinical leaders face unique challenges in balancing the clinical and organizational aspects of their roles. They often have to navigate between the need to provide quality patient care and manage the resources and budgets within their organizations. One of the key challenges for clinical leaders is the constant pressure to manage budgets effectively while also ensuring adequate staffing levels. This can create tension between clinical needs and financial constraints, making it difficult to strike the right balance. Clinical leaders are often pulled in different directions, as they need to advocate for the resources and staffing necessary to deliver high-quality care while also being mindful of the financial realities of the organization. Employee turnover and burnout are major concerns in healthcare, and clinical leaders have to address these issues within their teams. They must find ways to create a supportive work environment, promote employee well-being, and implement strategies to reduce burnout and turnover rates. Building trust among the staff is crucial, as mistrust within the organization can impede effective leadership and teamwork.

The working environments in healthcare can be complex, with a variety of stakeholders and competing interests. Clinical leaders need to navigate this complexity while ensuring that patient care remains the primary focus. This involves managing relationships with other departments, coordinating care across different specialties, and addressing conflicts or misalignments that may arise. Miscommunication and misinformation can further complicate the leadership role in healthcare. Clinical leaders need to promote clear and effective communication channels within their teams and address any misunderstandings or rumors that can undermine trust and teamwork. They also have to stay updated on the latest research and best practices to ensure that accurate information is being disseminated within the organization. Leadership development is another area of concern. Clinical leaders often have limited opportunities for formal leadership training and development, which can hinder their ability to manage their teams and navigate complex situations effectively. Investing in leadership development programs can help equip clinical leaders with the necessary skills and competencies to succeed in their roles.

Clinical leadership faces a multitude of challenges, including balancing clinical and organizational priorities, managing budgets and staffing, addressing turnover and burnout, building trust and alignment within the organization, navigating complex working environments, addressing miscommunication and misinformation, and investing in leadership development. Effective clinical leaders must be skilled at managing these complexities to ensure the delivery of high-quality care and the success of their teams.

Leaders that Enhance Function

If any of you peruse LinkedIn, you'll hear this array, a rainbow of sorts of various effective leadership strategies that is confusing for clinical leaders who are trying their best to do well but are being pulled in a multitude of directions. Absolutely, when evaluating leadership in any context, including clinical leadership in healthcare, it is important to focus on behaviors and abilities rather than solely relying on personality traits. The qualities and behaviors mentioned are crucial for effective leadership in healthcare settings. Here is a breakdown of the key points:

• Ability to influence and motivate: Effective clinical leaders should possess the skills to inspire and motivate other medical professionals, encouraging them to perform at their best.
• Alignment with organizational mission: Leaders should actively support the mission and goals of the healthcare organization, working towards its overall success.
• Improved patient care: Clinical leaders should prioritize and strive for continuous improvement in patient care outcomes, ensuring that healthcare services meet or exceed standards.
• Following standard procedures: Leaders need to ensure that established protocols and procedures are adhered to, promoting consistency and safety in healthcare delivery.
• Creating a supportive environment: It is important for leaders to foster a supportive environment that respects and values diverse cultural backgrounds and social needs, allowing all individuals to thrive.
• Employee growth and development: Effective leaders invest in the growth and development of their employees, providing opportunities for learning and advancement within the healthcare organization.
• Equality and fairness: Leaders should advocate for equality and fairness, treating all individuals with respect and ensuring equitable opportunities for growth and recognition.
• Advocacy for best practices: Clinical leaders should support and encourage their employees to adopt best practices, staying updated with the latest research and evidence-based approaches in healthcare.

It's important to remember that while not everyone may personally connect or vibe with every leader, the focus should be on their ability to fulfill their role effectively and serve as a resource for their team. By emphasizing these behaviors and qualities, organizations can strive for effective and impactful leadership in the healthcare sector.

Leaders that Create Dysfunction

• Discourage employees’ ability to advocate for patients, staff, or themselves. 
• Intentionally or unintentionally create injustices, mistrust, misalignment, while adding to the chaos. 
• Avoid problems or deflect issues rather than finding the solution.
• Allow an abusive work environment.
• Demonstrate counterproductive work behaviors. 
• Work from a place of ego. 
• Refuse to provide training or employee development

Unfortunately, dysfunctional leadership can have a detrimental impact on organizations and their employees. Your description highlights several negative traits and behaviors that can contribute to dysfunction within a leadership role. Some leaders may indeed discourage employees from advocating for patients, staff, or themselves, which can stifle innovation and prevent necessary changes from being implemented. Leaders who create injustice, mistrust, and misalignment often fail to establish a culture of fairness, transparency, and open communication. This can lead to conflicts, decreased morale, and a lack of cooperation among team members. Additionally, leaders who avoid problems or deflect issues rather than find solutions can perpetuate a cycle of unresolved problems, hindering progress and growth within the organization.

Allowing abusive work environments to persist is not only detrimental to employee well-being but also undermines productivity and organizational success. Counterproductive work behaviors, such as toxic competition or favoritism, can create a hostile atmosphere that hinders collaboration and innovation.

Leaders who operate from a place of ego and prioritize their own interests over the well-being of their team or organization may alienate employees and hinder teamwork and cohesion. Refusing to provide training or employee development opportunities limits growth and can lead to stagnation within the organization.

Overall, dysfunctional leadership behaviors have far-reaching negative consequences and can impede the success and growth of an organization. It is crucial for organizations to recognize and address these issues, fostering a healthy and supportive leadership culture that encourages employee advocacy, growth, and development.

Navigating around the Noise 

Creating awareness is an essential first step in navigating around the challenges described in dealing with leaders or colleagues who may perpetuate patient abuse, staff abuse, or discourage best practices. This is unfortunately reflected in quite a few leaders inside healthcare. Whether it is your direct leader, a nursing director, or a nursing manager, you have to interact with people that sometimes allow for patient abuse to the staff, staff abuse to the staff, discourage you from advocating for best practice, or tell you to brush it off, "that is just the way Dr. Blah Blah Blah is, you have to let it go, or this is how this respiratory therapist is, and you need to let it go." If you do not, I will get into that further, but here are some tools to navigate around this noise. 

Here are some steps you can take to create awareness and address these issues:

• Self-awareness: Start by understanding your own values, principles, and boundaries. Reflect on what you consider to be ethical and professional behavior in healthcare. This self-awareness will help guide your actions and responses.

What is the powerful influence of this person over me? Is this the physician that I feel muted around because they are brass, the way they respond, or out of fear of embarrassment? We have to honor that everyone is a human, and as long as we are performing our job at or above expectation and doing what is right, the likelihood of having negative retaliation for communicating and advocating is low. If it does happen, you have many steps that you can take to re-advocate for yourself. A tool I learned in the military is to respect the person's position. We do not have to respect the person. In the military, I would respect the rank on their chest, but I did not have to like them, I did not have to agree with them, but I could use them as a resource, a tool. That leads to finding those resources. What are these clinical leaders? What is their good spot? What is their gold star? What about them that you can use to learn from, grow from, and develop from? Then define your ideal leader.

The power of influence is something that I learned about when I read a book by Vanessa Bowens. She is a sociologist who documented a lot of her clinical studies that helped us realize how influential we are, how influential behavior is, and how influential a position of power can be to us as human beings. She referenced in her book the "smoke study," commonly known as the "smoke-filled room experiment" or the "smoke-filled classroom experiment." She provided her own insights based on similar research conducted by social psychologists Bibb Latané and John Darley in 1968. In the original experiment, participants were placed in a room and unaware that they were part of a study. The room would gradually fill with smoke, simulating a potential emergency situation. The researchers aimed to observe how individuals reacted when they were alone versus when they were in the presence of others who appeared to be unconcerned.

What the researchers found was that when participants were alone in the room, they tended to react quickly and seek help. However, when they were in the presence of passive bystanders (confederates of the experiment), who did not show any concern or take any action, the participants' response time was significantly delayed. They often hesitated, looked at others for cues, and adopted a more passive attitude. This phenomenon, known as the bystander effect, suggests that individuals are less likely to intervene in an emergency situation when they perceive that others are not reacting or taking action. The diffusion of responsibility and the desire to conform to social norms play important roles in shaping individuals' behavior in such situations. The smoke-filled room experiment highlighted the power of influence and social dynamics in shaping human behavior, particularly in emergencies. It emphasized the importance of individual responsibility and the need to overcome the bystander effect by encouraging pro-social behavior and intervention.

When there were two people alone in that room, the first person in the study saw that the other person was not reacting and ended up only reporting the smoke 10% of the time. When asked after, "Why did not you speak up when you noticed the smoke was filling the room?" They said, "I was embarrassed because they were acting like it was not a big deal. I did not want to make a big deal of it." When they did that with a group of three, only 38% of people spoke up. Now, when they did that alone, 75% of people spoke up. My question to all of you is, "Have you ever muted yourself when you knew something was inappropriate or an emergency out of fear of embarrassment because those around you were not reacting to it? An important point about the expectations we often place on healthcare professionals, such as doctors and nurses, due to their experience, professionalism, and expertise. While it is reasonable to have trust in their abilities, it is equally important for patients and other healthcare professionals to recognize the possibility of mistakes or oversights. No one is infallible, and it is crucial not to silence our concerns or observations when a red flag arises.

The fear of what others may think should not deter us from speaking up when we have genuine concerns about patient care or any other aspect of healthcare. It is better to risk feeling embarrassed or being wrong about something than to remain silent and potentially allow a mistake to occur. Patient safety and well-being should always take precedence over concerns about personal pride. Additionally, it is essential to acknowledge that leaders in healthcare, like any other field, are human beings. Placing them on pedestals and expecting them to have all the answers or be flawless in their decision-making is unrealistic and can lead to disappointment. Recognizing their fallibility and understanding that they, too, can make mistakes allows for a more realistic and collaborative approach to problem-solving and decision-making within healthcare organizations. It is crucial not to mute ourselves when we have concerns in healthcare settings. Speaking up, even if it feels uncomfortable, can help prevent potential errors and promote a culture of accountability and continuous improvement.

Furthermore, understanding that leaders are human and can make mistakes allows for a healthier and more productive work environment.Regardless of how amazing a leader may be, they are still human and prone to making mistakes or taking actions that some may disagree with. However, it is important to acknowledge and appreciate the positive aspects that a leader brings to the functionality of a team or organization, as well as the aspects that enhance dysfunction.

Respecting the position and authority of a leader is crucial for maintaining a productive work environment. Recognizing that they hold the responsibility for managing your schedule, professional development, work culture, and compensation is essential. They are also a valuable resource, possessing a broader range of capabilities and experiences. As such, effective communication with your leader is vital for addressing any issues or concerns related to equipment, personnel, or training. While it is natural to have differences in opinions and potential disagreements, approaching these situations with respect and open communication can lead to better outcomes. It's important to remember that leaders, like everyone else, are not infallible and may make mistakes. Constructive feedback and dialogue can help address any concerns and foster a positive working relationship.

Documenting your concerns and possible solutions via email is a proactive approach to addressing issues you have observed. It provides a clear record of your communication and allows your leader the opportunity to respond professionally and address the concerns raised. If they do not respond appropriately, it's important to maintain a record of your communication for future reference. Limiting the amount of influence a dysfunctional leader has on you is a sensible strategy to protect your own well-being and maintain a healthy work environment. By seeking resources and support from other individuals or departments within the organization, you can mitigate the negative impact of dysfunctional leadership.

Defining your ideal leadership qualities is an excellent step toward personal growth and development. By identifying the traits and qualities you admire in leaders, such as compassion, strong communication, equality, and leading by example, you can work towards embodying those qualities yourself. This self-improvement approach allows you to contribute positively to your work environment and potentially inspire others through your actions. Remember that even in challenging situations, focusing on personal growth and striving to be the best version of yourself can lead to positive outcomes. It's important to stay resilient and seek support from colleagues or mentors who align with your values and goals.

Shift to EMPOWER

• Express yourself. 
• Make your career goals clear.
• Practice professional assertiveness. 
• Own your strengths weakness (humility).
• Work on your communication documentation skills.
• Engage with your support network – define your allies.   
• Request what you the team need to be successful. 

I graduated from respiratory school in the military and received deployment orders within six months of completing my respiratory training. The experience was intensely scary, particularly when I arrived overseas as a female NCO leader, assuming the role of a new respiratory therapist in charge of a respiratory department. In that challenging situation, I took the time to reflect and define my personal vision of a good leader. I actively worked towards embodying that ideal over the past 15 years, hoping that my behavior would positively influence those around me.

To aid me in effective leadership, I found the EMPOWER acronym, developed by Dr. Destiny Petri, an industrial organizational psychologist, to be particularly valuable. The acronym stands for the following: Express yourself professionally, meaning the ability to communicate effectively and create solutions; Make your career goals clear with your leader, articulating your aspirations and intentions, such as advancing to an ICU therapist, then to a shift supervisor, and eventually pursuing specific objectives (e.g., X, Y, Z); Practice professional assertiveness, advocating for yourself even in uncomfortable situations, as growth often arises from such moments; Own your strengths and weaknesses with humility, acknowledging areas for improvement without undue concern about others' opinions. Remember, it is crucial to focus on personal growth rather than worrying about what others may think. By nurturing these qualities, you can cultivate effective leadership skills and foster a positive impact on your environment.

If you are concerned that Nurse Blah Blah Blah may spread the word about your intubation skills, it is important to acknowledge it. It is okay if your intubation skills need improvement. Give yourself the opportunity to grow and enhance this skill, treating it as you would a muscle that needs development. Additionally, focus on improving your communication and documentation skills, which are essential for effective professionalism.
Engaging with a support network and defining your allies is crucial. It is important to note that you do not necessarily need best friends at work, as the popular Gallup survey suggests. Instead, focus on finding allies—individuals with whom you can work cohesively, communicate effectively, and encourage professional growth.

When requesting what your team needs to succeed, practicing professional assertiveness is essential. Transformative changes can occur when we communicate directly rather than speaking behind each other's backs. When you face challenges, such as a nurse picking on you or someone throwing you under the bus, it is best to approach that person and address the issue professionally.
One helpful method for addressing such situations is the "what, what, what now" method. Approach the person and express the issue, stating your frustration with their negative comments and how it hinders your ability to work. Emphasize the importance of open adult communication moving forward, and suggest involving the chain of command if necessary. By standing up for yourself, you make it clear that you will not tolerate such behavior. While their response may vary, advocating for yourself is crucial.

Furthermore, effective and assertive communication skills extend throughout your entire shift, including interactions with advanced care providers. Remember the quote I lived by during deployments: "The smartest person in the code is always the calmest." This does not mean the person lacks awareness of the situation's importance; instead, they recognize the importance of maintaining a sense of calmness to maximize their cognitive abilities. When addressing chaotic situations or problematic behaviors during codes, I have often approached physicians afterward to express how their behavior added unnecessary chaos. I highlighted the need for collective and cohesive communication as a team.

In terms of documentation, do not hesitate to document important matters boldly and proudly. Use strong language to describe what happened, the outcomes, and the actions to be taken moving forward. Personally, I am skilled in effective documentation, especially after speaking with individuals about their actions. For instance, when working in a level II NICU, I encountered a physician who frequently insisted on placing every newborn on 100% FiO2—a grossly inappropriate practice. I directly spoke to him, my management, and his medical director, but he remained adamant.

Consequently, I began documenting these instances. I did so to protect my license and in the hope that someone with influential power would address and rectify the situation. In my documentation, I included details such as "Dr. Blah Blah Blah requested 38-week change to be placed on 100% FiO2 by blow by. Patient saturation prior to FiO2 administration is as follows..." I also expressed my disagreement with the order based on good care practices, standard operating procedures, and hospital regulations. I communicated this to the physician, who insisted on continuing the practice and stated that I would monitor accordingly. Throughout my 15 years as a respiratory therapist, I have documented similar instances in a factual manner. Although I have encountered warnings and confrontations, including a NICU physician who expressed dislike for me, my purpose was not to please individuals or the organization. I was there to provide safe and effective care, honoring the oath I took as a respiratory therapist to "do no harm."

If you are discouraged from documenting such incidents, I encourage you to do it anyway. Ensure that your documentation is objective, without excessive emotions or personal feelings. State the facts. Documentation can also address counterproductive, dangerous, or abusive work behaviors in the hopes of initiating change. While change may not always occur, documenting such incidents can prevent them from burdening you emotionally. For instance, if there is a patient in room seven who is known to be abusive, to throw things, cuss, or yell at staff, document it in your notes, send emails, inform the charge nurse, and ensure you document your communication with the charge nurse. They may say, "Oh, we already know about that, you do not need to write it in there, or Everybody knows, you do not need to write it," but how many people have they told, "We already know," how many people are actually documenting it in there? Despite potential discouragement, persist in your documentation efforts, as it may not be as widely known or acknowledged as they claim.

Functional Teams in Healthcare

Functional teams possess specific characteristics, and I will cover their functions and dysfunctions and provide you with tools to navigate these dynamics. In healthcare, being a nomad can be powerful as it allows you to explore different units within the hospital. This enables you to observe how different units function, understand their collective behavior, and identify any deficits that may exist. However, at the core of functional teams lies trust. Trust facilitates effective communication, ensuring that information is conveyed in a way that promotes action. Functional teams also create a supportive work environment, strive for happy and functional working conditions, and possess the ability to collaborate despite limited resources. They foster positive emotional and psychological safety within the hospital.

Moreover, functional teams have the capacity to perform their jobs and share knowledge, resources, tools, and training while working together cohesively for the benefit of patients and the unit as a whole. They exhibit coordination and collective effort in achieving their goals. Building trust within a team is essential, and effective communication plays a pivotal role in this process. Teaching people how to treat you and setting expectations of behavior around you are crucial aspects of fostering trust.

Dysfunctional Teams in Healthcare 

• Counterproductive work behaviors. 
• Judgement vs curiosity. 
• Lack of clarity or inconsistencies around tasks, protocols, or procedures.
• Lack of accountability.
• Self-anchoring bias or “group think”
• Lack of resources.
• Inadequate training or professional development.
• Interpersonal or interdepartmental conflicts

Now, let's shift our focus to dysfunctional teams in healthcare. You can all imagine a team or unit that exhibits some of these behaviors. Dysfunctional teams in healthcare often display counterproductive work behaviors, such as gossip, high absenteeism, disengagement, a blase attitude, resistance to change, groupthink, and a blame culture. They operate from a place of judgment rather than curiosity. For instance, a statement reflecting a judgmental attitude would be, "Did you see the way she tried to do that IV? Of course, she missed. She always misses."

On the other hand, approaching the situation with curiosity would involve saying, "I wonder why she struggles with this IV. Is there a particular tool she is using that is not beneficial for her, or is it her hand movements? I should find a way to support her and help her improve." While the previous example is from a nursing perspective, the same principle applies to respiratory therapists. Instead of judging why someone has not finished their first rounds, approaching it with curiosity might involve wondering if something happened that requires support, such as an issue with a patient, their family, or another staff member. We can foster a more positive and productive environment by shifting from a judgmental mindset to one of curiosity.

Dysfunctional teams in healthcare often arise due to a need for clarity or consistency in tasks, protocols, and procedures. When there is confusion or inequality in how things are done, mistrust and injustice can develop. Questions like, "Why do we have to do it this way when Blah Blah Blah does it differently?" create uncertainty and erode trust. Additionally, a lack of accountability contributes to team dysfunction. When no one takes responsibility, or it is unclear who is accountable for certain tasks, it becomes challenging to work effectively.

Self-anchoring bias, also known as status quo bias or groupthink, can further perpetuate dysfunction in teams. Accepting problems or dysfunctions as normal rather than actively seeking solutions or change is a common trap. Anchoring ourselves to the belief that healthcare dysfunction is how things are, prevents us from actively addressing and improving the situation. Inadequate or limited human capital or equipment resources significantly impact team functionality. It would be impossible to dig a moat with beach shovels in a day, and proper equipment is essential for performing our jobs accurately, effectively, and safely. Likewise, no single person can effectively care for an entire unit. Insufficient staffing and resources create challenges and dysfunction within teams.

Similarly, when there is a lack of training or professional development opportunities, it contributes to team dysfunction. It is concerning when hospitals expect employees to know everything within a few shifts, especially considering the limited resources available for training. Adequate training is vital for the functional performance of the team.

Interpersonal and interdepartmental conflicts also contribute to team dysfunction, as they create mistrust and division. Rather than being torn apart by conflicts, teams should strive to work together cohesively. Ironically, conflicts often arise during patient transfers between departments such as the ER and ICU or ICU and OR. Managing these situations differently and seeking more effective solutions can minimize or even resolve conflicts.
Addressing these dysfunctions and striving for functional teamwork is crucial in providing high-quality care and fostering a positive work environment in healthcare settings.

Navigating Around the Noise (cont'd)

• Define your objective
• Manage emotions attitudes.
• Professional direct communication. 
• Understand your impact purpose.
• Respect the position.
• Document effectively. 
• Encourage others to participate empower them through the process.
• Speak up to enhance safety measures. 
• Focus on “what's right” versus “who's right”

To navigate around the noise of a dysfunctional team, there are several strategies we can employ. First and foremost, we must define our personal objectives and encourage the team to define them. This clarity of purpose helps us shift our focus from drowning in the problems to navigating around the noise.

Managing our emotions and attitudes is crucial. Our emotions are our number one superpower, and the most powerful move we can make is not to allow someone else to impact those emotions. Refusing to be bothered by someone's attempts to trigger intense emotions or attitudes is a significant gut punch to their intentions. One approach, as suggested by a Harvard executive coach, is to respond to disrespectful behavior by asking the person, "Are you okay? Is everything all right?" This redirects the interaction and allows us to maintain our composure.

Direct and professional communication is key to navigating dysfunctional team environments. We should clearly communicate our needs, expectations, and advocate for ourselves, our patients, and other staff members. Understanding our impact and purpose helps us maintain focus. For example, we can enter a shift with goals such as making patients or families feel safe, completing rounds thoroughly, or supporting other staff members. While we may not have to get along with every individual, we can still respect their impact on the patient's well-being.

Effective documentation remains important. If we have communicated a concern professionally and directly, documenting it ensures the issue is recorded and allows further action if necessary. Encouraging others to participate and empowering them through the process is also essential. We should promote a culture where people feel comfortable speaking up and honoring their impact on patient care.

In navigating dysfunctional teams, we should focus on doing what is right rather than insisting on being right. The focus should be on the best outcomes for patients, their families, and the team as a whole. Additionally, it is important to be aware of behavior contingent theory. This theory suggests that behaviors become a sense of normalcy as a way for individuals to adapt and adjust. Whether superficial or deeply emotional behaviors, we must acknowledge and create awareness around them. We can work towards a healthier and more functional team environment by adapting, adjusting, and fostering change.

Steps to Enhance Teams 

To enhance our team, we must avoid gossiping and badmouthing others. Having a best friend at work can sometimes lead to counterproductive behavior, such as engaging in gossip. Instead, we should focus on cultivating allies—people we trust and can work with cohesively. These allies become our support system for creating systematic change and promoting teamwork through collaboration, resource sharing, and professional development.
It is important to stop making excuses for toxic people or behaviors. While we may find certain individuals charismatic or entertaining, we must recognize if their actions are toxic or detrimental to patient care or the work culture. We need to prioritize patient safety and the team's well-being over personal preferences.

Encouraging effective communication, trust, and cohesion is crucial for fostering the power of the team. This includes bolstering psychological safety, which is built upon a foundation of trust, advocacy, and empowerment. Clearly communicating team members' roles and priorities is vital. Utilizing opportunities for communication, such as riding in an elevator with a nurse or another care team member, can be beneficial. Taking the time to discuss plans, coordinate actions, and address concerns helps create a smoother workflow and reduces misunderstandings. For example, in a high-risk delivery situation, communicating with the nurse about intubation plans, medication administration, and areas of focus fosters teamwork and clarity.

We should cultivate work relationships rather than seeking best friends. Even if we have personal conflicts or negative feelings towards a coworker, finding ways to communicate effectively and work together towards the common goal is essential. Emotions or attitudes stirred by others should not distract us from maintaining professionalism and effective collaboration.
Following these steps can enhance our team dynamics and create a more positive and functional work environment.

Help Retain & Train 

To drive the needed changes, it is important to be direct in addressing issues related to policies, procedures, best practices, safety regulations, and roles and responsibilities. Clear communication lines should be established to ensure everyone is on the same page. This may involve being persistent and proactive, such as emailing the manager, copying the director and HR, and following up on important matters. We create an environment that supports staff retention and training by taking these actions.

Understanding team dynamics and actively promoting communication, trust, and advocacy are essential. Emphasizing a sense of curiosity and offering support to help others improve fosters a learning and adaptable environment. Building trust is crucial as it encourages individuals to be humble and open about areas of growth. It also creates a safe space where beneficial feedback can be provided and received, focusing on performance and effectiveness rather than seeking validation.

Rather than seeking a best friend at work, investing in building working relationships and finding allies is more productive. This involves valuing and supporting the talent within the team and engaging in direct, curious, and compassionate conversations. Instead of ostracizing new hires, efforts should be made to provide them with the necessary training, development opportunities, resources, and information. By investing in their growth, they can positively impact patients, and there is a higher likelihood of retaining them within the organization.
By taking these steps, we create a culture of continuous improvement, collaboration, and support within the team, ultimately enhancing the overall performance and effectiveness of the healthcare environment.

Soft Skills to Build Success

• Emotional intelligence
• Communication
• Documentation
• Feedback
• Conflict Resolution – What, what, What now
• Interpersonal – Power of perspective  
• Leadership  
• Adaptability
• Resilience

Personal soft skills play a significant role in building success. Emotional intelligence, for example, involves understanding the impact of our emotions on others and how others' emotions can affect us. It requires the skills and intelligence to navigate these emotional dynamics while maintaining control and regulating our own emotions, especially in high-emotion occupations.
Effective, professional, and direct communication is another vital soft skill for success. The ability to communicate clearly and assertively fosters understanding and collaboration. Powerful documentation is also important, as it ensures that information is recorded accurately and meaningfully.

Providing meaningful feedback and practicing conflict resolution are additional soft skills contributing to success. The "what now" method by Dr. Dudley E. Floyd is a useful approach to conflict resolution. It involves identifying the issue, understanding its significance, and determining the next steps or solutions to address the issue.
Interpersonal skills are crucial for building success. Recognizing the power of perspective allows us to transform how we see things and approach challenges. Understanding that we have control over our responses, reactions, and preparations enables us to navigate difficult situations more effectively.

Developing leadership capabilities is also important. This includes being adaptable and able to go with the flow, which is a skill often honed by respiratory therapists who regularly face dynamic and unpredictable situations. Resilience is another key attribute to cultivate, enabling us to bounce back from challenges and setbacks.
Developing tactful insubordination can be beneficial in challenging work environments where dysfunction and toxicity prevail. This involves finding strategic ways to navigate such environments while advocating for necessary changes and improvements. Focusing on these soft skills can enhance our effectiveness, contribute to a positive work environment, and build a foundation for success in our careers.

Tactful Insubordination

• Smoky room experiment. 
• Acknowledge your status quo bias. 
• Focus on doing what is right. 
• Create noise, even when they don’t want to listen. 
• Document - Remove people feelings. State facts, situations, impact. 
• Know the policy, procedures & state healthcare laws.
• Be honest in surveys.
• Provide leadership or team feedback. 

Tactful insubordination is a way of remaining professional while advocating for change. It means not conforming to the status quo bias, groupthink, or blame culture that may exist in healthcare settings. Instead, it involves professionally and directly advocating for necessary changes and improvements.

Acknowledging the smoking room experiment, where individuals often mute themselves out of fear or expectation that someone else will take action, we recognize the need to challenge the palpable status quo bias in healthcare. Unacceptable behaviors from staff, patients, or the organization itself should no longer be tolerated. Examples include denying restroom breaks for extended periods, not providing lunch breaks within 12 hours, or tolerating an abusive work environment. We must focus on doing what is right, even if it means going against the grain, in order to reduce moral injuries.

Creating noise and documenting situations without relying on personal feelings is crucial. We can assert our position effectively by stating facts, impacting and referring to policies, procedures, and state healthcare laws. When participating in surveys, it is important, to be honest and truthful, rather than giving all top ratings simply because a director requested it. If there is any fear of retaliation, it is wise to keep printed copies of emails and evidence of past expressions to protect oneself.

When asked or prompted for feedback from leadership teams, we should provide it in a way that aligns with what is right rather than who is right. By focusing on constructive feedback that aims to improve the organization, we can contribute to positive changes and a healthier work environment.
In summary, tactful insubordination involves advocating for change while maintaining professionalism. It requires challenging the status quo, being honest in documentation and surveys, and providing feedback to leadership teams in a way that promotes what is right. We can work towards a more positive and impactful healthcare environment by taking these actions.

Advancing in Respiratory Therapy

• Find define your passion.
• Advance your skills share those resources.
• Take advantage of educational assistance.
• Explore in-hospital growth opportunities.
• Explore life-science industry opportunities.
• Data science, compliance, regulations, medical & clinical affairs, medical & clinical liaisons.
• Employment services.
• Telehealth (limited)

When considering a career in respiratory, it is important to recognize that advancing in the field only sometimes means staying solely in the clinical setting. To explore career growth opportunities, define your passion and identify what drives you. For example, if your passion lies in advocating for others and ensuring equality, you can pursue avenues within respiratory that allow you to fulfill that passion.
Advancing your skills is crucial for professional growth. If you feel the need to improve your intubation skills, take the initiative to ask for additional training and seek opportunities to enhance your expertise. Once you have acquired new skills, be willing to share your knowledge and resources with others, fostering a collaborative and supportive environment.

Take advantage of any in-hospital education assistance programs available to you. These programs can provide valuable resources and support for furthering your education and career development. Additionally, do not limit your exploration to respiratory-specific opportunities within the hospital. Consider expanding your horizons by exploring other areas, such as data analytics, informatics, or the life science industry. These fields offer diverse career paths that complement your respiratory background and open new avenues for growth and impact. By staying proactive, continually seeking growth opportunities, and being open to exploring different paths, you can expand your career options and make a meaningful impact both within and outside the clinical setting.

• Remember your “why”.
• Organizations ultimately fail when they do not place employees first.
• Be an active part of the solution.
• Set your professional standards.
• You get what you tolerate – set the standard.
• You get what you encourage – this takes time.
• Find ways to ensure leadership works for you.
• Speak boldly!

As you explore opportunities outside the clinical setting, it is important to consider various roles in the life science industry that align with your interests and passion. These roles may include positions in data science, compliance and regulation, medical affairs, clinical affairs, or medical clinical liaison. Keep in mind that many of these positions typically require a Bachelor's degree or higher.
While telehealth is a limited option for respiratory therapists in terms of employment services, it is crucial to remember your initial motivation for choosing respiratory as a career. Reflect on what drew you to clinical healthcare and how it serves your purpose. You can stay aligned with your core values and motivations by honoring that connection.

Recognize that organizations ultimately fail when they do not prioritize their employees. As an active part of the solution, you can set professional standards and establish boundaries. Remember the adage, "You get what you tolerate." By setting high standards and not settling for less, you encourage others to treat you with respect and professionalism. Teaching people how to treat you takes time, but it is worth the effort.
When it comes to leadership, remember to advocate for yourself and ensure that leadership works in your favor. Boldly express your needs, concerns, and aspirations. Your voice matters, and speaking up assertively can contribute to a healthier work environment and better outcomes.

In conclusion, as you navigate your career in respiratory and explore opportunities beyond the clinical setting, stay true to your why, prioritize your well-being, set professional standards, and speak boldly. By doing so, you can shape your career path and contribute to positive change in the healthcare industry.

Questions and Answers

"How do I find ways to work with a manager who is coming from a place of ego?"

Working with a manager who has an ego can be challenging, but there are strategies you can employ to protect yourself and navigate such situations. Documenting your interactions is crucial. Whenever you have a conversation with this manager, follow up with an email summarizing what was discussed and the outcome. This documentation serves as a record and helps ensure that your voice and concerns are heard and acknowledged. In situations where the manager's ego is causing them to become animated or reactive, it's important to remain calm and composed. If the conversation becomes too heated, it can be helpful to suggest taking a break and resuming the discussion at a later time when it can be approached in a more professional manner. After the dialogue, make sure to send a follow-up email to the manager, and if necessary, consider copying HR or your director to bring awareness to the situation.

While it may go against the norm, advocating for yourself in a way that creates effective change is essential if the manager's behavior is creating a negative work environment for you. By taking proactive steps and addressing the issue, you are prioritizing your well-being and promoting a healthier workplace. Managing emotions in a high-stress environment is indeed challenging. It requires developing emotional intelligence and recognizing that your emotional response is within your control. Building the ability to regulate your emotions outwardly, even if you still feel their impact internally, is a powerful skill. Not giving others the reaction they seek, even when you may feel affected, demonstrates resilience and maintains your professional composure. Remember, it is normal to experience emotions in high-stress situations, but having the ability to regulate and manage them effectively is what sets you apart and contributes to your professional growth and success.

How can managers be able to identify dysfunctional culture?

Absolutely, you raise valid points about the challenges faced by clinical managers, especially in respiratory therapy, where they may not be physically present on the floor with the team. As frontline healthcare providers, it becomes crucial for us to effectively communicate with our managers, nursing leads, and advanced care providers to ensure they are aware of the dysfunction happening within units.

By providing them with clear and objective information using the "what, what, what now" method, we can outline the specific issues and their impact on patient care or unit functioning and initiate a conversation about finding solutions. It is important to remove emotions from communication and focus on the facts and the need for improvement. This allows managers to have a clearer understanding of the challenges and take appropriate actions.

Furthermore, we can also collaborate with our managers to address the issues and work towards retaining staff. If we observe new hires being ostracized or facing challenges, we can become their ally and advocate for their integration into the team. By communicating with other staff members, such as respiratory therapists and nurses, and encouraging patience, curiosity, and support for the new hires, we can foster a more inclusive and welcoming environment. Building this allyship and promoting a positive team culture contributes to the growth and success of both individual team members and the overall organization. Effective communication with managers, providing them with clear information about the challenges, and actively working together to address issues can help improve the working environment and support staff retention. Building alliances and advocating for new hires fosters a culture of inclusion and collaboration.

References

Bohns, V. K. (2021). In You have more influence than you think: How we underestimate our power of persuasion and why it matters. essay, W.W. Norton. 

Bridges, W. (2017). Managing transitions making the most of change. Da Capo. 

Chamine, S. (2016). Positive intelligence. Greenleaf Book Group Press. 

Dweck, C. (2016). Mindset: The New Psychology of Success. Random House. 

Herman, T. (2019). The alter ego effect: The power of secret identities to transform your life. Harper Business. 

Kashdan, T. B. (2022). The art of insubordination: How to dissent & defy effectively. Avery, an imprint of Penguin Random House. 

Robbins, S. P., & Judge, T. A. (2018). Essentials of organizational behavior (14th ed.). Pearson. 

Robson, D. (2022). The expectation effect: How your mindset can change your world. Henry Holt and Company. 

Swann, A. (2018). The human workplace: People-centred organizational development. KoganPage. 

Editor’s note: This text-based course is an edited transcript of the webinar, Respiratory Therapy Conflict Resolution Application in the Workplace, presented by Mira Rollins, OTR/L. 

It is recommended that you download the course handout to supplement this text format.

Learning Outcomes

• Discuss how to apply a conflict resolution matrix to clinical operations conflicts.
• Identify their personal communication style the best conflict resolution techniques for that identified style.
• Identify three personal specific areas of opportunity to improve their current conflict resolution style.

Conflict is...

Conflict is not necessarily a severe disagreement or clash. I wanted to start the first nugget of information, with that often, conflicts do not get resolved at all, or we inherently feel that conflict is negative. However, it does not have to be. That is the number one thing you should start thinking about mulling over as we review the rest of the content. Number two, conflict is not necessarily, serious discord or strife. When I looked up the definition of conflict, this was one of the definitions, I do not want to disagree with Webster, but I do not believe that conflict necessarily, has to be severe discord or strife. It can be, but it does not have to be. A better working definition of conflict is when two people or two parties sharing the same space, resources, or concerns have different opinions, perspectives, or preferences. With that definition, it can radically change how you approach, deal with solve conflicts. Conflict can be natural. It is necessary. 

Mindset Matters

I honestly believe that if you have a wrong, incorrect, negative mindset about a matter, it will affect any strategy that you implement. We see this with our patients. We have seen two patients with the same diagnosis, similar situations, with different outcomes. What is the difference? What has been unlocked for one, not the other? Often, we see a different mindset, positive over negative, the thinking that I can versus I cannot, or I am doomed. Mindset matters in everything, even in conflict resolution. The first mindset shift I want some of you to adopt is that there is no unsolvable problem. Frequently, when I go over conflict resolution strategies in a specific situation, I converse with someone who, no matter what strategy or technique, pounces on it and say, "It is not going to work." You are right. If you take that mindset into conflict, it will not work. 

The first thing is that there is no unsolvable problem. The worst boss you have ever had, the most horrible coworker, the rudest patient, it is not unsolvable in your dealings with them. Secondly, you cannot wait to feel comfortable before you navigate or handle conflict resolution. If you are waiting for this perfect situation, set of scenarios, perfect ending, perfect feeling that "Okay, now is the right time," it will never come. You cannot wait to feel comfortable addressing your boss about your raise because discomfort will always exist. You cannot wait to feel completely comfortable before you talk to this abrasive coworker because you will never feel comfortable. 
The mindset of knowing that I will have to push past the discomfort and still handles the conflict is the mindset that you must adapt. 

There will not be one solution that gives every character in the story precisely what they want, even you. There is no perfect solution. Take your time figuring out that one perfect situation before you engage in conflict resolution. Number two, you are not helpless. You have options. Those options might be including having a conversation with human resources. It may even lead to changing departments or leaving a particular job, but you are not helpless. You have options. Also, you have a choice on how you respond. My 13-year-old is dealing with anger management issues and, as a teen, is having a problem accepting this too. He feels that people make him mad. I am telling him, as I also am for you, that the window may be small, but there is always a window of opportunity you have between the catalyst, the thing that is causing the conflict, and your response. With practice, that window can grow larger because you will be able to implement these strategies in any situation, no matter how great or small.

Conflict Resolution Requires...

A recent survey found that 61% of employees delay or avoid initiating a conversation they should have with a coworker or supervisor. That is, six out of ten people at your office right now are delaying or avoiding a conversation they know they need to have with a coworker or supervisor. At any given moment, on any given day, six out of ten people are stuffing, suppressing something they need addressing. They have unmet needs and unmet expectations. Suppose 60% of everyone walking around offices interacting today feels they need to be heard or have unmet needs and expectations. In that case, it creates a negative workplace culture. We want to be part of the solution rather than this 60%. We want to be part of this 40% that lets maturity rise to the top as we effectively handle communication.

In speaking with these conversations, conversations should be planned. This is not a prerequisite course, but they are, I would say, partnering in like good supplemental courses. There is another course that I taught on this platform about basic conflict resolution. I think we went into a little bit more conversation strategies and things of that nature. If you would like, after this course, go back and revisit that particular one (Effective Conflict Management Between Multidisciplinary Teams).

Conversations Should Be…

In speaking about how to handle conversations, conversations should be planned. I will not stop the doctor in the hallway to tell him how he spoke with me earlier. That is not planned. He is not ready for it. I gave him no warning, and then I may not have vetted through all that I wanted to say. Whenever possible, ensure that the conversation with the person you are in conflict with is planned, not spur of the moment. It increases your potential for success. Conversations need to be practiced. Yes, practice. We are the culture that takes one selfie a hundred different ways because we want to get it right. If we can invest that much time in a selfie that we will post to the gram, then in that case, we can invest a small amount of time getting in front of the mirror, riding in our car, vetting through the things that you want to say, the conversations you want to have, anticipating what the other person might say—having this dialogue practicing conversations. Conversations need to be concise. Sometimes we want to have vent space with everything we feel with the person we conflict with. Sometimes what gets lost is what you need.

There needs to be a balance of feelings and facts. I am almost at an 80/20 percentage now that I think about my most effective conversations. I want to tell the person the impact of their interaction or what they said or did to make me feel, but I spend 80% of my time telling them the facts of the situation and what I would need afterward. It is much more effective. I have learned because I am a "feelings" kind of person that, I have had to practice being more concise in my communication. Making sure that we are balanced of facts and feelings, and having a "we" versus "me" approach saying that this is what the department would benefit from. Also, this could benefit the patient and be something the caregiver could use. When conversing about a conflict, make sure you are not the only character in the story but how it would benefit other key people. 

This is a huge one, ensuring that whenever you are having a conversation, you only initiate it within a level five, on a scale of one to ten, with ten being the peak of anger and one being a baseline. As with our vitals, with our O2 Stats, like as a therapist, I take those vitals I see where they currently are because before I start standing exercising with the client, I want to feel confident that when that oxygen saturation drops, I have somewhere to go safely. It will be okay when that heart rate rises because I started within a safe parameter—the same thing in handling conflict.

When you are upset with your boss, it is not the time to have a closed-door meeting because if you sit in that chair at an anger level of seven, you will rise. You do not want to be that close to a ten. When you have some safe calculated parameters, you only want to handle conflict so that if you get more emotional, upset, and charged, it will not be into the unprofessional territory. That is safe communication whenever you are at that one, two, or three. You make him push it to an emotional level of four or five, but make sure that your emotions are regulated, not above that anger or frustration level of five, because it could end badly if not checked. Then you want to sift. By sifting, I mean mentally or even out loud, saying everything you want. However, picking out the critical, key, and professional things you want to say leaves all the others out. Once you sift it, which makes it very important to practice, you can sift your energy and emotions. When you sift out the most important things, the professional things, the condensed things, it will also help you shift your energy from anger to maybe now through the sifting process. I am frustrated, whereas I am red hot mad. These are simple strategies that, as we build, get into specific scenarios we will implement into those cases.

Say This, Not That

• Head UP: That’s not my job
• Head ON: I would like to help but I don’t have the availability

The first thing, instead of saying, that is not my job when you say something like that, that is a head up, that is going right in at the person, negative energy going head up, that often will make the conflict rise. We want to hit the issue head-on, meaning very directly, calculatedly, and professionally. The head-on way to address this conflict is not to say that it is not my job, which it may not be. We are going to say instead that I would like to help you, but I do not have the availability. Now this sends out a message that it is not that I do not want to help, I am not being a team player, but I have limited resources on my time availability. It will end in the same result. I will not do your job, but it sends a different message.

• Head UP: You’re rude
• Head ON: I appreciate your directness, but it sometimes comes across as abrasive

Let's try another one. You are rude. How many people, doctors, nurses, families, and patients do you want to say flat-out you are rude, but we are not doing that. Our successful conflict management is going to go head-on. We will say, I appreciate your directness, but it sometimes comes across as abrasive. Frequently when someone is rude, what they do not have, is a very good method of sifting. We talked about it. They sometimes tell the truth, but not in a very timed or professional way. Oftentimes a problem is not exactly what someone says, but it is how they say it. In those instances, one example is to say, I appreciate how direct you are, but it sometimes comes across as abrasive starting the conversation from there.

• Head UP: I don’t like you.
• Head ON: We seem to have competing personality styles. I would like to discuss how we can work to complement one another better.

How about this one? I do not like you. How many people, doctors, nurses, therapists, patients, and family members, do you want to say that to? However, we are not. We are going to allow maturity to rule. We are going to say we seem to have competing personalities. I would like to discuss how we can work to complement one another better. That opens up the floor to say, you can also tell me some things that compete with your personality. Let's talk about that. Now, it also gives you the leverage to say, here are a few things that compete with my personality. What would work better for me would be. Now this goes back to that mindset where some of you say it will not work. If I came to that coworker or that boss, even with this head-on approach, it would not work. However, mindset matters. Instead of not having the conversation, I challenge you to practice the conversation and implement some of these head-on strategies

• Head UP: Dude, do your job!
• Head ON: There are a few incomplete tasks that are assigned to you. Can we go over those because they are causing delays in other areas? 

Next is, dude, do your job. Earlier, we talked about people wanting to pass things on to you, and you have to tell them that that is not your area of responsibility. What about when a coworker is not holding up their end of the responsibilities? It is saying, do your job. Instead of saying do your job, we are going to say, there are a few incomplete tasks that are assigned to you. Can you go over those? Can we go over those because they are causing delays in other areas. Now you can word this how you want, but the spirit of your communication should be in this head-on way versus the head-up. What we are doing in this head-on approach is we are clarifying expectations of the system of accountability.

• Head UP: You don’t know what you’re doing.
• Head ON: When you get the opportunity, can we discuss an observation and a small concern I have regarding one of your treatment methods?

How about this one? You do not know what you are doing. Have you ever felt that someone needs to be more competent or totally in an area where they are not practicing in their expertise or skillset? What do you say? We are not going to say you are not competent, but what we are going to say is, when you get the opportunity, can we discuss an observation that I made? Let's have a short conversation so that we can discuss one of your treatment methods. Again, you might not say it the way I organized it here, but what you are going to be communicating is number one, giving them a chance to have the conversation with you, not in real-time, not in front of the patient, not in front of other people, but when it is convenient for them. Then also, give them a heads up on what you will be discussing and then allow them the time to think that when you do come together to talk about it, it will not be in front of people. It will not be embarrassing. They will know what you are talking about.

• Head UP: I don’t like that patient. I don’t want to work with him.
• Head ON: I’ve tried various techniques of treatment style with this patient, but none have been effective. I believe another therapist may get a better response and participation from him. 

Here is another one. I do not like that patient I do not want to work with them again. I know ten patients have probably come to your mind. What we want to communicate is something more along these lines, I have tried various treatment style techniques with this patient, but none of them have been effective. I believe another therapist may get a better response and greater participation from them. Now what we have communicated is not your lack of tolerance, not your personality, I do not like this person, but you are saying I have tried, it shows effort, but now you are saying that it is impeding this patient's progress because we are not getting the results, that I think he can get because of a personality clash. This keeps it patient-centric.

• Head UP: My shift is over. I can’t do that right now.
• Head ON: My shift ended at 6 pm. It’s now 6:15 pm. I’m unable to stay late today, but if you still need it done tomorrow, I can help then.

My shift is over. I cannot do that right now. I know I have been caught with my purse on my shoulder and my keys in my hand. What do we say? My shift ended at 6:00, and it is now 6:15. I am unable to stay late, but if you still need it done tomorrow, I can help then. This is one example of how you can communicate that you are willing to help, but sometimes boundaries need to be respected. You may not say this exact verbiage, but how do you communicate a willingness to help but a way to respect your boundaries? Both can be done.

• Head UP: Why are you worried about my patient?
• Head ON: Thanks for the advice. I will consider it. However, for right now, I feel confident to proceed with my current treatment.

Or how about this? Why are you worried about my patient? You have a coworker that has their nose all in your business and your files when they should not be. What are we going to say? Thanks for your advice. I will consider it. What does that communicate? It communicates your openness being humble, to receive from your coworkers and your teammates, but it also articulates your competence, that you got this how can you communicate openness to receive but also your confidence in what is currently going on, your competence, your skillset, both can occur. 

Words That We Fear Saying

• “NO”
  • I appreciate the offer, but I can’t right now.
  • I don’t have the availability or capacity right now.
  • I don’t believe I’m the best person to complete that.
  • Unfortunately, I won’t be able to do that.

Here are some other things that cause conflict. When we are afraid or hesitant to say certain words, The first is "No." Many of us need better boundaries. We feel taken advantage of by our team. We get more of the work, the more challenging patients. We find ourselves taking on responsibilities and committees because we do not feel confident to say no. Saying no allows you to give your best yes to other tasks and responsibilities. Or you can say, "Unfortunately, I will not be able to do that." That is a clear no because I heard somewhere that no is a full sentence. It is not incumbent upon me to always validate my no. Sometimes saying, I am sorry, I will not be able to do that is having the confidence and the courage to say no when appropriate. 

• “I DON’T KNOW”
  • I am not certain but I can find out by …..
  • That’s outside of my specific expertise, but I know who has that information.
  • I will look into it and get back with you by …….
  • Here’s what I know about that situation.

Or how about this? I do not know. We feel that in our current position, especially as supervisors or team leads, we should know everything, but we do not. We will talk about some things you can confidently say when you do not know. How about this? I do not have the availability or the capacity right now. To be honest that it is not that I do not want to help you. I do not have the resource or time right now to do it. I do not believe I am the person to complete that. That is not where I excel, or that is not an area that I feel confident in. Like I believe that someone else in the department, you may know that specific person, is better at that. It is important that we say no to some things so that we can say yes to the best things for us. When it is an "I do not know the situation," saying I am not certain, but I can find out gives me some time between your question and answer. Sometimes you do not give accurate information when you feel compelled to answer on the spot. It would be better to say, right now, I do not know, but give me a day or two I will get you the resources. Alternatively, that is outside of my specific expertise, but I know who has that information. I will look into it and get back to you by this time. Alternatively, here is what I do know about the situation. All of these communicate a willingness to assist the person in getting the information, even if you do not have it at that moment. 

• “I NEED HELP”
  • I would appreciate your expertise on this subject.
  • Despite several schedule adjustments, I still could use extra support on this project.
  • Do you have availability to assist me with …

Then there is, "I need help." Much conflict happens when someone attempts to do something without having the proper resources or out of their scope because they are afraid to say, help me. What can we do in the spirit of conflict resolution when it comes to saying no, telling people that we appreciate the offer, and thanking them for believing you can do this, "Thank you for acknowledging my skillset." Thank you for thinking of me. I appreciate it, but I cannot right now. Literally saying thanks but no thanks. Regarding saying, "I need help," I would appreciate your expertise on this subject. Despite several schedule adjustments, I could still use extra support on this project.

As a manager, it was always great for me when my employees would tell me what they had already done because I was more willing to help. Even think about the last time you had a student. Maybe that student was like, "Hey, I have tried these situations, these techniques, these strategies, but I still want to pick your brain on this." When someone says, I do not know, versus, this is what I do know about it. Can I get your help because I have already tried these things? We are more open to giving that leverage of assistance. The same thing happens when you need help, being able to articulate what you have already done. People are more willing to help in those situations. 

Categories of Healthcare Conflict

• TERRITORY
  • Perception of infringing on one's job, schedule or workspace
• TONE
  • Perception of inappropriate communication of needs
• TECHNIQUE
  • Perception of lack of competency, efficiency, or compassion

We are going to review some things that were in the previous presentation that conflict in healthcare. This is bridging all up to about six or seven specific scenarios that we are going to get into in a few minutes. Most conflicts in healthcare occur because of territory, technique, or tone. It is when there is a perception, it is very important that we understand, that conflict occurs not because of your intent but because of the impact of your words or your actions and how they impacted a person. Unless we understand that it is not what your intent was that we have to deal with, but what the impact what that person perceived it. When we are talking about territory conflicts, this is the perception of infringing on one's job schedule or workplace.

An example is the RT who is taking over shared space, the office area with their things, or if you have a person that is PRN who comes on weekends every time you come back on a Monday, they have changed some things or told the patient's family something different, then what was communicated, it is a territory infringement. Alternatively, it could be a technique. This is the perception of a lack of competency, efficiency, or compassion. This is when someone does not like what you are doing or how you are doing it or when you do not like how someone is doing something or how they are doing it or the specific thing that they are doing or not doing. The last one is a perception of inappropriate communication or needs. Any healthcare conflicts or any conflicts can fall under one or more of these specific categories. However, typically one of these three is the predominant one. We will go into some scenarios, see which of these categories we would place it in, then discuss some very practical techniques and strategies to address them. 

Territory

Scenario 1 

• There are work culture and treatment method differences causing major disagreements.
• “We did it this way at my last hospital.”
• “We do it this way here” mentality.
• Lots of resistance from travelers to assimilate and adopt the culture of the new hospital.

In scenario one, there are work culture treatment and method differences, causing significant disagreements. Let me give you some examples of what we mean. This is when someone has the attitude of, we did it like this at my last hospital, or I will do it like that here. 

Alternatively, someone else is coming in doing something different, but someone else is saying, this is the way we do it here mentality. There may be much resistance from travelers or new people to assimilate or adopt the culture of the new hospital that they are working in. 

Territory Resolution Strategies

• Clearly establish roles and responsibilities
• Be aware of schedules
• Be aware of systems 
• Be an active member of the team

Of the three, it might be a bit of technique, but more than technique, and it is a territory issue. Whenever there is a territory conflict, we want to establish the roles and responsibilities clearly. Who is supposed to do what? If we had to check a nice neat box, what department, what person, what coworker, what supervisor, whose responsibility is this? When there is ambiguity in roles and responsibilities, we see lots of conflicts. That might be one of those practical takeaways for you. If you are a director or supervisor somewhere, do you have clearly outlined roles and responsibilities for your department, or are you being proactive? If you are an employee, you notice that many conflicts happen because there is much ambiguity along the lines of roles and responsibilities. That might be a conversation you plan with one of your supervisors. That is a very proactive strategy. We need to be aware of schedules like, what is the therapy schedule for this person? When do they get their meds? When is there a swallow study? When is lunch? When is checking to see if you know the residents by the CNAs? Are they clean, dry? Knowing these schedules, we know that in healthcare, one domino being pushed affects every other one.

We can prevent or decrease conflict in the territory when we know the schedules of a specific patient or how the hospital or the skilled nursing facility, whatever the schedules are in place. Then we need to be aware of systems. Often systems are as, if not more important, than schedules. How are things done here, ensuring that we respect those systems in place? Next is being an active team member. This says that if I am involved in what goes on here day to day, I will not feel like I am on an island. When you feel like you work in a silo on an island, you will feel deserted. Even if you are an RT that comes to different floors and you do not have a home base, you still need to find out how to integrate yourself to that when you come on that floor, they do not necessarily see you as a visitor, but are part of their team. When that happens, it is going to decrease the territorial conflicts that you have. Now let's go back to the scenario and get some specific strategies.

• As a Traveler/Contractor:
  • Considerate yet Confident Contributor
  • Move from Orientation into Discovery Period
  • Don’t make yourself known but make your presence felt
• As a Full Time/Permanent Employee:
  • Be Welcoming
  • Tell the Why with the What
  • Prioritize Policy over Preferences

If you are a traveler, a contractor, or a new employee, you want to be considerate yet a confident contributor. That means I will be considerate of the system and how things work here. I will not come in ignoring or trying to change everything in this environment because if I do, I will create unnecessary territory battles. I am also going to convey that I am a confident contributor. Yes, I am new to this hospital, but I am not new to RT. I know what I am doing. I will not shrink or try to bottle up my confidence and skill set, but I will be a confident contributor, not here as a warm body, but as helping the environment to keep things going. How can you balance that by considering the systems in place and showing that you are confident in your skillset that you want to move from an orientation checklist to a discovery period? Orientation shows you where the closet is and the code to the closet. It might show you how to get down to the dining hall, all that is important. 

What if you are a full-time or permanent employee in the situation? You want to be welcoming. That is very simple. I have worked in many different buildings where new people are not welcome and need assistance. They are not made to feel like they are wanted. When that environment is set up, the contractor or the traveler often goes into defense mode. They start doing their own thing, their way, because of the environment that was initially projected on them. 

How can you be welcoming? Also, tell the why, not the what. Understanding why something is that way and why a system is in place will increase their compliance. I am not suggesting that you have to explain the entire workings of your department, but whenever you sense that someone is not in agreement or has a question, be humble and mature enough to give a background on the why and then prioritize policy over preference. If it is a policy, we are supposed to do it this way, whether legally or because it is what the boss said or whatever. That is policy, but then there is a preference. People want their preferences honored. As long as it gets done, you will see a radical shift in territory battles wherever you can uphold someone's preference. However, when it is policy, of course, we need to manage that. If it is a preference, let's go ahead and let it be. 

Equally as important is your time, which you invest in discovering the culture. You want to watch how people work, watch how things play out. You want to get into the already established rhythm. If the rhythm is this, you want to avoid coming in at this rhythm, or if the rhythm is that, you want to get in at that rhythm, almost a Double Dutch. You watch what is going on. Once you watch it, that is the rhythm you want to come in at. If you need to change some things, it is only after you have established yourself as a part of the team who respects what was already in place. 

Next, do not make yourself known, but make your presence felt. This means you are going to avoid coming in with this foolish mentality of "this is what I know. I am here to get you all back on track and to show you some things" because you will not be integrated or accepted well. Instead, you will create territory battles. You want to make your presence felt that is very different. By your presence felt, that means going back to that confident contributor, where people can look around and say, since Mira joined the team, she has only been here three weeks, but she is made this improvement. She is helped us in this way. We are getting many more patients seen. You are establishing that you are a confident contributor. Rather than someone coming saying, I will put all my preferences on how I do things on an already established system. 

Tone

Scenario 2

• A new RT approaches a physician to double-check an order for COPD medication before administering the medication to its intended patient. The physician interprets the question as a sign of distrust in his expertise & publicly lashes out at the RT, and reports his dissatisfaction with the RT to the RT manager on duty.

A small amount of territory is working here, but the main one, the most significant percentage, of the one at work here is tone. In this situation, I want you to consider the frequency. How often does this happen? If you have worked with the doctor before, he or she has never done this before, which is a weird one-off. It may not be a big deal to address it. You can tell the supervisor, "Hey, this is what happened. He overreacted. I will, you know, make sure not to do this or that next time." However, if this is a trend, we need to implement more specific strategies.

• Consider:
  • Frequency
  • Factors Conflict
• Chain of Command:
  • Lowest Level Possible
  • Understanding the Formal and Informal Chains

Also, consider the factors. What is going on? Was there a medication error with another patient that was not yours? Since then, the doctor has been very, very distrusting of your whole department. That is a factor that you need to consider. Or was it with you that you disagreed before on a recommendation or something you made? What is the history surrounding this? If we only deal with conflicts, at the level of the conflict, without understanding the iceberg effect, then conflict resolution will not be successful. What are the factors? We also need to know the conflict chain of command. Whenever possible, how can we handle conflict at the lowest level possible? In this situation, it is having a conversation with the doctor, yes, having a conversation, making sure that we are at that level, 1, 2, 3. In this situation, we need to go further down from where we have thought about it, planned it, and emotionally regulated it before having a conversation. 

Alternatively, we can understand the formal and informal chains of command. By formal, I mean nothing has happened if you talk to your supervisor, but he continues to take this approach, disrespecting and embarrassing you. 
What is the formal chain of command? We are hesitant to go up this chain of command, but I want to encourage all of you that there are policies and HR procedures for a reason. If you have attempted to handle it at the lowest levels, you went to the doctor, you talked to your supervisor no one is doing anything, then here is one of those options that makes you not this helpless victim, but you may want to look into the system, of what is the HR chain of commands, in situations like this. However, look at the informal. What if this doctor has a nurse that has worked with him for 20 years? Everyone knows he or she has his or her ear. Go to the nurse and say, "I have been working with Dr. G., who is chewing me out. It is getting more frequent. What do you think I can do? What are some strategies? Would you mind talking to her?" Things of that nature are those informal chains of command. That discovery you looked at the place's culture might be helpful for you.

Scenario 3

• RT is trying to pacify an aggressive family member whose loved one is on the ventilator with a poor prognosis. The family complains to the nurse manager.
• Avoiding Aggression
  • Practice crucial conversations
  • Consider timing, technique, tone
  • Listen. Wait. Restate. Validate.
  • Provide appropriate outlets
  • Don’t push back but lean in
  • Define and display directness
  • Create opportunities to coach

We have all had this where you have an aggressive family member, and their loved one is on a mechanical ventilator with a poor prognosis. The family complains to the nurse manager about some of your treatments and how you are doing something that is tone. We want to look at ways to avoid aggression. Here are some ways to practice your crucial conversations and provide appropriate outlets. We want to listen to the family member, wait, restate, and validate. Even though she is level 10 sounding off, how can you hear through how she is saying something to what he or she is saying? How can you listen, wait, restate?

Territory

Scenario 4

• Physicians change ventilator settings without notifying the RT or writing orders, which may/may not make a difference in patient care. RT finds out from routine Q4 vent checks.
• Possible Solutions:
  • Respectfully ask to be notified
  • Increase communication cadence
  • Increase your interaction with the MD to increase confidence
  • Investigate to determine if its “procedure” vs “personal”
  • Determine if its “negligence” or “nuisance”

Scenario three is some technique, but it is more territory. I have changed these settings, and this is my patient. What are you doing messing with them? Here are some possible solutions. Respectfully asked to be notified about the changes. Again, having the professional maturity and courage to go to the physician has a fact, little feelings conversation. You should tell them why you need to know due to what it could cause using calculated facts over feelings conversation with the doctor. Increase your communication cadence. Here is a significant point that I am getting ready to tell you. Conflict resolution is not how you directly handle conflict or the words you say, but more the environment you set that can decrease the likelihood of conflict. That is a huge takeaway. 

What strategies or systems do you need to put in place that change the environment, so things of this nature will not happen as much? A possible situation here is increasing your communication cadence with this doctor, letting them know this is an update on the person. 

If you are sending him notes, communicating through a specific app you all use for internal communication, or seeing the doctor in the hallway, give him an update. How can you most effectively increase your communication with this doctor? Not on this one patient but with all their patients? Now you are creating an environment of trust with this doctor that may not have been there before. You are painting a picture of collaboration competence. When he or she sees competent collaboration, they will be less likely, to go tinkering with your settings. 

Increase your interaction with the MD to increase confidence. A similar thing also investigates to determine if it is procedure versus personal. By procedure, I mean this doctor's procedure. If she does this to everyone, then you would implement a different set of strategies, versus she is only doing it to you, because if she does it with everyone, then the issue is with her that would implement a certain way to approach it. If she only does it to you, then you need to find out what it is about you, your skillset, or previous interaction that has her interacting with you that way, and find out not just the situation but looking at those iceberg things underneath. Next, determine if it is negligence or a nuisance. If this doctor did something wrong because the scenario said it may or may not cause problems with patient care. Suppose it is negligence that needs to be handled properly, and the proper way depends on the level of the situation and on the policies in place at that particular hospital, clinic, or skilled nursing facility. However, if it is a nuisance, sometimes conflict resolution says, I will let this one go. Now that is not avoiding conflict. That is not what I am suggesting. I want you to pick your battles. Sometimes you have to say, is this important enough to address? Depending on the frequency and level of harm it would cause, it would be up to you to choose if this is something you need to address. 

Technique

Scenario 5

• New RT tapes an endotracheal tube using a different technique than the seasoned RTs. The seasoned RTs are negatively discussing this technique in private conversations that ultimately get shared with the new RT.

They're over there gossiping about you. You find out about it. This is a technique. Let's talk about some strategies to mitigate technique conflicts.

• Technique Resolution Strategies
  • Be proficient and efficient at what you do
  • Be able to articulate the why of what you do
  • Seek an understanding of other roles and responsibilities

The first one is to be proficient and efficient at what you do. The more you show confidence and competence, the less people are likely to question what you do. Number two is to articulate the why of what you do. Now, this is only sometimes you do something new. You should be forced to prove that this is right. If there is a conflict, be humble enough to say, "Hey, this is why I am doing it this way." Seek an understanding of other people's roles and responsibilities, looking at their technique and why they feel theirs is better.

Here are some more strategies and ways to think about this scenario. Number one, the evidence speaks. if you want to say, "Hey, this is a journal article, it is a new procedure, it is working." Be confident enough to know where to go to get information backing up your technique. Results speak. Say, "I have tried this technique for the last five of my patients. It is more comfortable, and I have seen better quicker results" Instead of saying, "I can do it the way I want to," say instead, "Here is the evidence and results to support it. I am creating an environment of collaboration, not competition. Being able to say, "Hey, I heard there were some concerns. Here is why I am using this. What are your concerns about it?" being able to, even though they were gossiping about you, you be the mature voice of reason, creating an environment of collaboration. Then consider if it is preference, practical, or principle. Sometimes we fight battles because that is the energy, then how can we change that? Alternatively, sometimes it is practical, yes, you can do it this way, or I can do it this way. Both are correct, but there is one that is quicker, faster, and more cost-efficient. If you say, "Yeah, even though I like this way, I see how this is more practical." Be willing to grow and be lifelong learners, but also humbly show why I do it this way—again, being able to get that ebb and flow of standing your ground when you know something you are doing is right to show other people why, but also to adjust and learn if there is an opportunity to do so.

Identifying Caregiver “Types”

When our caregivers manage many emotions, they are often not at their best. We want to hear how they are saying it and what they are saying. I typically put caregivers in three different buckets. 

The “Squirrel”

• Weaknesses
  • Visibly Overwhelmed
  • No Systems
  • Start but only Partially Completes Many Tasks
  • Emotional, Often Teary
• Strengths
  • Admits Being Overwhelmed, Thus Easy to Identify and more Receptive to Ideas and Suggestions
  • Small Changes and Strategies Make Big Changes
  • Have Basic familiarity with Most Necessities
  • Expressive and willing to Process through emotions

The first one is the squirrels. They are visibly overwhelmed, back and forth, all out of sorts. You have seen them like they physically look frazzled sometimes. The good thing about these caregivers is that they admit to being overwhelmed. They are easy to identify and are receptive to ideas. One weakness is that they do not have systems. They are all over the place. However, the positive thing is that because they have no systems, any small change or suggestion you can make will create huge benefits. They are very receptive because of small changes in ideas, and they are like, I never thought about that, thank you. A weakness is that they start but only partially finish things, and they are very emotional. It is another weakness. However, you get to hear and understand their issues because they are expressive.

How to Help the Squirrel

• Fix the Low Hanging fruit first
• Operate well with Check Lists
• Need Assistance Prioritizing (tasks and feelings) • Support Groups
• Scheduled Weekly Meeting or Phone calls
• Needs to hear, “Can you work on this task first?”

How can we help a squirrel? Fix the low-hanging fruit, the easy things we can fix for them. They operate with checklists. They are all over the place. They do not have systems. If you can give them a checklist of things that they can do, it eases their anxiety. They need assistance prioritizing what is most important. It is good to have suggested support groups because they will often catch you as an RT and give you all their concerns which do not even concern you. In a support group, they get to vent. That is the appropriate place for it to air out everything. Schedule weekly meetings because they need frequent touchpoints. They need to hear, "Can you work on this one task right now/first?"

The “Deer"

Weaknesses

• Visibly Overwhelmed (but may appear apathetic or “lazy”)
• Paralysis Analysis
• Slow to Make Decisions
• Reserved. Decrease Conversations

• Strengths
  • Admits Being Overwhelmed, Thus Easy to Identify and more Receptive to Ideas and Suggestions
  • Familiar with Multiple Options
  • Increased Comfort when Decision is “Finally” Made

The deer is the opposite of the squirrel. They are not moving at all because they are overwhelmed. They are visibly overwhelmed. They have what I call "paralysis analysis," and they do not want to make decisions because they are like, "If I make the wrong decision, I will make the wrong decision."  One good thing is that they research and research. They are familiar with options they are very reserved. However, they listen.

How to Help the Deer

• Pros and Cons Discussion Format
• “No Perfect Suggestion”
• Needs Dates and “Deadlines”
• Needs Streamlined Options, Not all the Options
• Testimonials
• Needs to hear, “I support that Decision.”

How we help the deer is that we give the pros and cons. We tell them there is no perfect suggestion, do not wait on the best, on the optimal, the number one, a hundred percent correct, but go on the best suggestion they need to hear, "I support the decision."

The “Lion”

• Weaknesses
  • Appears “on top of things” but may be concealing burn out
  • Needs to be “in control”
  • Can make decisions in Haste
  • Appears angry, rude, or inpatient
• Strengths
  • Slightly less “emotional” than other types
  • Involved. Present. Timely.
  • Decisive
  • Communicates their emotions and feedback

Now to the lion, the lion is the one that is going to chew you out because you did not do something for their mom or their husband. The lion does this, not necessarily because they are rude, but because they feel this is their way of protecting their loved one. When I am not here, even when I am nowhere to be found, they will ensure that Mom is taken care of because the staff knows who I am and how I am. A lot of the anger the frustration you see is because of them trying to protect their mom or their husband. 

How to Help the Lion

• Meeting with those “in charge”
• Frequent Communication
• Seek their option, even on smaller matters
• Give resources and ask to circle back after reviewing
• Needs to hear, “We appreciate your input. That was helpful.”

How can we help the lion? Lions often want to meet with those in charge. They want to feel that the top people know what is happening. Sometimes they meet with you as one of the staff RTs, but when can they meet with the Director of RT from time to time? It may seem unnecessary for you, but lions like to meet with, for example, the Rehab Director. It is okay, and it is not personal—provide frequent communication. Give them information, information, communication, communication. Let them know that their opinion matters. Give them resources, and tell them you appreciate and welcome the input. Those are a few ways to mitigate those over-the-top responses from the lion.

Summary

• Conflict resolution is not just the words you say but the environment you set and the “energy” you bring.
• Conflict is not avoidable, but volatility is.
• Conflict resolution is not “stuffing” or “stifling”
• Successful conflict resolution requires level appropriate intentional steps.
• Conflict resolution is a skill that must be refined and a muscle that must be strengthened.
• You can not determine someone’s response, but you can increase the odds of creating a response you can live with.

Remember that conflict resolution is not your words but the environment you set and the energy you bring. Conflict is not avoidable, but volatility is. How can you set systems in the environment to decrease the likelihood of volatility? Conflict resolution is not stuffing or stifling like I will not say anything, but finding a method, when, and how to say it. Successful conflict resolution requires level-appropriate intentional steps. It is also a skill that must be refined and muscle that must be strengthened. Lastly, you cannot determine someone's response, but you can increase the odds of creating a response you can live with. 

References

Doyle, A. (2021) “Top Soft Skills Employers Value with Examples”. The Balance Careers. July 22, 2021. https://www.thebalancecareers.com/list-of-soft-skills- 2063770

Goleman, D. (2008) Working with Emotional Intelligence. Bantam Doubleday Dell Publishing Group.

Maxwell, J. (1997) Becoming a Person of Influence. HarperCollins Leadership.

Editor’s note: This text-based course is an edited transcript of the webinar, Subacute Care Discharge Planning for the Respiratory Patient, presented by Vrati Doshi, MSc, RRT. 

It is recommended that you download the course handout to supplement this text format.

Learning Outcomes

After this course, participants will be able to:

• Describe the characteristics of respiratory patients who require subacute care.
• Describe effective steps for respiratory therapists and their patients in the transition home or to subacute care.
• Explain examples of researched backed discharge plans.

With this demographic shift, health service needs will grow. Older adults often have multiple chronic conditions requiring treatment. Improved healthcare means more survivors of once terminal illnesses now require long-term care. Caring for these complex patients long-term can strain healthcare workers, including respiratory therapists.

Patient Journey 

The patient's journey often continues after hospital discharge. Patients may be sent to a skilled nursing facility or receive home health care depending on their needs and current health status. Skilled nursing facilities provide 24/7 rehabilitative care and medical services for patients not yet ready to go home. The goal is to help patients regain mobility, self-care abilities, and baseline functioning so they can eventually transition home with support in place. Skilled nursing facility care plans focus on intensive rehab and nursing to improve the patient's condition.

Home health provides care to medically stable patients in their residences. Home health services include assistance with daily activities like walking, bathing, dressing, meal preparation, medication management, and overall disease management. Care plans ensure patients receive the appropriate level of care to heal and manage health conditions at home, with the coordination of intermittent skilled nursing, therapy, and aide services.

Initial Patient Destinations Following an Inpatient Hospital Stay 2020

Over half of hospital discharges return home, but many require post-acute care services to aid in their continued recovery. Post-acute care settings include skilled nursing facilities for those needing rehabilitative care and nursing services, home health for those more independent but still needing intermittent care, long-term acute care hospitals for those with complex medical needs, and inpatient rehabilitation facilities for intensive therapy.

Utilization of post-acute care services is expected to rise significantly as the population ages. By 2030, all baby boomers will be over 65, leading to a 73% increase in the number of seniors. For the first time in history, the number of people over 65 will outnumber children under 5 globally. This dramatic demographic shift will drive more older adults with chronic conditions and functional impairments to require care in skilled nursing and home health settings. Healthcare systems must prepare for escalating demand for post-acute care services.

An Aging Population and Workforce 

This growing aging population highlights another challenge - 92,000 respiratory therapists, key providers of post-acute respiratory care, will retire by 2030. This impending wave of retirements coincides with escalating demands for respiratory services. Healthcare systems must prepare for this staffing cliff. Consumer preferences shaped by COVID-19 are also fueling home health growth into 2022. Value-based care has motivated providers to control costs through new methods focused on care quality over quantity. This payment model has expanded into home health and skilled nursing facilities.

Consumer Preferences and the COVID-19 Pandemic Are Key Drivers of Home Health Growth In 2022

The COVID-19 pandemic also accelerated consumer interest in at-home care. The number of home care patients increased from 5 million to 12 million by the end of 2020 as patients sought to avoid virus exposure in facilities. This surge in demand for in-home services is spearheading an expansion and transformation of home healthcare.

The growth in demand for home health is reflected in increased funding and utilization. Home health funding from Medicare and private insurance grew 9.5% from 2019 to 2020. There is also a clear aging population preference for care at home. Nearly $265 billion worth of care services, representing 25.5% of total costs for Medicare and Medicare Advantage beneficiaries, could shift from traditional facilities to home-based care by 2025 without reducing quality or access.

The COVID-19 pandemic spotlighted the vital role home health can play in alleviating strain on overburdened healthcare facilities struggling with surges in hospitalizations. Keeping vulnerable seniors and chronic disease patients healthy at home helps avoid unnecessary healthcare system utilization. Most patients agree that in-home recovery is more convenient comfortable, and reduces infection exposure risks.

Home health allows patients to continue therapy treatments started in the hospital from the comfort of home. Common home health therapies include respiratory, physical, occupational, speech and nutritional therapies tailored to manage disease and improve quality of life.

Common home health therapies include physical therapy to improve mobility and function, speech-language pathology to work on communication and swallowing disorders, occupational therapy to increase the ability to perform activities of daily living, and respiratory therapy to manage chronic pulmonary diseases and optimize breathing.

The cost savings of home-based care are significant, too. One study found substituting home care for hospital admissions reduces costs by 30% per admission while achieving equivalent health outcomes. There are many factors fueling growth in home health demand, but a key driver is simply that people want to heal and manage care in the comfort of their homes rather than facilities. The patient preference for in-home recovery and care is increasingly being heard and supported across the healthcare system.

Medicare’s Hospital Readmissions Reduction Program (HRRP)

A major value-based purchasing program is Medicare's Hospital Readmissions Reduction Program (HRRP). Since the HRRP began in 2012, hospitals have lost billions in Medicare reimbursement dollars due to readmission penalties. This drives hospitals to prioritize reducing readmissions. This penalizes hospitals for excess readmissions to encourage better care coordination and transition planning during discharge. The HRRP accelerated coordination between hospitals and post-acute facilities to align on care transition processes. Setting up communication pathways and protocols for sharing patient information is key.

Specifically, CMS looks at three prior years of unplanned hospital readmissions within 30 days of discharge, regardless of the reason for that return admission. For example, if a COPD patient is initially admitted for an exacerbation and then comes back 30 days later with pneumonia, the discharging and admitting hospital are both penalized for that readmission. The HRRP has driven more strategic targeting of patients at high readmission risk for care management. Hospitals are investing in dedicated care transition staff and post-discharge services.

The goal is to motivate hospitals to partner more closely with post-acute care providers like home health and skilled nursing facilities to ensure continuity of care after discharge. The HRRP led to the development and adoption of new quality measures around care transitions and post-acute care coordination on top of readmission rates. This allows for more robust measurement. The cumulative impact is that the HRRP is catalyzing hospitals to think beyond their four walls to build bridges with partners like home health and skilled nursing facilities. Managing patients across settings is imperative to avoid penalties and reduce costs.

This program adds further impetus for health systems to invest in smooth care transitions and the ability to manage complex patients at home to avoid readmission penalties. Adequate discharge planning is necessary to ensure patients leave the hospital with proper education on disease self-management and avoid payment reductions.

Common Respiratory Diagnosis Related Groups (MS-DRGs)

Of the top 20 most common diagnosis-related groups (MS-DRGs) discharged from hospital to homecare, four are respiratory, and for the most common readmit diagnoses, 3 are pulmonary conditions. Respiratory conditions are major drivers of 30-day hospital readmissions. Analysis shows three pulmonary diagnoses—simple pneumonia, pulmonary edema, respiratory failure, and respiratory infections and inflammations—are among the top 20 reasons for early unplanned return visits. Further, COPD flare-ups also contribute significantly to readmission rates.

Of particular concern, pulmonary edema and respiratory failure account for over 22% of all-cause 30-day readmits, while respiratory infections and inflammations with major complications or comorbidity make up another 15%. Comparatively, simple pneumonia and pleurisy with major complications or comorbidity drive roughly 19%. Still, pulmonary edema with hypoxemic respiratory failure follows closely behind.

This readmission prevalence indicates respiratory therapists have pivotal opportunities to reduce recurrence through acute and post-discharge intervention. Inpatient treatment optimization, patient and family education, discharge protocol enhancements, and transitional support coordination can better equip high-risk patients to sustain lung health outpatient.

Goal-directed respiratory therapy across the care continuum can target at-risk populations with multiple touchpoints - addressing both acute incidents and long-term disease self-management. Developing this discharge-to-home bridge is crucial for mitigating avoidable readmissions related to preventable pulmonary complications.

Top Respiratory Home Health Disorders 

Figure 1. Top respiratory home health disorders.

In Figure 1, chronic obstructive pulmonary disease (COPD) represents a predominant respiratory disease fueling the growing utilization of home health services post-hospitalization. However, acute conditions like pneumonia, pulmonary edema, and respiratory failure following ICU stays also drive considerable skilled nursing and at-home respiratory therapy needs.

These preventable diagnoses signal opportunities to refine transitional care coordination and discharge education for at-risk groups. Patients hospitalized for pneumonia, volume overload, and hypoxemia often face a high probability of readmission within 30 days after index stay discharge. Enhancing outpatient treatment readiness for those diagnosed with recurrent lung disease can sustain capacity longer term outside the hospital.

Respiratory therapists have pivotal roles in managing both acute incidents and long-term pulmonary disease through optimized ventilation protocols, disease education, smoking cessation, airway clearance techniques, and medication/oxygen adherence coaching. Tightening gaps between inpatient and home care settings can reduce the likelihood of ER returns.

Goal-focused respiratory therapy across the entire care continuum represents a crucial link for mitigating the severity of subsequent exacerbations. As more services shift home-based, therapists must split time between bedside, transitional, and home health responsibilities to maintain incremental patient progress.

Home Respiratory Equipment

A vast array of equipment accompanies patients discharged to home care - ventilators, BiPAP, CPAP, cough assists, oxygen systems, and vest therapy. While introduced in the hospital, the transition to daily self-management proves extremely difficult. Mastering new devices alongside new diseases, medications, and an unfamiliar caregiver role is understandably overwhelming without adequate preparation and support.

Consider our own rigorous RT equipment training - part clinical engineer, part plumber. Now imagine facing that intensity as a wholly new user with a critical illness and minimal medical background. The mountain of operational, maintenance, and troubleshooting education fuels considerable anxiety, improper use, and non-adherence post-discharge.

As frontline therapists, we bear great responsibility for simplifying this transition process. Standardizing discharge coordination and hands-on training can profoundly shape patient trajectories. Thoughtful education and competency checks before discharge may provide the only chance to prepare patients functionally, mentally, and emotionally for integrating respiratory technology successfully into daily living. Our role in promoting self-efficacy persists well beyond hospital walls. The learning curve is steep, and we can play a big role in standardizing and simplifying the process of transitioning home.

When Building a Discharge Plan, Have These Outcomes In Mind

• Patient understands their condition, medications, equipment, and where to go for escalation of care 
• Patient can live as independently as possible and has control over their life 
• Patient can manage care at home to prevent future hospitalizations

When formulating a discharge plan, it is crucial to envision specific outcomes. Firstly, ensure that the patient comprehends their condition, medications, equipment, and knows where to seek escalated care. Secondly, empower the patient to live as autonomously as possible, asserting control over their life. Lastly, equip the patient with the ability to manage their care at home effectively, minimizing the risk of future hospitalization.

During the transition phase, whether at home or a facility, respiratory therapists play a pivotal role by undertaking significant steps to support and guide the patient. One essential aspect involves providing education about what to anticipate upon returning home or entering a skilled nursing facility. This education encompasses information about their disease state, the operation of equipment, medication management, and the appropriate contacts for escalating care. This proactive approach sets the foundation for a smoother transition and empowers the patient with the knowledge necessary for self-care.

Transition to Home or Facility

• Education on what to expect 
  • Disease
  • Equipment
  • Medication 
  • Who to call for escalation of care
• Include family members / caregivers
• Discuss any particulars with discharge nurse 
  • Patient’s ability to understand instruction
  • Socio-economic implications that can impact quality of care at home

When crafting a discharge plan, keep these outcomes at the forefront. Firstly, ensure the patient comprehends their condition, medications, and equipment and knows where to seek escalated care. Secondly, empower them to live as independently as possible, retaining control over their life. Lastly, equip the patient to manage their care at home effectively, minimizing the risk of future hospitalization. The transition, whether to home or a facility, involves significant steps that respiratory therapists can take to support the patient.

Include family members and caregivers in the process. If meeting them before discharge, involve them in the conversation. Discuss specific details with a discharge nurse, such as the patient's ability to understand instructions, potential memory issues, and socio-economic factors impacting home care quality.

Consider adapting communication to the patient's level, avoiding complex language. For instance, explain tasks using relatable examples like blowing out candles. Establish a goal, whether attending a family event or celebrating a new addition, to foster a commitment to the discharge plan. Provide tools tailored to their learning style. For visual learners, create videos demonstrating equipment assembly or inhaler use. Engaging patients in this way enhances commitment to home care.

Recognize the importance of patients sharing personal information, such as job loss or home issues. This data is crucial during the handoff between departments or from hospital to post-acute care. Informing RTs and nurses about these circumstances allows them to tailor care accordingly. For instance, if a caregiver has lost their job, this information can guide the provision of assistance and education to another person in the home, ensuring continuity of care beyond the RT's presence.

Case Study

Let's delve into a compelling case study that underscores the pivotal role of a Respiratory Therapist (RT) in ensuring comprehensive care for a patient both at home and in the hospital. A 68-year-old female was discharged home with a new COPD diagnosis, accompanied by a prescription for oxygen, salmeterol, and albuterol. The durable medical equipment (DME) provider received a thorough handoff from the hospital RT, outlining the patient's history during the hospital stay. Unbeknownst to the physician, the patient, recently widowed, was now living alone. The RT proactively communicated with the primary care physician (PCP) before the initial visit, shedding light on the patient's situation.

During the in-person assessment, followed by a virtual wellness visit 72 hours later, the RT uncovered concerning issues. The patient exhibited wheezing and demonstrated incorrect medication techniques. Furthermore, the living conditions were suboptimal, with the patient appearing disheveled surrounded by dishes in the sink. Recognizing the urgency, the RT took the initiative, ordering an Uber to ensure the patient attended a sick appointment with the physician. This intervention was crucial, as the physician was unaware of the patient's post-discharge struggles. The RT's dedication went beyond the norm, conducting a virtual wellness visit to monitor the patient's progress. These findings were promptly shared with the PCP, initiating a wellness check.

• Impact of RT intervention: 
  • Prevention of potential COPD exacerbation and hospital readmission
  • Patient admitted to SNF 
  • Coordinated care led to a hospital partnership between the hospital, PCP, and DME to manage respiratory patients

The collective efforts proved instrumental in averting a COPD exacerbation and potential hospital readmission. The patient, unable to manage care independently, was admitted to a Skilled Nursing Facility (SNF) instead of staying home. The coordinated care approach forged a hospital partnership involving the hospital, PCP, and DME to manage respiratory patients effectively. In summary, the proactive measures taken by the RT prevented readmission, facilitated appropriate care, and established a collaborative healthcare framework benefiting all parties involved, particularly the patient. This case exemplifies the significant impact an RT can have in ensuring holistic patient care.

Project Re-Engineered Discharge (RED)

Let's delve into the details of the discharge plan project developed by Boston University Medical Center, a culmination of seven years of work supported by funding from the Agency for Healthcare Research and Quality (AHRQ) and the National Heart, Lung, and Blood Institute. The project's primary objective was to enhance the discharge process by developing and testing activities and materials. Subsequently, they expanded the toolkit for hospital implementation. The overarching goal was to promote patient safety and contribute to a reduction in rehospitalization rates.

Crucially, the AHRQ played a pivotal role in funding the discharge toolkit for hospital implementation. This funding underscores the recognition of the project's significance in improving the quality of patient care during the crucial transition from hospital to home or another care setting. By investing seven years in research and development, the Boston University Medical Center has contributed valuable tools and strategies to healthcare institutions, aiming to optimize the discharge process and ultimately enhance patient outcomes. The collaborative support from AHRQ and the National Heart, Lung, and Blood Institute highlights the commitment to advancing healthcare practices and addressing the challenges associated with post-discharge care.

RED Components

The RED (Re-Engineered Discharge) framework encompasses a set of 12 mutually reinforcing actions, with certain actions standing out as having a direct impact on respiratory therapists. Let's explore these actions and the potential involvement of RTs in ensuring a smooth and effective transition at discharge:

1. Ascertain the need for and obtain language assistance:
   • RTs can play a crucial role in ensuring that patients with limited English proficiency have access to language assistance. This includes arranging for interpreters during the hospital stay and communicating this need for continued language support post-discharge.
2. Make appointments for follow-up care:
   • While RTs may not directly schedule appointments, they can emphasize the importance of follow-up care to both patients and their families during their interactions. Advocating for post-discharge medical appointments ensures continuity of care.
3. Plan for follow-up of results from tests and labs:
   • Collaborating with the care team, RTs can contribute by highlighting the importance of timely follow-up on pending test and lab results. This involves communication with the discharge coordinator to address any necessary adjustments to the patient's care plan.
4. Organize post-discharge outpatient services and medical equipment:
   • RTs can actively participate in coordinating outpatient services and ensuring the provision of necessary medical equipment. This involves working closely with the discharge coordinator to align hospital equipment with what the patient will use at home, reinforcing consistent education.
5. Identify the correct medicines and plan for the patient to obtain them:
   • RTs can reinforce medication education, especially in the case of respiratory medications. Ensuring that patients are proficient in using inhalers and understanding the prescription details contributes to a well-informed discharge plan.
6. Reconcile the discharge plan with national guidelines:
   • Although not solely an RT responsibility, ensuring alignment with national guidelines is crucial. RTs can collaborate with the broader care team to confirm that the discharge plan adheres to relevant guidelines.
7. Teach a written discharge plan the patient can understand:
   • Recognizing diverse learning needs, RTs can support patients by providing written discharge plans that cater to individual understanding. This might involve written instructions, visual aids, or notes to enhance comprehension.
8. Educate the patient about their diagnosis and medications:
   • From the initial encounter, RTs can consistently educate patients about their respiratory condition, emphasizing the manageable nature of diseases like COPD. This ongoing education is vital for patient empowerment.
9. Review with the patient what to do when a problem arises:
   • RTs can contribute by providing patients with clear action plans for potential issues. This includes educating them on whom to contact in case of emergencies or worsening symptoms, helping prevent unnecessary emergency room visits.
10. Assess the degree of the patient's understanding of the discharge plan:
    • RTs should actively engage patients in discussions to assess their understanding of the discharge plan. Encouraging questions and seeking feedback ensures comprehension and compliance.
11. Expedite transmission of the discharge summary:
    • While direct involvement in transmission may not be an RT responsibility, collaboration with the care team ensures that key information is conveyed during the handoff to clinicians providing post-discharge care.
12. Provide telephone reinforcement of the discharge plan:
    • RTs can contribute to reinforcing the discharge plan through telephone follow-ups. This involves checking in with patients, answering questions, and addressing any concerns, promoting continuity of care beyond the hospital.

In summary, RTs can actively participate in several key actions outlined in the RED framework, contributing to the overall success of patient transitions and reducing the likelihood of readmission. Their involvement is particularly impactful in actions that directly relate to respiratory care and patient education.

RED Hospital Implementation

• How to begin implementation at your hospital
• How to deliver the Re-Engineered Discharge
• How to deliver the RED to diverse populations
• How to conduct post-discharge follow-up telephone call
• How to monitor RED implementation and outcomes

The RED toolkit offers comprehensive guidance for hospital implementation, covering essential steps to enhance the discharge process. Let's delve into the key components outlined in the toolkit:

1. How to Begin:
   • The toolkit is initiated by exploring the advantages and disadvantages of integrating discharge education functions into the responsibilities of the staff nurse responsible for patient discharge. It also considers the option of hiring dedicated discharge educators for these functions. This step is crucial for determining the most effective strategy for implementing the RED components within the hospital setting.
2. Tasks for Discharge Educators:
   • This section outlines various tasks that discharge educators can undertake to implement RED components. Tasks range from reconciling medicine lists to reviewing the After Hospital Care Plan (AHCP) with the patient. The toolkit provides instructions on creating an AHCP—a patient-friendly booklet with clear instructions on self-care after hospital discharge.
3. Delivering the RED to Patients from Diverse Backgrounds:
   • Recognizing the diversity among patients, this step focuses on delivering RED to individuals from varied backgrounds, including considerations for language, culture, race, ethnicity, education, literacy, and social circumstances. Ensuring that discharge education is accessible and tailored to diverse needs is crucial for effective implementation.
4. Post-Discharge Reinforcement and Phone Call:
   • A critical component this step involves scheduling a phone call within 72 hours of a patient's hospital discharge. The objectives include reviewing appointments, medicines, addressing medical issues, and providing guidance for non-emergent problems. The toolkit offers a script for the phone call, a documentation form, and a role-play script for training callers, ensuring consistency in post-discharge follow-up.
5. Examine Readmission Rates and Implement Monitoring Programs:
   • To drive continuous improvement, the toolkit encourages hospitals to examine current readmission rates and implement monitoring programs. It emphasizes the reasons for measuring transitional care, suggests implementation and outcome measures, and reviews the availability of data to create benchmarks. This step is essential for hospitals to assess their progress and make informed adjustments.

In summary, the RED toolkit provides a structured approach for hospitals to enhance the discharge process. From initial considerations of how to begin to the detailed tasks discharge educators should undertake, the toolkit addresses the multifaceted aspects of patient transition from hospital to home. The emphasis on diverse patient backgrounds, post-discharge reinforcement, and ongoing monitoring ensures a comprehensive and patient-centered approach to transitional care.

Impact of RED

The impact of the RED (Re-Engineered Discharge) framework is substantial, as evidenced by the following key findings:

1. 30-Day Readmission Decrease:
   • Implementation of the RED framework resulted in a remarkable 25% decrease in 30-day readmissions. This reduction is a significant indicator of the effectiveness of the discharge process improvements facilitated by RED.
2. Cost Savings per Patient:
   • The implementation of RED led to a cost savings of $412 per patient. This financial impact is a testament to the efficiency and positive outcomes associated with the RED framework.
3. Prevention of Readmissions or ED Visits:
   • Notably, one readmission or Emergency Department (ED) visit was prevented for every seven patients who received RED. This statistic underscores the preventive nature of the RED framework, contributing to improved patient outcomes and healthcare resource utilization.
4. Lower Observed Cost:
   • RED demonstrated a lower observed cost of 33.9%, emphasizing the potential for significant cost savings in healthcare delivery. This reduction in cost aligns with the broader goal of optimizing resource utilization and improving the overall efficiency of care.
5. Improved Primary Care Follow-Up:
   • The RED framework facilitated improved primary care follow-up, a critical aspect of post-discharge care. A nurse discharge advocate actively worked with patients during their hospital stay, arranging follow-up appointments, ensuring medication reconciliation, and conducting patient education. This personalized approach contributed to better patient engagement and adherence to the discharge plan.

The study utilized a randomized trial design involving English-speaking hospitalized adults with a mean age of approximately 50 years. The trial was conducted in general medical service at an urban academic safety net hospital, involving 749 participants. Funding from reputable organizations, including the Agency for Healthcare Research and Quality, the National Heart and Lung and Blood Institute, and the National Institute of Health, underscored the significance of the research.

Given the success of the RED framework, particularly in the roles played by discharge nurses and pharmacists, there is potential for respiratory therapists (RTs) to adopt similar responsibilities in follow-up care. RTs could actively engage in post-discharge calls, reinforcing education, ensuring equipment adherence, and contributing to the reduction of costs and readmissions. This approach aligns with the patient-centered and comprehensive care principles promoted by the RED framework. It provides an opportunity for RTs to play a vital role in enhancing the continuity of care for patients transitioning from the hospital to home.

COPD Caregiver’s Toolkit

The COPD Caregivers Toolkit, launched by the Respiratory Health Association (RHA) with support from the National Heart Lung and Blood Institute's Learn More, Breathe Better Program, has proven to be highly effective. In a study conducted in 2018 to assess the toolkit's acceptance, notable findings were observed:

1. High Acceptance Rate:
   • The study revealed that 68% of participants found the COPD Caregivers Toolkit helpful. This high acceptance rate indicates that the toolkit effectively addresses the needs of caregivers in supporting individuals with COPD.
2. Recommendation Rate:
   • An impressive 92% of participants stated that they would recommend the toolkit to someone else. This strong endorsement underscores the perceived value and utility of the toolkit among caregivers.

Designed with a focus on supporting caregivers rather than the patients themselves, the COPD Caregivers Toolkit serves as a valuable resource for those involved in the care of individuals with COPD. This includes respiratory therapists (RTs) working on the home side or in skilled nursing facilities who can provide the toolkit to patients' families during the discharge process. The toolkit offers comprehensive support by providing caregivers with essential information on who to contact, what to expect, and an educational component on the COPD disease state. This proactive approach ensures that caregivers are well-equipped to manage the care of COPD patients effectively, contributing to better patient outcomes and overall caregiver satisfaction.

For RTs, incorporating the COPD Caregivers Toolkit into the discharge process can enhance the continuum of care by extending support beyond the patient to their caregivers. By empowering caregivers with the necessary resources and information, RTs contribute to a more informed and capable support system for individuals managing COPD in a home or skilled nursing facility setting. The COPD Caregivers Toolkit, structured around five common questions, is designed to provide practical and accessible support for caregivers. The toolkit addresses key areas of concern for individuals caring for someone with COPD, making the information easily understandable through a combination of visuals and text. The simplicity of the content ensures that it can be comprehended by individuals up to a fifth-grade level. Let's explore the questions and topics covered in the toolkit:

1. How do I help the person I'm caring for manage COPD?
   • This section likely includes guidance on assisting with medication management, recognizing symptoms, and supporting the individual in adopting a healthy lifestyle to manage COPD effectively.
2. What should I know about managing at home for someone living with COPD?
   • This may cover aspects such as creating a COPD-friendly living environment, understanding the use of respiratory equipment, and ensuring a safe and comfortable home setting.
3. How do I prepare for a visit to the doctor?
   • Caregivers can benefit from information on preparing for medical appointments, questions to ask healthcare providers, and understanding the importance of regular check-ups for COPD management.
4. How do I help after a COPD flare-up or hospital stay?
   • This section likely provides guidance on recognizing signs of a flare-up, responding to emergencies, and supporting the individual's recovery following a hospital stay.
5. How do I take care of myself while managing someone else's care?
   • Caregiver self-care is crucial, and this section may include tips on managing stress, seeking support, and ensuring that caregivers prioritize their own well-being.

The toolkit's emphasis on simplicity and visual elements enhances its accessibility, ensuring that caregivers of varying literacy levels can effectively utilize the information. By structuring the toolkit around these common questions, it provides a practical and user-friendly resource for caregivers navigating the challenges of supporting someone with COPD. This approach aligns with the goal of empowering caregivers with the knowledge and tools they need to provide effective care at home.

Research on Discharge Plan Effectiveness

• Systematic review focused on effects of early follow-up after hospital discharge for patients with heart failure or COPD
  • Randomized controlled trail, 2 non-randomized controlled trials, and 7 observational studies
  • Early follow-up was associated with reduced risk of all-cause readmission, ED visits, and mortality

A 2021 systematic review and meta-analysis examined the impact of early outpatient follow-up after discharge for patients hospitalized with heart failure or chronic obstructive pulmonary disease (COPD). The analysis pooled data from 10 studies - 1 randomized controlled trial, two non-randomized controlled studies, and seven observational cohort studies. In total, the review included 24,730 patients admitted with decompensated heart failure or acute exacerbation of COPD.

Across all studies, an early follow-up visit within 7-30 days of hospital discharge was associated with significantly reduced risks of all-cause hospital readmission, emergency department revisits, and all-cause mortality compared to routine follow-up. Specifically, early clinician follow-up decreased relative odds of readmission by 11%, ED visits by 20%, and mortality by 17%. These findings remained consistent even in sensitivity analysis of the highest quality studies.

Notably, one RCT found a clinic visit within one week of discharge effectively reduced 90-day readmission for high-risk heart failure patients by 36%. The systematic review concluded that early outpatient follow-up represents an impactful, low-cost intervention to improve outcomes after heart failure or COPD hospitalization.

• Randomized clinical trial studied outcomes of standardized transition bundle and care coordinator for patients with acute exacerbations of COPD
  • Transition bundle cohort were 83% less likely to be readmitted within 7 days and 26% less likely to be readmitted within 30 days of discharge 
  • Care coordinator did not influence readmission or ED revisits 

A 2022 randomized clinical trial examined the impact of implementing a standardized care transition bundle, with or without an assigned care coordinator, for patients hospitalized for acute exacerbation of COPD. The transitional bundle included enhanced education on disease self-management, medication reconciliation, as-needed action plans, follow-up scheduling, and post-discharge needs assessment. The study randomized 568 COPD patients from 2 hospitals to receive either:

• Usual care
• Transition bundle
• Transition bundle plus assigned care coordinator

The main outcome measures were 7-day and 30-day all-cause and COPD-related readmission rates, as well as ED revisits. The transition bundle group demonstrated significantly lower 7-day readmission - 83% relative risk reduction compared to usual care. The bundle also reduced 30-day readmits by 26%. However, adding a dedicated care coordinator did not confer any additional reduction in readmissions or ED visits. The findings highlight the potential for standardized transition protocols to dramatically improve short-term outcomes for COPD without increasing resource use. Implementation would require interdisciplinary coordination with respiratory therapy to identify high-risk patients pre-discharge.

The insights from these studies highlight the importance of early follow-up and the potential benefits of standardized transition bundles with care coordination. However, it's noteworthy that there is a lack of large, methodologically robust studies specifically focused on the effectiveness of discharge plans for respiratory patients. While there are studies on COPD protocols, much of the emphasis is on nursing care and discharge planners in education and follow-up. 

The potential influence of clinicians over care coordinators in readmission outcomes suggests that the roles of different healthcare professionals in the discharge process may have varying impacts. Additionally, replicating some of these studies with a focus on respiratory therapists and their effects on patient care at home and during the discharge process is valuable. This could contribute to a more comprehensive understanding of the role of respiratory therapists in improving outcomes for respiratory patients post-discharge.

In summary, the studies mentioned underscore the importance of early follow-up and the potential benefits of specific interventions in reducing readmissions. There is an opportunity for future research to delve deeper into the specific contributions of respiratory therapists in discharge planning and post-discharge care for respiratory patients.

Respiratory Therapists Taking the Extra Step

Respiratory Therapists (RTs) can collaborate with home care and DME companies to establish a clinician-to-clinician handoff document. This document includes crucial particulars about patients and their family caregivers, especially when dealing with diverse languages, the presence of babies or pets in the home, and assessing the availability of proper electricity for equipment. It is essential to ensure that patients discharged with oxygen have the necessary facilities at home to manage their care effectively. Key considerations include evaluating the patient's ability to take medications correctly and determining if they require constant reminders. Standardizing education is paramount, fostering continuity in communication and care. Utilizing toolkits that maintain consistent communication from the hospital to home reinforces crucial information.

Incorporating videotaped techniques demonstrating equipment cleaning, medication administration, and disease state explanations provides valuable resources for patients and their families to reference. Encouraging patients to document key points during education, akin to taking notes in school, enhances retention. In summary, the shift in care delivery from facilities to homes necessitates robust and standardized processes to minimize hospital readmissions. Discharged respiratory patients require comprehensive education on their diseases, medications, equipment, and self-management. RTs can significantly contribute to patient satisfaction and long-term quality care. It is recommended to consider implementing a standardized discharge protocol tailored specifically for respiratory patients.

Questions and Answers

Do you think we often miss the window of opportunity to apply long-standing solutions in our profession?

Presenter: I won't dismiss the potential inherent in these opportunities; I firmly believe that possibilities abound. Attending webinars like the one we're engaging in now offers a chance to ignite meaningful conversations. It's an avenue to observe the innovative practices shaping our field, allowing us to return to our departments armed with insights and possibilities. These forums empower us to pose the question: Can we implement similar strategies in our own setting? Consider, for instance, the COPD toolkit—a valuable and complimentary resource. Accessible through download or order from the Respiratory Health Association, this toolkit is a tangible asset that can be readily stocked in both clinical departments and on the home health side. Here lies an opportunity waiting to be seized. It involves actively participating in departmental discussions and, when needed, elevating the discourse to higher levels. Collaborating with the pulmonary department to establish it as a standard of care is an impactful role that Respiratory Therapists (RTs) can play. Engaging with nursing staff and physicians, RTs can present compelling studies and their outcomes. The pertinent question then becomes: Can we integrate these findings into our department's practices, especially for COPD patients entering the ED or ICU? It's not a matter of missing opportunities; rather, it's an ongoing pursuit of optimizing patient care to the best of our abilities. In most hospitals, a discharge planning committee is typically led by a nurse who serves as the nexus of resources available to patients upon departure. This encompasses a comprehensive array, including vendor lists for home care and durable medical equipment (DME). Collaborating with this discharge planning nurse becomes crucial for Respiratory Therapists (RTs). It involves assessing the proficiency of home care companies in respiratory care. If there's a gap in knowledge, introducing the discharge planning tool to these entities becomes an imperative step. Engaging with discharge planning nurses in this manner is not just beneficial for patient care; it also aligns with the interests of these home care companies. Those on the preferred provider list inherently desire to fulfill the hospital's expectations. By equipping them with the tools and knowledge specific to respiratory care, we create a win-win scenario. These seemingly minor interventions can make a significant impact, fostering better care for the patient. It's about being a staunch advocate for the patient's well-being and using our influence to push for elevated standards of care.

How does the dynamic nature of various components in the discharge plan, evolving from the beginning to the end of patient care, contribute to promoting patient safety?

Hospitals aim to minimize readmissions, emphasizing the importance of patient safety. Educating patients throughout the team is key, enabling them to implement these measures upon discharge and further reducing the risk of readmission. This aspect resonated with me. In terms of patient safety, hospitals have a vested interest in adopting toolkits and resources to prevent readmissions. Anything that aids in reducing costs and facilitating earlier discharges aligns with the hospital's goals. The RT department plays a crucial role in championing these initiatives, and while many are open to listening, it requires a strong voice within the RT department to effectively advocate for these practices.

Is the toolkit something that we are able to access and download? 

To access the COPD toolkit, you can visit the Respiratory Health Association website and navigate to the "Resources" tab. There, you'll find the COPD toolkit available for download or bulk ordering for your facility. It's recommended to provide this toolkit to any new patient diagnosed with COPD and their caregivers present in the room. The widespread distribution of this toolkit is beneficial, as evidenced by positive outcomes data. Users have found it highly helpful, and its utilization can extend to friends and family who may also be dealing with COPD. Furthermore, the toolkit serves as an objective measuring tool. It facilitates the collection of essential information from patients, enabling effective communication with relevant team members such as physicians, nurses, and family members. This structured approach helps prevent miscommunication, ensuring that the information conveyed remains accurate and consistent throughout the healthcare team.

Can the COPD toolkit be used one time, or is it applied both initially and periodically throughout the patient's care journey?

Certainly, I would recommend providing the COPD toolkit to a patient during the initial encounter, particularly when dealing with a new COPD diagnosis. It's beneficial to walk them through the various components of the toolkit. The COPD toolkit is specifically designed for caregivers, allowing you to give it to both the patient and their caregiver. This approach reinforces the support structure that the patient will have at home. For individuals managing COPD at home, the multitude of educational pamphlets provided during hospital visits—accompanying new diagnoses or medications—can be overwhelming. The toolkit serves as a simplified resource, helping caregivers organize and comprehend the information effectively. It streamlines expectations, such as the need for the patient to take medication multiple times a day or use specific equipment for secretion removal. Caregivers gain insights into the level of support required at home, addressing nuances like ensuring accessibility to equipment for less mobile patients. The toolkit proves crucial in highlighting these subtleties, especially for those transitioning to the home care setting. By distributing it from the outset, caregivers have the opportunity to familiarize themselves with the contents, seek clarification, and return with any questions before the patient's discharge. This ensures that key information is reiterated and thoroughly understood.

Why are the respiratory diagnoses so high in readmissions? What are we missing?

Absolutely, it is a critical question to consider. Respiratory patients often present with a multitude of comorbidities, extending beyond respiratory issues to encompass conditions like heart problems and diabetes. The aging population, largely consisting of baby boomers, includes a substantial number of smokers and ex-smokers, contributing to the prevalence of complex health challenges. With this demographic shift, a growing number of individuals are grappling with various health issues and leaving hospitals without adequate education or support for home care. The challenges intensify as the aging population faces a shortage of caregivers—a reality underscored during the COVID-19 pandemic. This shortage extends beyond hospitals to encompass home care, impacting respiratory therapists, nurses, and physicians alike. Consequently, there's an escalating demand for care while the available support for patients is diminishing. A noticeable gap emerges wherein patients receive care at the hospital, but its adequacy for discharge may vary. Upon returning home, they encounter difficulties managing their care, grappling with multiple medications, unfamiliarity with equipment usage, and the complexity of dealing with various vendors for different aspects of their care. The intricacies are compounded for patients lacking a robust support system. Even with a healthcare background, navigating insurance, finding a covered primary care physician (PCP), identifying pharmacies that deliver medications, and addressing other healthcare-related queries can be challenging. Respiratory patients, often dealing with chronic conditions, require ongoing care. The recurrent readmissions observed in these cases underscore the need for a comprehensive and continuous support system. In some instances, the ease of seeking emergency care may appear more appealing than waiting for a physician's appointment, emphasizing the chronic nature of these healthcare challenges.

How can we address the challenge of patients who may not realize the questions they need to ask during their healthcare journey, leading to a sudden influx of overwhelming queries after the acute care phase?

The RED toolkit includes a section with suggested questions to ask healthcare providers such as primary care physicians or pulmonologists. These questions cover aspects like insurance coverage, follow-up appointments, and coordination with DME and pharmacies. Patients may not be aware of these questions, and physicians might lack time to address them comprehensively during visits. In this context, respiratory therapists (RTs) play a significant role, even in reactive situations when patients are already ill upon hospital admission. Educating patients during such overwhelming moments is crucial. Recognizing the complexity of healthcare transitions, utilizing toolkits, and speaking up early can help eliminate barriers, creating a positive domino effect for patients and their families. Despite the challenges RTs may face in gaining attention, finding influential champions within the healthcare system, such as supportive physicians, nurses, or department heads, can drive change. Utilizing evidence-backed approaches and emphasizing the business aspect of healthcare can facilitate the acceptance of initiatives like implementing toolkits, especially when they are offered for free and endorsed by reputable agencies. The gradual nature of change in healthcare emphasizes the importance of building support from key stakeholders.

How can we navigate and overcome common barriers encountered, whether as an RT, nurse, or physician? Examples include dealing with patients or team members lacking enthusiasm for consistent communication, addressing tension within multidisciplinary teams, or assisting patients who don't speak English as their primary language. How do we effectively navigate these challenges?

In the realm of respiratory therapy, individual differences among practitioners are inevitable. We've all encountered environments where dedication levels vary. When you, as an RT, consistently go above and beyond, you are inherently prioritizing patient care. Continuing to uphold these standards is crucial. While disparities in enthusiasm among RTs may become apparent, especially when it affects patient outcomes, it's imperative to communicate such concerns to department heads. Advocating for standardized practices ensures that efforts to improve patient care, such as introducing new toolkits, are embraced across the entire respiratory department. Reflecting on my experience in an ICU with a service-based model, where all RTs adhered to the same protocol, it became evident that a unified approach fosters enthusiasm. Having a shared education script and learning from each other created a contagious enthusiasm. However, disparities in enthusiasm can be detrimental, impacting patient care. Initiatives should focus on creating an infectious culture where all RTs contribute to standardized practices. In a hospital situated in the culturally diverse city of Chicago, language barriers were a common challenge.

Employing strategies such as interpreter services and enlisting nurses fluent in the patient's language proved effective. Collaborating with colleagues who shared language skills not only facilitated communication but also fostered camaraderie among clinicians. Encouraging patients to bring in caregivers during hospital stays for comprehensive education, utilizing interpreter lines, and recording bilingual instructions contribute to setting patients up for success at home. Consistency in communication is vital for patient understanding. Breaking down education into manageable chunks aligns with patients' routines and enhances retention. While the timing may vary based on individual circumstances, providing information incrementally allows patients and their families to absorb, record, and ask questions. The goal is to create a supportive environment that encourages ongoing communication, ensuring that patients feel confident managing their care beyond the hospital stay. Some of the interventions that we did when we were in the hospital were because it was an academic hospital, where a substantial number of residents rounded regularly. We identified key gaps in their understanding of respiratory therapy, particularly when it came to ventilators and durable medical equipment (DME). Physicians generally possess a foundational knowledge of anatomy but may lack specific expertise in equipment and medication intricacies. Recognizing this, our respiratory department took the initiative to enhance overall understanding and communication among healthcare professionals. Acknowledging the absence of a dedicated course for physicians on ventilators and DME, we implemented a series of 15-minute courses throughout the year. These sessions aimed to reinforce effective communication with patients and ensure that both nursing teams and physicians were equipped with the necessary knowledge. The approach was well-received, emphasizing collaboration rather than condescension. We emphasized the importance of being collectively well-informed to guarantee that patients leave the hospital with a comprehensive understanding of equipment usage. 

Encountering situations where patients had nebulizers running without medication due to incomplete instructions, we viewed these instances as opportunities for education rather than shortcomings. The respiratory department actively engaged nursing teams, offering assistance without judgment and encouraging future collaboration. By providing clear guidelines on equipment use and communicating openly, we successfully fostered a cohesive team dynamic. Over time, our department became recognized as experts, not only in respiratory care but across various aspects of patient management. Recognizing the importance of a unified approach, I stress the significance of showing the value of our expertise through actions. While one person cannot carry the entire team, having a strong leader who listens, pays attention, and champions evidence-based initiatives are crucial—establishing trust within the multidisciplinary team and showcasing the ability to teach and ensure patient well-being positions respiratory therapists as vital contributors in various healthcare aspects. This collaborative approach and effective communication are pivotal for achieving comprehensive and patient-centered care.

How important is networking?

Absolutely, networking is a crucial element. Demonstrating your value within the team is not only beneficial for your department and the respiratory field but also impacts the long-term trajectory of patient care. You never know the lasting effects of your contributions. Patient safety is paramount, and ensuring that the patient receives the care they need is the ultimate goal.

I work in the hospital setting, and we have an eval and treatment protocol that MDs will order as RCP. We evaluate the patient and develop a care plan for the patient while they are in the hospital. What are ways that we can help manage the care at home?

Firstly, that iss fantastic. Not all hospitals have such protocols. To manage care at home effectively, consider creating a document for the patient's chart or discharge planner. Include details about the patient's home environment, such as living alone, recent life changes, or any factors affecting care. Outline the treatment provided during the hospital stay, including educational videos, and note the patient's understanding and motivation for improvement. Highlight upcoming events or milestones important to the patient, as this can serve as a motivator for both the patient and the RT managing care at home. Foster relationships with home care organizations and ensure a smooth handoff of information between hospital and home RTs. Advocate for the patient's needs, ensuring that the receiving facility, whether home health or a skilled nursing facility, is equipped to manage respiratory patients. Leverage your relationship with the discharge coordinator to communicate crucial information for effective post-hospital care. Managing the care transition from hospital to home involves collaboration and effective communication, ensuring the patient continues to receive comprehensive and tailored respiratory care.

Is it important to have a well-defined plan and process, ensuring continuity of care and the seamless transfer of information between facilities, even if the information is documented electronically in systems like Epic or other hospital systems?

In the case of readmission, especially for frequent flyers, having a documented history proves invaluable. With prior documentation, you can recall details about the patient, such as recent widowhood, allowing you to approach them with empathy and discuss relevant aspects of their care. Inquiring about their experiences at home and any potential improvements they would suggest enables you to gather crucial insights. It becomes your responsibility to ensure that the primary care provider, nurse, and coordinator are well-informed about the factors contributing to the patient's return, facilitating better care coordination. As a hospital RT, the post-discharge phase typically involves a hands-off approach. However, establishing a system, be it in the form of documentation or communication with the coordinator, becomes crucial. These measures are important not only for advocating for the patient but also for contributing to more informed and effective care. Recognizing the significance of socioeconomic factors and identifying barriers to care is a process that may not yield immediate results but can lead to substantial positive outcomes in the long run. These seemingly minor adjustments and insights into patient motivation can have a profound impact on the patient, their family, the hospital, and your role as an RT.

References

Bestsennyy, O., Chmielewski, M., Koffel, A., & Shah, A. (2022, February 1). From facility to home: How healthcare could shift by 2025. McKinsey & Company. https://www.mckinsey.com/industries/healthcare/our-insights/from-facility-to-home-how-healthcare-could-shift-by-2025.

The COPD Caregiver’s Toolkit | NHLBI, NIH. (n.d.). NHLBI, NIH. https://www.nhlbi.nih.gov/education/copd-learn-more-breathe-better/copd-caregivers-toolkit.

Haddad LM, Annamaraju P, Toney-Butler TJ. Nursing Shortage. [Updated 2023 Feb 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan.

Holly, R., & Holly, R. (2021, December 15). Accelerated by pandemic relief programs, national home health spending hits $123.7 billion. Home Health Care News. https://homehealthcarenews.com/2021/12/accelerated-by-pandemic-relief-programs-national-home-health-spending-hits-123-7-billion/.

Hosp. Readmission Reduction | CMS. (n.d.). https://www.cms.gov/medicare/quality/value-based-programs/hospital-readmissions.

Jack BW, Chetty VK, Anthony D, Greenwald JL, Sanchez GM, Johnson AE, Forsythe SR, O'Donnell JK, Paasche-Orlow MK, Manasseh C, Martin S, Culpepper L. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009 Feb 3;150(3):178-87. 

Le, N. C., Rahman, T., Kapralik, J. L., Ibrahim, Q., Lear, S. A., & Van Spall, H. G. C. (2022). The Hospital at Home Model vs Routine Hospitalization for Acute Heart Failure: A Survey of Patients’ Preferences. CJC Open, 4(3), 263-270.

Leaders, O. T. (2019, April 19). 4 major In-Home Healthcare Market Drivers to watch. HIT Consultant Media. https://hitconsultant.net/2019/04/18/4-major-in-home-healthcare-market-drivers-to-watch/.

McIlvennan, C. K., Eapen, Z. J., & Allen, L. A. (n.d.). Hospital Readmissions Reduction Program. Circulation. https://doi.org/10.1161/circulationaha.114.010270.

Mcconnell, T. (2022, March 3). 2022 Outlook: Home Health and Hospice - HealthCare Appraisers. HealthCare Appraisers. https://healthcareappraisers.com/2022-outlook-home-health-and-hospice/

Popowitz, E. (n.d.). The growing demand for at-home care. Definitive Healthcare. https://www.definitivehc.com/blog/growing-demand-home-care.

Project RED (Re-Engineered Discharge): Toolkit. (n.d.). https://www.bu.edu/fammed/projectred/toolkit.html.

Editor’s note: This text-based course is an edited transcript of the webinar, The Power of You: Unlocking Purpose Within Your Career, presented by Linda Nozart, MPH, BSRT, RRT, AE-C. 

It is recommended that you download the course handout to supplement this text format.

Learning Outcomes

• Recognize their current position while learning to grow professionally
• Determine opportunities for professional growth
• Identify their emotional intelligence skills

Do You Love What You Do?

We will talk about finding your purpose within your career, being in love with what we do, and how we provide services. Let me tell you something, guys. SpongeBob SquarePants is my TV cartoon mentor. Yes, you can have mentors from all kinds of spaces and people. He is my cartoon version. The reason is that SpongeBob loves what he does so much that he counts the sesame seeds on the buns. He pays Mr. Krabs to come to work and does not want him to ever take his vacations. I always loved this character when he first came out. I always wanted to know, can we have this type of love and passion for what we do? Is it real? Can it be real? I am always trying to go after this level of happiness.

Career Development  Experiences

There are many decisions to make in our careers. I love this because it is about you and the decisions that you make. What do you become by making these decisions? As presenters, our experiences and perspectives come from our pasts, histories, and other factors we are exposed to, both outside our careers. For example, I started working at the young age of 14. My parents approved me having working papers. My first job was at the local annual carnival, and I was the promoter for the game booth called Prize Every Time. 

The Power of You

I am going to circle back to why how this relates to this presentation, but what I want you to know with all these different experiences is that within 14 years as a respiratory therapist and eight years within the public health field, I have learned, I have gained the skills of knowing making decisions that put me on a journey of finding my passion of what I do. I have a lot of experience managing work relationships throughout this journey. That is what we are going to talk about today. Stop thinking you will be happier when you get the promotion, earn more money, get to the day shift, or become the director. Know that you can become. You own your happiness, and there are ways to embrace your position from where you are now. 

Keys to Embracing Your Current Position

• Adopt an attitude of gratitude 
• Create milestones for yourself celebrate when you reach them
• Have pride in the RT profession
• Start shift on a positive note always look on the bright side
• Reflect on how much you have grown in the position  
• Look forward to learning new things

Adopt an attitude of gratitude. I know a lot of gurus say this, people sometimes think this stuff is hocus pocus, but there is a lot of fact to it. There is evidence that shows when people have an attitude of gratitude, it makes their day. It makes getting up in the morning easier. Meaning being grateful so you can put a roof over your family's head, so that you can help grandma and grandpa with their housing. For example, my grandma is in Haiti. She is living her best life because I can help my parents, but they still help financially take care of her. She is glowing at 100 years old. Do you understand what I am saying? That makes us happy. We are grateful for that. This field has helped my family. Create milestones for yourself and celebrate when you reach them. What do I mean by that?

Often, people wait for supervisors to create competencies for them. What you can do is you do not have to wait for them to do that. You can create your competencies and your milestones. For example, I was terrible at intubations, terrible. I made for myself when I first started in my level one trauma center position. I said, "If I could get five successful intubations, this would be such an improvement. I would celebrate that." I kept track of that, and it really helped me to feel happy where I was. I encourage people to do this for themselves, keep track of it, and keep setting milestones throughout their careers.

Have pride in the RT profession. I hear people say many times, "Oh, I feel like I am pushing a ventilator." If you feel like you are pushing a ventilator, then you are going to push a ventilator. Everything starts from the mind. I do not feel like I am pushing a ventilator. I feel like I am the life support. Not the ventilator. I am the life support because, at the end of the day, if something happens to the ventilator, I know what to do, and I am confident in what I have learned.

This is the attitude that we should have as respiratory therapists. Trust and belief that people think: if they can manage their iPhone, they know how to manage a ventilator, because we are pushing buttons. Once you know what a peak pressure is, you know why the tidal volume is what it is. You know when to suction a patient by looking at the ventilator and the patient. Please have pride in what you do. Carry yourself solely, and it will really help you embrace the position that you have.

Start your shift on a positive note. Always look on the brighter side because it really does set the tone at the start of the change. Whether day shift or night shift, start on a positive note. Listen to good music, listen to positive podcasts, and self-improvement stuff. Keep everything on a positive note because, as we all know, respiratory is not glamorous, it is not a glamorous job, we deal with so much. Know that you can create your sense of being in a positive bubble and set the tone for yourself.

Reflect on how much you have grown in the position. Once again, this aligns with the milestones. Progress equals happiness. When we see ourselves from a baseline, then we see how far we have gotten. It is like, "Wow, I cannot believe how far I have come in this amount of time. When we do not often see this, we start to feel we are in a rut. Understand where that can begin to fester. Reflect on how you have grown. During my intubations, I was not able to intubate one person successfully on my own. Then I ended up with 20 intubations, 50 hundred, then so on.

Keep reflecting, and look forward to learning new things. This has helped me a lot because respiratory care is one of those things we have to keep learning. When you leave school, that is not it. We still have to continue. Here is the point of the CEUs: making sure we stay on top of them. Find ways to enjoy learning what you do and learning new information. I created this silly thing called "Linhale." Linhale because I am Linda. Linhale is for me. I say, "Linda, you are about to learn something new. We are going to Linhale." Meaning I am going to inhale something new? I come up with silly songs or silly acronyms to help me remember things. This allows me to look forward to learning new things, which I enjoy. Then piggyback off that, once you learn new things, you have to apply them.

PDSA – Plan, Do, Study, Act Cycle

Figure 1. PDSA cycle.

I have a younger brother who had the Super Nintendo. I was a big fan. If you played Super Mario Bros., remember that when he got a power star, he was invincible for 10 seconds. He could knock everything and do all that he wanted to do. My point is that when we are motivated, we learn something new. When you are motivated, know that it lasts only for a couple of days. It does not last long. You have to apply it. Here is a good way. I actually call this a life hack, the PDSA cycle in Figure 1. The PDSA is a quality improvement technique, a method. Basically, I make many quality improvements. This is where we are because we want to do better, but what do we need to do? Those are the things that we are looking at. The PDSA is to plan, do, study, and act. We are actively focused on trial and error. That is all it is. You are tailoring it as you go. Plan, do, study, act. I really use this for almost everything in life. It is amazing.

Body Mind Set 

• Be adoptable welcome change 
• Help co-workers with out expecting anything in return – “Helpers High”
• Practice great self-care – Listen to your body (get quality sleep eat well)

Adapt, be adaptable, and welcome change. When I took a management position, I even struggled with this in the beginning. I did not know how quickly things changed in management. You trickle down information from the higher-ups, and you have to quickly find a way to deliver it to your team. This was something I had to learn to unlock my own power in my career and be an adaptable, welcome change. Change is always coming, and nothing stays the same forever. Do you understand what I am saying? We have to find ways to be adaptable and to welcome change. Look what happened with COVID. That is a prime example of change coming and having to roll with it. 

Helpers High 

• Concept arose in the 1980s 
• It consists of positive emotions following selfless service to others
• Greater health increased longevity are associated with this psychological state
• Generosity, selflessness, an extended sense of self-favor are our ability to tackle successfully the environmental challenges we face on our planet

Helpers High is a genuine concept developed by therapists. To describe it, many of us take public transportation in New York City. I take the train. When you are on the train during rush hour, you will frequently not get a seat. You will be standing, and often facing the door. Now, when you are facing the door, you will see somebody hear a message that says, "Stand clear for closing doors."

Furthermore, the door is about to close. Now you may see someone running for their dear life trying to get on this train. They might be holding children in a stroller with suitcases. Now, you decide to put your foot, body parts, or whatever out. New Yorkers get creative, helping to wave them in or watching to see if they make it. When you put your foot out to help them come in, they may or may not say thank you. This is New York City.

Nevertheless, the point is this is about you. That tingly feeling you got from doing that is real. You do not know if you helped them get to that job interview on time or get the flight on time; you do not know. All it is that you took a split second or a minute to decide to help them for absolutely no reason. 

Figure 2. Adapted from the self-care wheel.

Once again, we have to listen to our bodies. You cannot find or unlock your purpose if you do not feel good; your body tells you you need rest, so take the time to take care of the things identified in Figure 2. Self-care is another place where I struggle. I am being proactive in real-time. There is plenty of evidence to show that this increases happiness and longevity. People live longer when they are in this state of mind.

An example is when you are helping that mom bring her stroller up the stairs, or helping elders cross the street, without expecting anything in return. Helping people at work, this does create a sense of happiness. You will find ways to flourish where you are, even by doing this alone. Once again, when we talk about the body and the mind, we know there are many factors involved in self-care.

Know that you can be doing well in one aspect, not well in another, and still not understand why you do not feel happy. The aspects are different. Sometimes, we must focus more on some than others. Health is wealth, as we may know. It can mess up your money, relationships, and everything else if you do not feel good. Make time for a timeout or to process all your emotions. Know it is to go backward and forward. I have had to do it. If you take more responsibility or a higher position and feel like you cannot do it, know that it is time to step back. You succeeded. You did not fail. It is a shift. You can always recover from that.

Working with Strong Personalities 

• Find a few things even if small that you appreciate about that person 
• Give genuine compliments, don’t expect anything back
• Don’t test other team members' or co-workers' egos 
• Forgive the co-worker that hurt you

Yes, working with strong personalities does exist. We all know we do not get to choose who we work with. My advice, which has helped me, is to find things you can appreciate about that person. Even if they are small, everyone has something to offer. I am telling you, there are people you know or others who are like, Oh my gosh, this person is the worst. When you see them on the shift, try to find something you admire or appreciate about them.

For example, it could be that their notes are well written. "I read your notes the other day. It was very well written." You are not looking for feedback. It is a genuine compliment; the person may or may not respond to you, but you want to keep finding those things. Somebody is super neat, or their penmanship is fantastic. Keep finding those things because it will cushion working with such a personality. You can continue to bring down the wall. Do not test other teammates' or coworkers' egos. In healthcare, we all have our stories about what got us into this role and this profession.

Suppose we do not know how hard it was for the person to get to where they got, how easy it was, or what challenges or barriers they faced. Know that we all got here in some shape or form, and that we all have a story. Testing other team members' coworkers' egos is not worth it. It might feel good in the short term, but it brings negativity. The negativity lasts longer than the short-lived feeling of good after you tear that person to shreds. That is the advice that I give. Forgive the coworker who hurt you. Forgiveness was hard for me because I had been hurt at work a few times. I am somebody. When I am hurt, my guard goes up. I wall up and will give you surface stuff only. When I start to let my guard down, then someone does something, and the wall goes right back up. Do your best to forgive and move on when dealing with strong personalities and people who hurt you.

I am trying to remember the quote from Steve Harvey. Steve Harvey said something, I do not remember where he got it from, but he said that "Holding resentment, grudges, not forgiving people is like drinking poison expecting the person to die." It is true because they are no longer thinking about you. You carry that to the next shift, to the next month, and the whole year. It is enough. Let it go. Say to yourself out loud that you forgive X for Z. Look in the mirror. You can turn on your selfie camera and press the record button, say. I forgive X for Z. It will make your life much better, then move on. That is it. 

Negative Feelings Towards Co-workers

Which stair step are you on as far as forgiving? The arrow moves to build from the bottom of the stairs to the top: I will not do it, cannot do it, want to do it, how do I do it, I will try to do it, I can do it, I will do it, lastly, yes, I did it. I always love the "how do I do it" because that means you know this is the direction that you are supposed to be on.

How do I do it? Know what holding these feelings can lead to. We have all seen some form of passive-aggressive behavior that disrupts quality patient care. Please find a way. Look at the person from the bottom. Think about the bottom of the stairs. That person saying "I will not do it" is not going anywhere. Then, to the top of the stairs, "Yes, I did it." Imagine how happy that person is. It is the way to go when it comes to success.

Success is an Iceberg

Figure 3. Adapted from the success of an Iceberg.

When someone sees someone who is successful or appears to be shining, many people do not realize how much work that person has put in. They may think it came out of nowhere. Oh, that person is lucky. It must be who they know or whatever. Not knowing how much work they did, being persistent while people's heads are on the pillow, that person is the one doing the presentations, that person is the one studying, that person is the one doing self-education. That one is the person who heard the 'no's before the big 'yes'. Understand that a lot is going on underneath that success. 

I always love showing the iceberg analogy because people think they got it, but no, they do not. They usually put in the work, have been through a lot, and eventually become the iceberg.

As respiratory therapists, we all know we are the Batmans and the Batgirls of the hospital, saving the day. We know this. We get the call, come in with our gadgets, take care of things, and return to where we came from. Know that we are cardiopulmonary specialists and subject matter experts. Moreover, this is a superpower. Understand that this is a superpower. I have learned to control my superpower and take what I have learned from the hospital and apply it in different settings. Now I am in the communities. I am now at the patient's home.

I am in the inpatient unit, the ER, and other settings, and I am also a communicator. I used my superpower in different places. I value the respiratory care field because there are few professions where you can be in many settings, build multiple relationships, be this person, and figure out where you can go next. 

Subject Matter Expert 

Figure 4. Adapted diagram of foundational growth.

Foundational growth is seen in Figure 4. Respiratory therapy is the foundation for moving to the next level. You already have the foundation. Invest in your skills. You are here now. You paid for your CEUs. You are investing in yourself. Self-education is scary because when someone does self-education, nothing can knock them down. Trust and believe I know what I am talking about in being proactive and building confidence. I started by volunteering. People do not want to hear that stuff. Volunteering helps people see you doing and saying, even when you have yet to gain the experience. It is a starting place for finding mentorship, and we want to continue to grow and learn. Then you could create your opportunities. Look at someone like me. I am in the communication phase. I am communicating and educating other people. I am creating content. I am confident. The folks at Continued Respiratory Therapy know why they picked me as a speaker.

Being an Asthma Champion 

Here I am, the crabby patty formula to improving yourself, leveling up to being an asthma champion—my version of controlling, unlocking my purpose. Still, as a respiratory therapist, I learned to harness my superpower to cater specifically to the communities and the hospital. As an asthma educator, no one nominated, promoted, or picked me to do this. I decided to do this. I nominated myself. After one night in 2010, I was in a level one trauma center, and on one of my shifts, I was on the night shift. I was covering the pediatric ER when I received a five-year-old African-American boy who went into cardiac arrest three times because of status asthmaticus.

The story is that the grandma was in the kitchen cooking, and he was in the living room playing. She had no idea he had a full-blown asthma attack. When she realized what was going on, he was completely blue. As I am putting him on the ventilator, the mom is screaming, "Give him his prednisone, give him his prednisone." Mom knew the routine. Then, when I caught eye contact with the grandma, she was utterly silent because she did not know the routine. I strongly felt he would not make it through the shift because he was in such bad shape, and he did not. 

I cried after work. My husband asked me, "Linda, why are you crying? You have seen children die before. What is this case special?" I said, "Strangely enough, it's not for the boy. It is for the grandmother. For the rest of that lady's life, she has to live with the fact that her grandson died in her care. That broke my heart. I never want that to happen to another family again." It was a decision I made. Nobody made that decision but me. Now, when I do what I do, I do it from my heart with passion. It is my why.

Know that in any vehicle I choose, I am educating you on asthma awareness. I shine in this capacity as an asthma champion, educator, and respiratory therapist because I do it from my heart. I want to show you guys how to find the thing in your career that fuels a fire in you, and how to serve people this way. I hope that is the vibe you are getting when you hear my voice and see these slides. Ultimately, my 'why' led me to pursue my master's degree in public health. I wanted to understand why some communities are sicker than others. 

Figure 5. Adapted from Theory at a Glance.

I learned about many evidence-based theories that help predict health behaviors and why people make life decisions. One of them is PAPM in Figure 5, which is the Precautionary Adaptive Process Model. All this is a journey from unawareness to awareness in making a decision. We are going from 'I did not know' to 'I do know'. Then what are you doing with that information? Here is an example of what it would look like in the real world, what it would look like for someone with, let's say, diabetes or wanting to lose weight. 

Eating veggies is healthy. You would be surprised at what people have yet to learn. I think everybody knows that, but you would be surprised by what patients in different communities and settings know. When they are aware of something like health promotion, or when they find out, where do they go from there? What are they exposed to after? Did they receive a pamphlet or see a friend eating healthy? What do they base that on? Will they change their habit, or will it be like, "Yeah, I know, but it is what it is." That is where we are going with the PAPM.

Figure 6. Professional Growth chart.

See this example in Figure 6, where it says, decide to act on how to become an asthma educator. I always encourage you guys in your careers to be curious. There is nothing wrong with that. You are on different floors. You are meeting other people. Ask people questions. Do you like what you do? If you feel curious, volunteer. This is what this is about. You can take the asthma exam using this example, volunteer at a health fair, and go from there. Then you see where the green arrow is. You are creating an opportunity for yourself where you have moved a step, got another certificate, and now you can work part-time in this specialty. You are creating opportunities for yourself. You see how a manager or a supervisor does not have to tell you any of those things. If they are good, many of them will encourage you to do this. However, you have to do this for yourself.

Opportunities for Growth  

• Networking Skills
• Communication skills
• Emotional intelligence
• Unification skills
• Time management
• Mentorship
• Leadership skills
• Change management
• Budget management
• Conflict resolution
• Case management
• Project management
• Chronic disease management

You want to be the manager. There are plenty of opportunities to prepare yourself in advance. You would be surprised by how many folks need to learn how to do this. It might hurt some people's feelings, but it's reality. Just because you have been working somewhere for 30 years, or you have been the most senior respiratory therapist at the institution, the hospital, or whatever, does not mean you deserve to be the supervisor, the director, or the lead therapist, because it takes a whole rack of skills to be in a position of leadership to be able to be successful in this role.

Some people who want these positions do not know how to resolve conflicts. You cannot be in the middle of every conflict and then expect to be in a leadership position. You have to understand how to resolve disputes and manage a budget. I took a management position at my job. I had a million dollars to operate on my first day of work. I am good with budgets, I had thought. In change management, can you guide people through change? Change always comes. Change is in death, getting older, or giving birth to something new. Can you coach people through that? Mentorship: Can you coach someone to be the best version of themselves? Unification skills: Can you unite people for a cause? Emotional intelligence, can you read the room? Communication skills: How do you communicate? Can you communicate effectively? In chronic disease management, can you coach patients to take care of themselves with these chronic conditions that are with them for life? There are many growth areas, and folks will say, "Well, I did not get the position." If you go for these types of positions, assess yourself. Once again, you do not have to wait for a supervisor to do that. See what you are good at. I am strong here, and I need more over there. "Oh, I definitely need to work on that and hit the ground running." Take these classes, and start watching videos and podcasts. There is so much free information out here now.

Another thing, if you are on social media, use it positively. Find ways to learn from it. Do not spend three hours on social media if you are not learning or you should be making money. That is my opinion. It boggles my mind because people will tell you they do not have time to volunteer or to learn to study all these things, yet they are on social media for three hours a day. I understand escapism, but when you need to level up we have to make these decisions. 

Gain Allies at Work

Have a piece of humble pie. Not everyone has to be your friend. At work, this is a harsh reality. There will be people who will not like you because you are who you are. It is great to have friends, but you need allies. Allies are people with whom we work together for a common cause. That is it. We are working together. Know that gos are shackles on the feet. I am going to share my humble pie story with you.

When I started my first job, I was their fifth wheel. It was a team of four that needed the extra body. They were a fantastic team. They worked very well together. I was not that warm in the beginning; I do not know, but they did not precisely take me in. They would say, "Oh, the four of us are working together." I would say, "Well, shoot, I am here too," and things like that. They would eat lunch together, and they were a good team. I would call them all types of things, like the super troopers, the fantastic four, or the dream team, but knowing it was coming from a place where I did not feel accepted.

What I started to do was, " Okay, you guys do not need me. I do not need you guys, either." I began to roll by myself. What ultimately did was cut me off. I was not learning; instead, I plateaued. I needed help understanding. As I said, I was struggling with intubations. They were good at that type of stuff. I was unhappy. I returned to my mentor, which is why I mentioned mentorship is crucial. I went back to a mentor, my old school professor, and told her everything that was happening. She listened, said nothing, and let me finish. She said, "Linda, you need a piece of humble pie." I said, "Oh, I like dessert, but humble pie is not one of them that I think I would enjoy." I said, "Humble pie, ma'am, please. They are the ones who were treating me like that, etc." I told her everything. I told her I wanted to quit. She said, "Linda, you need the humble pie. You are the new one. You are the one who has to show your value." I did not want to hear it. I was like, Ma'am, please. I fought it. She said, "Well then quit." She turned around and went to her computer. I thought, No, I am not a quitter. I do not want to let you down.

My mentor was the one who accepted me into the respiratory program. We have a solid mentor-mentee relationship. Ultimately, I did not want to let her down. I took her advice and returned to work with this new thought that I would have a piece of humble pie. I started to go to every trauma team, and for every rapid response, I was there. As I said, they were a fantastic team. They did not need me, but I went anyway. Do you need help? They would say, "Nope." Then I would hand them the scissors, the ET tube, and the pulse ox. I would do little things like that. They would snatch things out of my hands. They gave me that humble pie dry. They did not make it easy for me. Eventually, they started to open up to me. They would be like, "Linda, come here." They would have the endotracheal scope pulled up, and they would say, "Linda, pass me the ET tube, push the ET tube through here, you see the vocal cords?" I would push it through, and it was everything. It helped me so much. Now I was starting to learn.

They opened up to me. They invited me to lunch. I will not lie; it was awkwardly uncomfortable at first. I was not invited to their birthday parties, or their kid's parties, or anything like that, but they were starting to open up to me. Ultimately, when I decided to go back to school to get my Master's degree in public health. I had to leave them. The lead of that group said to me, "Linda, at the end of the day, you were always there." I said, "Yes." He said, "We will miss you." He hugged me. I could not believe it. But at the end of the day, it is a fact. They could not deny it. I was always there. Understand this is my humble pie story.

Have Compassion for Those Who Seem Not to Get Along With Others

• Be an active listener
• Respectfully admit when you don’t know something
• When wrong, apologize sincerely
• Don’t take yourself serious
• Past Give credit to those that give you "aha!" moments
• Value everyone and show appreciation for their time

It is how to get people to open up to you and how you can learn from all types of people. This is how you grow. You can learn from people who do not like you. You can learn from people who are not necessarily like you. You can absorb the good things from people. You do not have to absorb everything from people. For example, sometimes people have difficulty learning from people who make different lifestyle decisions, but know they can still learn from that person. You should not let those things distract you. That is the advice that I give to many people.

Absorb the good. You can pick and choose what you can absorb from people. Here is my advice: Have compassion for those who seem not to get along with others. When you see these types of personalities, think about what happened to that person that made them like that. Why is that wall up like that? Why are they combative or mean? Know that trauma comes through people in different ways. It is easier said than done, but sometimes we have to start looking through their lens, and it will make your life easier to maneuver through people. Then you could learn from those types of people, too.

They will start to open up to you if you are compassionate. They will say, "Hey Susie, you need help? You need something?" "No, I am good." Eventually, the wall will go down, and you can learn from them if they are good at things. Be an active listener. Be good at listening. Know that when people are teaching you something, if you keep saying, "yeah, yeahing," saying, "Oh yeah, I know how to do that. Yeah, yeah, I know how to do that." Well, then, what am I wasting my time with you for?

Do you know what I am saying? Now get cut off. I do not have to teach you anything. Then what happens? You plateau. You are not growing. This is about the decisions you make if you want to grow. Respectfully admit when you do not know something. What I mean by that is to say that you do not know how to do that. There is a sure way to say something. "That is not my area of expertise, but I would love to learn it." Know the vibe you give and how you say things. Do not be scared to admit that you do not know something. "I have been exposed to it, but I need a refresher." Learn different ways to say it because this is how you grow. People will show you. You would be surprised by what people want to share and show you. They will give you all seven spices if you open yourself in a way that allows them to teach you. When wrong, apologize sincerely. "Hey, I messed up. I am sorry. Period." Not "Oh, if you felt that way. It is like whatever." The person felt something. "I am sorry, I was wrong." Be sincere about it. Do not take yourself seriously. What do I mean by that? Respiratory is very serious. We are dealing with life and death, but when learning from others, you want people to feel comfortable teaching you things.

What has worked for me is that I always joke about myself. It makes you harmless when you do this. People say, "Oh, that is Linda, come on, come here, learn this thing." I am making fun of myself, and it allows people to open up to me. That is an extra tip that I give people. Do not take yourself that seriously. You know your stuff, but when you want to learn, you want to let the person give you all you are looking for. Give credit to those who give you "aha!" moments. I always like to do that. When you learn something new, say it came from X, Y, or Z. You did not get that from yourself. Make sure you are giving people credit. Value everyone and show appreciation for their time.

Emotional Intelligence

• Emotional intelligence is the ability to monitor one's own and other people's emotions

Emotional intelligence can get you further than actually being book-smart. Emotional intelligence is the ability to monitor one's own and other people's emotions, classify the different emotions and label them appropriately. I have these feelings, you have these feelings, and what are we going to do about these feelings? That is what it is. Be able to read a room, to read when someone is feeling you or not, to know how far you can get with a patient, how far you can get with a coworker, or how far you can sell something in health promotion. Emotional intelligence is a skill that folks should invest in. It is not something that you are born with. You can continue to work on this.

Take Control of Your Career  

Take control of your career. I am dating myself. The Truman Show and The Matrix are movies I enjoyed for their themes of taking control. In both films, the leading actor is unaware tthat hey are being controlled. In The Truman Show, Jim Carrey is the main character. Have you watched the movie yet? He does not know that he is in a reality show. He was born for this reality show. Even though everything looked perfect, he knew something was off.

Know what intuition is when your spirit tells you something is awful, you should be doing more, or you should be somewhere else. I know these things are in us, and these movies show that. They put all these characters in his life to make the show enjoyable and to keep him under control. To make this long story short, he was afraid of water. They put the fear of water in him by having this large body of water at the end of the production set. They said he could in no shape or form get on that water.

Every time he went on the water, he would always wonder what was on the other side of that. They would do something to stop him. One day, he gets out on the sailboat and says, "I want to see what is on the other end of that." The production team panics and turns on the weather storm to stop him. He did not turn back. They put on the weather storm harder, and he almost dies. Now the show's creator says, "Wait, wait, wait a minute, wait a minute. The value... He is the whole show. We cannot kill him." Now they know the value.

The creator starts to speak through the sun, saying, "Truman, this show is about you. This is all about you. You do not need to go see what is out there." Eventually, Jim Carrey notices that in the water, there is nothing behind that. He finds out everything. Look what happens after he gets over the fear of the water. The show's creator gives him a choice. He says, "Listen, there is nothing out there for you. You belong here. You are this." Truman has a choice to make. He created options for himself. 

He fades to black, and he leaves the production set. Look at that. What I love about that movie is that we do not know what happens to him when he leaves the set. We do not know if he came right back in, we do not know if he got a job, we do not know. However, what he did was overcome his fear. By doing that, he created options for himself. He had choices to make a decision. "The Matrix." If you do not know this movie, Neo was the one who did not know. He knew, but he did not think he was the one. He took control of what was going on. 

Make a Decision

• You won’t always be right, but at least you know it was your choice…..You are the boss of you.

You make the decisions about your career, the red or the blue pill. You will not always be correct, but at least you know it was your choice. Like Truman, he made a choice, and it was his. Are you the boss of you? 

Add Value from Any Position on the Team

• When you learn something new or a more efficient way to do a task teach others – Sharing is Caring
• Be resourceful – If you don’t know something, but know someone that does, be the link or coordinator 
• Be an extra hand or just be present to brainstorm ideas
• Become good at closed loop communication – help make sure everyone on the team got the memo

Key takeaways: value your reputation. It is everything. Guard that with your life. Know your standards and be passionate about them. I am all things asthma, awareness, and education. I do not play with it. I use every vehicle to promote it. I am fighting asthma disparities, period. People know that, so they come to the asthma lady. That is why they call me that.

RTs or subject matter experts, period. It is our superpower. Carry yourself accordingly. Start by volunteering your talent. I already told you guys that this lets you be seen. When you do volunteer, do you volunteer like you are getting paid? You do it as if you are getting paid, because they will think of you when it is time to pay, whether it is one month, one year, or five years from now. Remember that lady or that man who volunteered that time? He was amazing. There you go. You are creating options for yourself. Find a mentor and build a strong mentor-mentee relationship. I told you what happened between me and my mentor, Ellen Becca.

I am still cool with her to this day. When she calls, "Linda, I am coming to New York." You do not have to say anything else. "Where can I meet you? I am available." If she wants the lobster, I will pay, because her relationship has guided me a lot. It is priceless. I recommend you find that—master emotional intelligence because it gets you far. Start from where you are and assess for areas where you can improve. Do it on your own. You do not have to wait for somebody else to do that. Do not be discouraged while waiting for new opportunities; prepare for them in advance. Remember, I showed you areas for improvement. There is a whole list of them we went over that. It is ok if you do not get the position you went for. Prepare for them in advance. People say, "Oh, you are lucky." No, you are not lucky. You prepared for that opportunity in advance. Understand how this works. Challenge yourself. Be comfortable being uncomfortable. This is something that I constantly do—public speaking. I would not say I liked public speaking when I first started. I could not do it. I challenge myself to look at where I am today one day.

I cannot believe who I am today. I became comfortable being uncomfortable, and I actively engaged in meetings. I will tell you guys in many meetings, I am often the youngest, the brownest, the only woman. I had to learn how to be comfortable with being uncomfortable. At first, I was uncomfortable with that. However, here I am, and I get invited. They are inviting me. I know my value. It helps with confidence levels. Keep doing little by little, trying new things, and stepping outside your comfort zone. You will be surprised how far you get.

Doing things will make you afraid because, ultimately, dying is the worst thing that can happen. Once you do not die, it is like, "Oh, that was not that bad." I tell you guys, try that path. Invest in yourself. We have been talking about this the whole time. If you want to truly unlock the power within you in your career, invest in yourself. Continue to learn to pick a subspecialty in the RT field, and you will shine. I found where I shine because it comes from a purpose. It is coming from passion. People know it is coming from my heart to come to me for this thing.

While I initially did not want to be a one-trick pony, I knew I was good at other things, too. Where I shine in this niche, or this area of purpose, is what attracts people to me. Once people enter the store, you can sell whatever you want, right? When you go to the store, everything is on. The sale sticker is on the window because they know that once you come in for the interest in what is on sale, they can sell you whatever they want inside the store. The same thing applies here. Asthma education with passion is me; I am in the patient's home, the ED, and the inpatient unit.

I have been in senior centers and daycares. Any vehicle I can use to provide asthma education and awareness to underserved communities, I will use. I have done back-to-school zoomba parties. I am in high school. I have worked alongside the teen pregnancy prevention program. After sex education, I have come in with asthma education. We have done health fairs. Name it, and I have done it. Understand that asthma education is provided with passion. I am not handing you a pamphlet. I am saving your life. I do not play with that. Understand your shine. Once you know your intentions, you do not have to do anything.

You get to do it. You choose to do it. Choose now to do it with your heart. As a respiratory therapist, you will save lives and unlock purpose within your career. 

Questions Answers

What value do you think continuing education, advanced degrees, and licenses bring to us to enhance ourselves in this profession?

Oh wow. It is one of the golden tickets for me, actually. Because you have to keep investing in yourself. I am not saying you always have to spend money on big courses, but if you want to continue to grow. When people see you, yes, we know all the letters behind your name and whatnot, but you want to make sure that you can apply the information. That you are getting behind all those letters. You want to continue adding value wherever you go. Once again, that is a part of the prize every time. That means that you know your stuff, you keep investing in yourself, and your value continues to increase. You can offer more in your service in servicing others.

If I am PRN because I have 5 kids, what advice do you have for advancing my career even if I do not have a lot of time?

I do this because I now have a one-year-old. What I do is if I am on transportation, if I am driving, I surround myself with educational stuff, like podcasts or any type of series, like YouTube. People will tell me things like, "I don't have time to read books." The author will read the book to you. I mean, where they are reading you the main key points. Information is available in many different channels now. That is what I would tell you. If you have downtime or they are not with you, try to set aside a little time for information, then start applying it. Make the time.

References

Glanz K, Rimer BK, Viswanath K, editors. Health behavior and health education: theory, research, and practice. John Wiley & Sons; 2008 Aug 28.

Kelly PJ. Health Program Planning and Evaluation: A practical, systematic approach for community health. Family & Community Health 2006;29(1):72-3.

US Department of Health and Human Services. Theory at a glance: A guide for health promotion practice. Lulu. com; 2018 Nov 22.