Respiratory Therapy Workforce Analysis

Respiratory Therapy Workforce Analysis I. Introduction The purpose of this project was to determine the current and projected respiratory therapy workforce for the Winnipeg Regional Health Authority (WRHA) facilities in Winnipeg and in doing so to predict the likelihood of a balance between supply and demand in the future. In particular, it was deemed important to identify potential workforce deficiencies with the idea to mitigate such shortages. Originally the intention was to review the available data and develop a document similar to the WRHA RN Required Supply Model document. 1 Due to the numerous challenges unique to the Allied Health Professions, it was determined that as well determining future workforce it was important to develop an understanding of the factors affecting supply and demand. These factors have been identified to assist in formulating potential strategies to alter the future situation favorably. The data required to make projections was not readily available and so a primary focus of the project became the development, implementation, and maintenance of the appropriate tools for projecting and monitoring workforce so that the process was repeatable, if desired, and could remain ongoing. The overall aim of the project was to contribute to achieving and maintaining an optimal and stable Allied Health Workforce. Respiratory Therapy Workforce Analysis 1

II. Methodology The first task was to define the type of data required and to determine how best to utilize the available data to provide a projection of workforce. Secondly, it was determined that, as the prediction of workforce balance will be based on a relatively small sample size it was important to further clarify the issues affecting workforce supply and demand. The findings and observations noted in this discussion paper are based on a review of the current literature and related reports as well as interviews with a variety of sources. The literature used in formulating the RN Required Supply Model was reviewed. 1-7 Medline was searched using workforce and the discipline, in this case respiratory therapy, health human resources, health manpower, and human resource planning. Data was collected from the registering organization - the Manitoba Association of Registered Respiratory Therapists, and the educational institution - the Health Sciences Centre, School of Respiratory Therapy. The information reported by the registering organization is self reported data. Reports formulated by other interest groups were reviewed and key points identified. The position vacancy data was obtained through the WRHA's collection system and clarified by the WRHA Director of Respiratory Therapy. Information regarding retirement, ages, and years of service was obtained through the payroll systems (Ceridian, Health Sciences Centre, and St. Boniface General Hospital), as the HEPP database was not usable due to varied union affiliations and a lack of common labour codes among the respiratory therapy employees. Respiratory Therapy Workforce Analysis 2

Information regarding the number of respiratory therapy graduates was obtained from the Health Sciences Centre, School of Respiratory Therapy. Data regarding the employment patterns and age ranges of practicing therapists for the past five years was obtained from The Manitoba Association of Registered Respiratory Therapists. The data was reviewed to determine whether there would be an appropriate supply of respiratory therapists in the future. The information reviewed included information regarding supply, which included the numbers of graduates. The current and attrition numbers were based on the information available through the payroll systems. Magic 80 and age ranges were available through payroll and were used to estimate retirement. The attrition rate for reasons other than retirement was not accounted for, as that information was not available. The number of respiratory therapists working within the WRHA amounts to approximately 174 positions. Considering these low numbers caution must be used when interpreting the data. For the purposes of this project the need or requirement side of the equation was based on the current requirement of the Winnipeg region, that is, the number of respiratory therapists currently employed by the WRHA at this time. Future needs or variations to these needs have not been considered. The identification of trends and issues affecting the respiratory therapy workforce as well as factors affecting work life, recruitment, and retention have been outlined. Recommendations, gleaned from the review of numerous sources, have been included for consideration. Respiratory Therapy Workforce Analysis 3

III. Profession Description Respiratory therapists (RTs) are self-regulated, registered health care professionals. The Manitoba Association of Registered Respiratory Therapists (MARRT) is the professional and licensing body governed by the Respiratory Therapy Act of Manitoba. 13 RTs are graduates of training programs offered by community colleges, institutes of technology, and universities. Respiratory therapists assist physicians with the diagnosis and treatment of lung disorders. They provide education and promote wellness in patients who suffer from respiratory ailments. The profession continues to evolve as technology and treatment techniques develop. The majority of respiratory therapists work in hospitals. They are also employed in the community, research settings, diagnostic clinics, and private enterprises involving medical equipment sales and service. 8 Respiratory therapists participate in research studies and it is likely that this area of practice will increase as medical technology and knowledge continue to grow. 9 Respiratory therapists provide care 24 hours a day seven days a week. Twelve-hour shifts are common at most tertiary care hospitals. 9 The Canadian Institute for Health Information reported that from 1988-1997 the number of respiratory therapists registered in Canada has increased 71.4% for a total of 5,644 in 1997. 10 Each province has demonstrated an increase of at least 30% with the exception of the Yukon and Northwest Territories. This increase has resulted in a lower population to therapist ratio across Canada. Respiratory Therapy Workforce Analysis 4

The United States Department of Labor predicts that job opportunities for respiratory therapists will increase at a faster than average rate of 21-35% through the year 2010. 11 This potential growth rate is primarily attributed to the aging population. The government of Alberta predicts that growth in respiratory therapy is likely to continue at 2-3% per year with 10 to 30 positions being created each year. High turnover is also predicted over the next ten to fifteen years as the "baby boom" generation retires. 12 Of the 190 RTs licensed to work in Manitoba, 78.5% work for the Winnipeg Regional Health Authority, 4.2% are educators, 7.3% work in rural Manitoba, and 9.9 work in private enterprise. 13 The profession is predominately female with the percentage of females remaining fairly constant at about 60% (see Table 1). 13 The increase in maternity benefits from six months to one year will likely have workforce implications. Table 1: Male/Female Distribution of Respiratory Therapists in Manitoba 13 1999 2000 2001 2002 # % # % # % # % Female 124 60% 122 61% 122 61% 114 60% Male 84 40% 78 39% 78 39% 76 40% Total 208 100% 200 100% 200 100% 190 100% The profession has a high percentage of workers who work part-time. Within the WRHA, approximately 45% of respiratory therapists work full-time, 34% work part-time, and 21% list their employment as casual. Respiratory Therapy Workforce Analysis 5

Table 2: WRHA Respiratory Therapists - Work Status and Numbers Work CGH GGH HSC SBGH SOGH VGH DLC MHC RVHC School Total % Status FT 3 7 26 19 8 2 1 2 3 7 78 44.8 PT 6 4 23 11 2 6 3 3 1 0 59 33.9 Casual 8(6) 8(3) 11(3) 7 14(5) 9(6) 5(2) 7(7) 0 0 37 21.3 Total 11 16 57 37 19 11 7 5 4 7 174 100 Note: Bracketed numbers indicate the number of casuals working at more than one site. A high proportion of respiratory therapists (18%) work at more than one site, as reflected in Table 2. Sixty-nine therapists are listed through payroll as working casual at various facilities, of these therapists, 32 therapists list a different facility as their employer as well. For the purposes of this analysis, therapists were only counted in the casual category if their name did not appear on a staff list from another facility. Although it appears as though there are many therapists available for relief coverage, this is not the case, as therapists would be more inclined to take a shift at their own facility and be paid overtime rather than pick up a shift at another facility. The numbers of RTs working in management positions and those working directly for the WRHA were not included in Table 1 or the analysis of vacation time, retirement, and age ranges as the payroll data was unavailable for this group at this time. This amounts to approximately 22 positions. Respiratory Therapy Workforce Analysis 6

IV. Literature Review A number of reports describing the respiratory therapy workforce experience have been generated in recent years and key points from these reports and articles are provided. i. Profile of the Allied Health Workforce (Winnipeg Hospital Authority - September 1999) The Winnipeg Hospital Authority prepared this report in September of 1999. 14 An update to this document was completed in 2002. 9 Points from these documents are included throughout this report. The reports provided a comprehensive overview of each allied health profession employed in the Winnipeg hospital system. Important issues common to the allied health professions were identified such as wage rates, recruitment and retention issues, scope of practice concerns, student education and enrollment, program management, seven-day week coverage, relief budgets, and workload measurement standards. Data from this report has been incorporated in other sections of this document. An issue raised in the1999 report was the difficulty in providing clinical placements for students due to increasing caseloads. The need to ensure that career-laddering opportunities exist for RTs was also identified, particularly as facilities are moving more towards a program management model although at the time of the report respiratory therapy had maintained a central department structure. Recommendations from the report included salary review, implementation of exit interviews, provision of opportunities for career advancement, and support for continuing education, clinical practice, and research among others. Respiratory Therapy Workforce Analysis 7

ii. Recruitment and Retention of Respiratory Therapists: Recommendations (Prepared by the Provincial Health Care Worker Recruitment and Retention Committee - Manitoba Health Organizations, Inc. January 1991) The mandate of this committee was to determine which groups of health care workers were experiencing difficulties with recruitment and retention and to develop recommendations to rectify the situation. 15 The recommendations included, among others: Developing a strategy to ensure competitive salaries within Manitoba as well as with other provinces. The use of incentives was not recommended except for allowances for employment in remote or northern areas. Increasing enrollment at the school to twenty-six students per year. At the time of this report 40% of new graduates left the province. As well, the job market had increased in areas such as private practice, home care, sales, and cardiopulmonary perfusion. Utilizing a standard exit interview, administered by the facilities and forwarded to a central agency to assist in tracking the reasons therapists leave and where they are going. Surveying workers in rural and Northern Manitoba to determine factors affecting job satisfaction/dissatisfaction. Promoting the career of respiratory therapy with high school students particularly in rural areas. Conducting a study of the role of respiratory therapists to determine whether or not they are being underutilized and which tasks could be assigned to a less highly trained worker. Allocating funds for continuing education. Providing opportunities for flexible scheduling where possible. Attempting to recruit respiratory therapists from the United States. Attempting to recruit non-practicing respiratory therapist back into the workforce. Respiratory Therapy Workforce Analysis 8

iii. Review of Relevant Articles The American Association for Respiratory Care (AARC) recently released a study that identified a shortage of respiratory therapists in the United States (USA). 16 The study projected that based on 111,706 therapists working in the USA and a report of 6,500 full time equivalent vacancies the overall vacancy rate was approximately 6%. Three quarters of the therapists working in the USA are employed by acute care hospitals. The shortage in the USA parallels that being experienced in Canada and makes recruitment from the USA unlikely. The need to direct efforts and resources towards the retention of respiratory therapists was highlighted by a study undertaken by Stoller, Orens, and Kester in 2001. 17 Key hospital personnel were surveyed to determine the rate of staff turnover as well as the costs associated with orientation and training of new staff members. The three most important reasons identified by respiratory therapists for leaving a job were to seek more job satisfaction, to seek higher salary, and lack of opportunities for job advancement. The rates of turnover varied greatly, from 3-18% per year with rates being higher at centres where the workloads were higher as reflected by the number of beds per respiratory therapist. The hospital with the highest rate of beds to RTs (29.2) also had the highest turnover rate (18%). The hospital with the lowest rate of beds to RTs (10.6) reported the lowest turnover rate (3%). This trend was not consistent and the likelihood of other factors offsetting this trend was noted. The cost associated with training a new employee was estimated to be $3,447.11. Based on these findings the authors supported efforts to decrease staff turnover by focusing efforts on retaining existing staff. Turnover is costly, disrupts clinical care, and requires existing staff to provide training. The need to create a work environment that encourages RTs to remain on the job was advised. Respiratory Therapy Workforce Analysis 9

Sobel, Litwin, Seville, and Homuth (2000) reviewed data from the Canadian Society of Respiratory Therapy in an attempt to determine if a shortage of respiratory therapists was imminent. 18 It was noted that the number of therapists over age 55 was increasing and that retirement will contribute to the predicted shortage. At present 95-100% of graduates attain employment and if enrollment is not increased the number required to replace retirees will be inadequate. Nationally the ratio of males to females is 37:63. The effect of the increased length of maternity leave will be a factor adding to the predicted shortage. The potential for increased demand in the face of an aging population was also identified. As nursing and other allied health disciplines experience shortages the competition for recruiting suitable students will be great. Factors, cited by Sobel et al, as affecting recruitment and retention included; inadequate wages, lack of funding and incentives for continuing education, lack of career opportunities, workload, shift work, lack of support for families of shift workers such as provision of daycare, and the grouping of respiratory therapists with technical staff rather than professional staff when negotiating contracts. Concern regarding the program management structure was also expressed. It was felt that it was difficult to attract new recruits because of the poor public perception of healthcare professions, limited awareness of the profession of respiratory, length of the program without acquiring a degree designation, competition with high technology areas and other healthcare professions, and a lack of understanding by other healthcare professionals of the nature of the job. Strategies proposed to alleviate the shortage included increasing enrollment, decreasing the drop out rate, promoting the profession, and continuing efforts to demonstrate awareness of the problem. Respiratory Therapy Workforce Analysis 10

Shelledy, Mikles, May, and Youtsey conducted an extensive study in 1992 to identify the factors contributing to job satisfaction and those contributing to burnout among respiratory therapists. 21 The strongest predicator of job burnout was stress. Factors related to burnout were department size, work satisfaction, satisfaction with co-workers, coworker support, job independence, job control, recognition by other health care professionals, and role clarity. Absenteeism increased as factors associated with burnout increased. Job satisfaction increased with increases in employee participation in decision-making, overall communication, and organizational stability. Job satisfaction was correlated with a decrease in job burnout. As well, as job related factors such as flexibility in scheduling, ease of obtaining time off, and perception of an appropriate workload improved, job satisfaction increased and burnout decreased. Job freedom, autonomy, independence, and control were all positively correlated with job satisfaction. Recognition by other health care professionals and increased support from co-workers and supervisors was also associated with increased job satisfaction. Improvements in family and social support decreased levels of burnout and improved job satisfaction. Increased job stress and decreased job satisfaction were associated with increased intent to leave the job and the field of practice. In an attempt to reduce burnout, supervisors must decrease job stress and increase worker's control over their jobs. It was noted that higher salaries were not related to lower burnout levels. The best predictors of job satisfaction were recognition by other health care professionals specifically nurses and physicians. The best Respiratory Therapy Workforce Analysis 11

single predictor of job satisfaction was actual pay. Respiratory therapists who were more highly paid tended to be more satisfied. Although a high stress work environment may decrease satisfaction with salary levels. When opportunities for advancement were not perceived to be available turnover increased. The implementation of a career-laddering system was suggested as a strategy to improve job satisfaction. Satisfaction with supervision was associated with ease of obtaining time off, job independence, clarity of role, and supervisor support. Managers need to address these issues in an attempt to retain staff. By addressing the factors that reduce job stress, improve job satisfaction, and decrease burnout, retention of respiratory staff may be improved. Gurza-Dulley and Melany (1992) determined that the most significant predictors of future performance, absenteeism, tardiness, and tenure among respiratory therapists were grade point average in respiratory training school, college training in addition to respiratory therapy training, and neatness of the application form. 22 The strongest relationship existed between grade point average (GPA) and absenteeism (the higher the GPA the fewer the absences). There were no significant differences in performance related to type of respiratory training program. This data must be interpreted with caution, as the correlations were relatively low. Burke, Tompkins, and Davis (1991) conducted a study to determine whether respiratory directors in hospitals in Texas suffered from role conflict and/or ambiguity. 23 Previous studies determined that as role conflict and role ambiguity increased, job satisfaction decreased. Role conflict scores for this group were low and role ambiguity scores were even lower. It appeared that the directors surveyed had a clear Respiratory Therapy Workforce Analysis 12

understanding of the tasks and responsibilities required for their jobs. The directors did score high in the area of role overload. This may indicate that the managers have difficulty with the volume of job demands. As a measure of job satisfaction the clarification of the role of a director is important. Attention to role overload may be required. In 1989, Akroyd and Robertson randomly surveyed a group of respiratory therapists to determine the factors that affected job satisfaction. 24 Satisfaction with work on the job and satisfaction with supervision were the only two factors that were identified as significantly affecting job satisfaction. Factors that did not significantly affect job satisfaction included overall job satisfaction, pay, promotion opportunities, and co-workers. The development of a job enrichment program may lead to more autonomous, meaningful, and interesting jobs, which may result in increased job satisfaction. The modification of job routine so that the job is not boring or overly complex may improve satisfaction. As well, the importance of developing excellence in managers was noted. Frequently, supervisors are selected for management positions based on clinical expertise. In the interest of developing appropriate leadership, the hospitals were advised to provide additional management training. The purpose in identifying these factors was to enable employers to provide a higher quality of life for employees as well as a better quality product. In 1987, Shelledy and Mikles conducted a study aimed at identifing factors affecting burnout of respiratory personnel in an attempt to provide direction to managers and to determine the need for further research in this area. 19 High levels of burnout have been associated with high rates of turnover, absenteeism, tardiness, discipline problems, and alcohol use. The burnout rates did not vary across a variety of hospital settings with different caseloads, bed numbers, staff Respiratory Therapy Workforce Analysis 13

sizes, etc. Longer work tenure was associated with a higher level of burnout. Higher education levels, higher perceived freedom and responsibility, and a higher perception of the quality of the respiratory department were all associated with less burnout. As the strongest predictor of burnout was the staff member's perception of the quality of their department, it may be of benefit for managers to direct effort towards ensuring that employees perceive their departments as being of high quality.this study was limited to four hospitals in a particular area and the survey return rate was only 58%. In a similar study, Rawlins (1987) surveyed 71 respiratory therapists in three hospitals to determine factors affecting job satisfaction and turnover. 20 The best predictors of attrition were stress with the job role, financial stress, and dissatisfaction with supervision and co-workers. Lack of respect from medical staff was also identified as stressful. Rawlins emphasized that to reduce the loss of desirable staff members; managers must reduce stressful job factors and provide therapists with greater control over their work environment. Rueben (1981) identified a number of approaches to recruitment of respiratory therapists. 25 Methods ranged from advertisements in journals, provision of clinical rotations, and advertising at schools of respiratory therapy. It was noted that benefit packages with such incentives as career and educational opportunities might attract workers. A review paper completed by Mobley (1979) summarized a number of studies examining employee turnover. 26 There existed a negative relationship between turnover and tenure, job satisfaction, and satisfaction with supervision. Higher salaries generally resulted in higher tenure and in situations where salaries were high, if there was a perceived difference between the expected and the actual salary, Respiratory Therapy Workforce Analysis 14

tenure was shorter. The perception of status within the organization, generally demonstrated by knowledge of the organizational procedures and a perception of control, were associated with longer tenure. Mobley also noted that the availability of alternative jobs was positively associated with turnover. Abelson identified the need to determine why staff leave and whether the departure is avoidable or unavoidable, desirable or undesirable. 27 Factors were described that positively affected turnover such as ambiguity, conflict, and job tension. Individual factors that reduced turnover were age and tenure as well as employees having greater family responsibility. Factors that were inversely related to turnover include organizational and professional commitment and positive leader behavior. The identification of units with high turnover and planning for future needs may assist in decreasing turnover. Other managerial strategies described included decreasing job pressures, implementing career development programs, providing more job autonomy and responsibility as desired by staff, and having appropriate levels of flexibility and rigidity. In regards to salary, Abelson determined that the amount has the most influence at the entry level and decreases after that. Employees who were satisfied with most other important factors were not inclined to leave an organization, even if the pay was a little less than that at other locations. Selby Smith and Crowley reviewed issues surrounding labour force planning for Allied Health in Australia. 28 The need to refine the tools of analysis and to continue to identify factors affecting supply and demand was noted. The high proportion of women in allied health professions, which was associated with greater demands in regards to child rearing and responsibilities in the home, was identified as contributing to shortages. Respiratory Therapy Workforce Analysis 15

The National Health Service (NHS) had been experiencing difficulties with staff recruitment and retention and health service employers identified the need to improve performance in this area. With this in mind, Gray and Phillips looked to businesses in other sectors of the economy to determine if recruitment and retention techniques used there could be applied to healthcare. 29 The companies reviewed were chosen based on their importance in the economy, their varied staffing requirements, and their high percentage of female employees. The companies included Midland Bank, a supermarket chain, and British Rail. Salaries are frequently cited as a major consideration in regards to recruitment and retention and yet there is evidence that indicates that other factors may play a major role as well. One survey of nurses who had left the NHS indicated that staffing levels were more influential than pay in their decision to leave. In regards to recruitment, nurses not currently employed claimed that the availability of part-time positions and assistance with childcare arrangements was more important than salary in determining their return to work. Changing pay levels was identified as one method of altering recruitment and retention and was being used by other companies. The NHS has a central system whereby a review group sets salary rates. Salaries may vary based on location and difficult to fill positions have been supplemented, but otherwise managers have had little ability to alter salaries. The NHS has now given local managers more discretion in setting salaries. As well as allowing salary adjustments, the three companies surveyed instituted policies to improve recruitment, which included; targeting recruitment, reducing organization restriction on recruitment, improving Respiratory Therapy Workforce Analysis 16

community links, increasing part-time positions, introducing new technologies and work-practices to decrease the need to recruit, implementing training for new staff, and improving information systems. Companies improved community links by liaison with the education sectors, providing job experiences, and supporting school projects. The three companies surveyed identified the part-time work force as the major target of their efforts. Midland Bank began heavily promoting part-time employment and ensured that part-time contracts were brought in line with full-time contracts in terms of benefits and the provision of regular work hours. Job sharing opportunities were supported whenever possible. The ability to provide time off over the summer months was supported by replacing workers with student workers over the summer when possible. The implementation of recruitment strategies necessitated improved information systems to enable the tracking of the effect of the strategies, staff recruitment efforts, employees' career development, and the number of staff leaving as well as the reasons why they leave. British Rail implemented the use of a system that was able to monitor who applied for positions, the background of the applicant, the number interviewed, the number offered positions, and the number of jobs accepted. The supermarket chain had implemented a "Career Bridge Scheme" which allowed staff to take temporary breaks in employment to pursue other activities. The break could be up to three years with an option of part-time employment for the subsequent two years. Midland Bank offered a similar plan for employees who had been with the company for at least two years. These employees were able to take a hiatus Respiratory Therapy Workforce Analysis 17

from work for up to five years without experiencing a loss of benefits. During the break time the employees were required to work at least two weeks each year and attend refresher meetings. The strategy of allowing career breaks may result in increased turnover but in the long run may result in an improved supply of workers over the long term. As many workers within the businesses surveyed were women, the provision of childcare was considered an important tool in keeping women at work. Midland Bank estimated that the cost of replacing an employee was equal to one year of salary and was about twice the cost of subsidizing childcare for four years. The Bank implemented a cost-sharing scheme with workers in the late 1980's. Employees' returning to work had risen from 30% in 1989 to 50% by late 1991. Other strategies aimed at improving retention of staff included providing career counselling, providing additional education for managers, providing staff support during the initial months of employment, and the hiring of occupational health nurses to address health-related concerns of employees. Improved information systems were felt to be essential. Both the Bank and British Rail routinely conduct exit interviews in order to better understand the reasons for staff leaving employment. The evaluation of recruitment and retention strategies was encouraged to ensure cost effectiveness. Respiratory Therapy Workforce Analysis 18

V. Other Factors Affecting Recruitment and Retention Discussion took place with the Winnipeg Regional Health Authority (WRHA) Respiratory Therapy Director, the Director of the School of Respiratory Therapy, the president of the licensing body, and the registrar of the licensing body. Continuing Education Additional resources are required to satisfy the need in regards to continuing education for this progressive area of health care. Respiratory therapists are required by their licensing body to acquire a minimum of 24 hours of continuing education credits per year. The need for resources to support a dynamic continuing education program is required. Relief Budgets Despite the fact that many therapists appear as casual employees on the payroll lists it must be noted that a high number are also listed as part-time or full-time employees at other facilities within the region. A high proportion of respiratory therapists (18%) reported working at more than one site. The need to have adequate and equitable relief budgets as well as a WRHA float pool of therapists available for relief work was identified. Considering the current workforce shortage this may not be able to be realized in the near future. Relief budgets must be adequate to provide coverage during times of vacation. Table 3 indicates the relief budget by EFT available at each facility. Information was not available from a number of the facilities. Table 3: Respiratory Therapy Relief Budgets (as reported by facilities) CGH GGH HSC SBGH SOGH VGH DLC MHC RVC EFT 1.21 N/A 3.8.37.47 Respiratory Therapy Workforce Analysis 19

Table 4 depicts the number of weeks vacation allocated to staff at each facility. The "per week" row indicates the number of staff members who would be off work each day if vacations were allocated equally throughout the year. Table 4: Respiratory Therapists - Years of Service and Weeks Vacation 31/12/01 Years CGH GGH HSC SBGH SOGH VGH DLC MHC RVHC School Totals 0-3 1 3 10 1 3 3 3 2 0 0 26 4-9 1 2 6 3 2 1 1 0 0 1 17 10-19 5 4 24 19 5 3 0 2 1 2 55 20+ 2 2 9 7 0 1 0 1 3 4 29 #Staff 9 11 49 30 10 8 4 5 4 7 137 Weeks 44 49 228 91 42 34 13 22 23 50 596 Per week 0.8 0.9 4.4 1.6 0.8 0.7 0.3 0.4 0.4 1.0 Note: Does not include casual staff. Scope of Practice The updated profile report identifies that respiratory therapists are underutilized in certain areas and that the WRHA External Review Report validated this concern. 9 Work Patterns The profession has a high percentage of workers who work part-time. Within the WRHA, approximately 59% of respiratory therapists work full-time, 41% work part-time. It is assumed that many therapists work part-time by choice. Respiratory therapy is primarily a female profession (60%) and this maybe a factor in the high rate of part-time employment. Research As health care funding is being more critically associated with evidence based practice the availability of a research budget may be essential in ensuring that treatment is effective and based on best practice. Respiratory Therapy Workforce Analysis 20

Student Supervision The ability to provide supervised clinical practice for students is an important factor in the training and recruitment of new graduates. The ability to provide student placements affords the facility an opportunity to preview performance of potential staff members. When students have positive experiences they may be more likely to apply for employment at that facility. It is extremely important to create a vision of a good working environment for students as an aid to recruitment. The supervision of students requires a commitment of time as well as a manageable caseload. In situations where staff shortages may exist or caseloads are high, staff may view the supervision of students as a hardship. Clinical specialists exist and are employed by the HSC School of Respiratory Therapy. They are responsible for the coordination of student placements and supervision of clinical activities. The respiratory departments, utilizing funds that are available due to attrition and vacancies, have been able to hire respiratory program students during the summer and into casual positions during the school year to assist with workload. This provides the students with the opportunity to be exposed to the hospital environment as well as receiving payment that can assist with their program fees. The number of students hired is variable depending on funding available and the needs of the department. This is felt to be a valuable recruitment tool. Salaries and Union Affiliations Specific salaries will not be discussed in this document. It is important to note that salary scales and union or non-union affiliations vary from facility to facility. Respiratory Therapy Workforce Analysis 21

Respiratory therapists are represented by MAHCP and UFCW as well as remaining non-union at Seven Oaks, HSC, and Concordia. Salaries tend to be comparable with private enterprise although private companies may be able to offer some additional benefits. Discrepancies in salaries also exist with other comparable health care disciplines. Hospital wages are generally not on par with other jurisdictions making recruitment and retention difficult. 9 Recently RTs in Saskatchewan reached a settlement entitling them to a 30% increase in salary. The top of their salary scale will now be in the range of $28.00 whereas here in Manitoba the maximum is approximately $24.00. Future Considerations The profession of respiratory therapy is highly technologically based. There is a need to have up-to-date equipment and technology to enable therapists to perform the duties of their jobs. 9 The availability of state of the art equipment, computer programs, and information systems is an essential tool in the recruitment and retention of staff. Management Structure Respiratory therapy has remained as a centralized service and in general has not moved into the program management model. The reporting structure may vary but decentralization has not occurred. There are some variations, for example, the respiratory therapist assigned to the operating room at Seven Oaks reports through the surgery program. The respiratory therapy directors at Grace General Hospital, Concordia General Hospital, and Seven Oaks General Hospital report to the vice president level. Deer Lodge Centre has a respiratory director. All the acute care facilities have managers except Respiratory Therapy Workforce Analysis 22

St. Boniface General Hospital and Victoria General Hospital. Both of these respiratory services have asked for a review of their management structure. A respiratory therapy leadership group exists and meets regularly. At this time both in scope and out of scope therapists attend these meetings. Remaining as a centralized service has been viewed as positive for the following reasons as reported in the updated profile document: 9 "it allows the discipline the freedom to define and adjust their domain of practice it allows the discipline the opportunity to develop functional mechanisms to evaluate their own work there has been no impedance to continuing student education and other clinically-related activities the development and maintenance of individual professional identify is supported the ability to address and comply with professional accreditation and licensing requirements is acknowledged." 9 In Alberta where a program management structure was adopted, costs increased as a result of less flexibility in the system. As well, this adoption of the program management model may have contributed to the national shortage as requirements in Alberta increased. Staffing Ratios As reported in the update of the Profile of the Allied Health Workforce staffing ratios vary across the region as well as across the nation. 9 The External Review (Deloitte and Touche- 2002) indicated that staffing levels at the tertiary centres are deficient. The minimal recommended staffing ratio for intensive care units is one RT for every four ventilated patients. This standard is generally not adhered to in the tertiary care Respiratory Therapy Workforce Analysis 23

centres in Winnipeg. 9 As a result of shortages, scope of practice has been affected. Labour Mobility MARRT has signed Agreements on Internal Trade with other jurisdictions using the postgraduate entry to practice examination provided by the Canadian Board for Respiratory Care. The mutual recognition agreement exists with all provinces except Quebec and Ontario. MARRT is close to signing with these two provinces. This agreement ensures that there are no barriers for recruitment from other jurisdictions although it has been noted that the lower salaries in Manitoba do not entice therapists from other provinces to relocate. 9 The successful completion of the national exam is required prior to licensure. The exam may be written in English or French. At present Manitoba, Alberta, Quebec, and Ontario are regulated jurisdictions and British Columbia is close to being regulated. 13 A reciprocity agreement exists between Canada and the United States that allows registered respiratory therapists to practice anywhere in North America. Canadians must write a state exam and complete the clinical portion of the exam to ensure that English is not a problem. The state of Arizona allows Canadian to practice as long as they are eligible to write the exam. 13 Respiratory Therapy Workforce Analysis 24

VI. Education Information Manitoba will be the first province to offer a degree program in respiratory therapy with the introduction of the baccalaureate program at the University of Manitoba in September 2002. The program is accredited nationally. Student enrollment will be approximately sixteen students. 9 Prior to the institution of the degree program, the Health Sciences Centre (HSC) operated the School of Respiratory Therapy. The program has been operational since 1964 with teaching occurring at both of the teaching hospitals, St. Boniface General Hospital and the Health Sciences Centre, as well as other community hospitals and the private sector. There was not a graduating class in the year 2000 as the School was anticipating the approval of the degree program and so there was no intake for that year. A high proportion of the students admitted to the program have already completed a baccalaureate degree. All students accepted into the program have, at minimum, completed University One prior to admission. The minimum GPA for acceptance is 2.5. Students are required to complete clinical placements as part of their training program. In view of increasing workloads at the WRHA facilities the provision of student placements is difficult. The 2004 graduating class will be the first year of students to graduate with a degree. A degree completion program will be offered to graduates of the previous program and will require 30-36 credits. Respiratory Therapy Workforce Analysis 25

Table 5: Manitoba Respiratory Therapy Graduates 1997-2001 Year 1997 1998 1999 2000 2001 Graduates 7 13 8 0 6 Table 6: Predicted Manitoba Respiratory Therapy Graduates 2002-2006 Year 2002 2003 2004 2005 2006 Graduates 10 5 8 10 16 The Manitoba Association of Respiratory Therapists reported the number of RTs licensed to practice in Manitoba over the past five years who were not graduates of the Health Sciences Program as follows: 1998 4 1999 7 2000 3 2001 4 2002 5 Of these therapists it was noted that at least one therapist registers each summer and provides relief work but returns to another province for the remainder of the year. The out of province registrants are graduates from a variety of schools including schools in Ontario, British Columbia, Alberta, and one American graduate. On average 97.5% of all practicing RTs are Manitoba graduates. The annual tuition fees and costs for books/supplies are substantial. The annual fees including supplies, books, and clinical placements costs are as follows; Year 1 - $4955.25, Year 2 - $5046.25, and Year 3 - $5162.00. 29 These amounts do not include the cost of their first year of university, which all applicants have obtained prior to entry into the program. Many students who enter have already completed degrees or more than one year of university education. Clinical placements are an integral part of the education of respiratory therapy students. The majority of placements occur in WRHA facilities. During first and second year students complete basic fieldwork and are Respiratory Therapy Workforce Analysis 26

in clinical placements for ten days each year. The purpose of these placements is primarily exposure and observation. During third year students participate in a number of Clinical Education Placements including: Clinical Education in Intensive Care -12 weeks at St. Boniface and HSC Clinical Education in Pediatric Respiratory Care - 4 weeks at Children's Hospital Clinical Education in Neonatal Respiratory Care - 5 weeks at Children's Hospital Clinical Education in Maternal/Fetal Respiratory Care - 1 week at Women's Hospital Clinical Education in Pulmonary Diagnostics - 4 weeks at HSC Clinical Education in Anesthesia - 4 weeks at Seven Oaks General Hospital Clinical Education in Community Care - 5 weeks at various facilities Clinical Education in Medicine/Surgery - 5 weeks at St. Boniface and HSC Health Sciences Centre, Seven Oaks General Hospital, and St. Boniface General Hospital are accredited facilities for respiratory therapy. Respiratory Therapy Workforce Analysis 27

VII. Registration Information The Registered Respiratory Therapist Act of Manitoba (R115) governs respiratory therapists. (See Appendix) The Manitoba Association of Registered Respiratory Therapists (MARRT) is the licensing body. 13 Membership in MARRT is required to be able to practice in the province. The role of the licensing body is to ensure that the "public receives safe, effective, and ethical care within the scope of practice of respiratory therapy". 13 Respiratory therapy is regulated in some provinces but not all. Licensing is required in Quebec, Ontario, Manitoba, and Alberta. After graduating from a Canadian Society of Respiratory Therapists (CSRT) approved training program students are eligible to write the national registration examination. The Canadian Board for Respiratory Care (CBRC) offers the credentialing examination. 30 The exam must be successfully completed prior to licensure at which time the CSRT grants the "Registered" credential. The exam is offered in Winnipeg in July and again after January first outside of Winnipeg. The cost is $490.00. Therapists practicing in Manitoba are licensed annually and must maintain membership in the CSRT. To maintain licensure therapists must participate in continuing education activities. The use of professional portfolios was implemented in 2001 with the first year of audits occurring in 2002. Therapists will be chosen randomly for audit at a rate of 10% per year. MARRT has implemented a minimal requirement of 24 hours continuing education with a suggested goal of 48 hours annually. As well practice hours must be a minimum of 480 hours over three years. 13 Respiratory Therapy Workforce Analysis 28

VIII. Age Distributions and Retirement Information Canadian healthcare providers are, on average, getting older. The CIHI reports that from 1994-2000 the average age has risen almost 2 years from 39.1 to 40.8 years. 10 For the respiratory group there has been a marked increase in the number of therapists practicing in the 40 plus range from the year 2001 to 2002. 13 The percentage over 40 increased from 43.1 percent in 2001 to 59.4 percent in 2002. 13 As this group approaches retirement workforce issues will increase. For the year 2002, only 10.7% of the workforce is in the 20 to 29 age range. Table 7: Age Distribution of Practicing Respiratory Therapists 1999-2002 13 YEAR TOTAL 20-29 30-39 40-49 50-59 60-69 # % # % # % # % # % 1999 197 34 17.3 74 37.6 80 40.6 9 4.6 0 0 (208) 2000 190 32 16.8 76 40.0 74 38.9 8 4.2 0 0 (200) 2001 190 32 16.8 76 40.0 74 38.9 8 4.2 0 0 (200) 2002 187 20 10.7 56 29.9 98 52.4 13 7.0 0 0 (190) Avg% 15.4 36.9 42.7 5.0 Note: Bracketed number indicates actual number registered. Information provided in the profile update document noted that the MARRT database indicated that 45% of members licensed to practice in Manitoba are age 40 or older. 9 Of these numbers, a minimum of 4% will reach age 55 plus over the next five years. Only 15.4% are age 29 or younger. The Manitoba Association of Registered Respiratory Therapists reported that twenty-nine percent of the respiratory therapists in Manitoba will be eligible for retirement within the next ten years. This would equate to 55 positions. 13 Respiratory Therapy Workforce Analysis 29

Within the WRHA the age ranges are similar with the majority of therapists being in the 40 to 49 age range (48.3%) representing 84 employees. The age distributions indicate that only one respiratory therapist is working past the age of 60 and the age 50-59 group represents 8% of the total working group. Table 8: Age Distribution of WRHA Respiratory Therapists Frequency 100 80 60 40 20 0 Age Distribution of WRHA Respiratory Therapists 29 39 49 59 69 More Age Range Table 9: WRHA RTs - Age Ranges and Percent of Workforce 2001 Age CGH GGH HSC SBGH SOGH VGH DLC MHC RVHC School Totals % 0-29 1 2 7 6 3 1 2 0 0 0 22 12.6 30-39 0 5 23 10 6 2 3 0 1 3 53 30.5 40-49 9 8 22 19 9 6 2 4 2 3 84 48.3 50-59 1 1 5 2 1 2 0 0 1 1 14 8.0 60+ 0 0 0 0 0 0 0 1 0 0 1 0.6 Total 11 16 57 37 19 11 7 5 4 7 174 100 Early retirement is becoming more common and this is particularly true for the public sector with 55 being the most popular retirement age for that group. As well, women tend to retire earlier that men, likely as a result of the age difference between spouses. 31 Employees are entitled to an unreduced pension benefit once their age plus years of service total 80. Table 10 indicates the number of employees at each site that will reach Magic 80 over the next five years. Respiratory Therapy Workforce Analysis 30

Information from the Healthcare Employees Pension Plan indicates that 20% of members with Magic 80 at age 50 retire and 25% of members with Magic 80 at 55 years of age retire. Table 10: Number of Employees Attaining Magic 80 Year CGH GGH HSC SBGH SO VGH DLC MHC RVHC Totals 2002 0 1 4 0 0 0 0 1 1 7 2003 0 0 0 0 0 0 0 0 0 0 2004 1 0 1 0 0 1 0 0 0 3 2005 0 0 1 0 0 0 0 0 0 1 2006 0 0 1 1 0 0 0 0 1 3 Totals 1 1 7 1 0 1 0 1 2 14 Table 11: Number of WRHA Respiratory Therapists Age 55, 60, and 65 Year Age 55 Age 60 Age 65 2002 7 1 0 2003 1 0 0 2004 2 1 0 2005 2 0 0 2006 2 3 1 Totals 14 5 1 Table 11 indicates the year at which WRHA respiratory therapists will reach age 55, 60 and age 65. Over the next five years 14 respiratory therapists will reach the age of 55. This represents 8% of the workforce. Respiratory Therapy Workforce Analysis 31