Chair
Susan P. Pilbeam, MS, RRT, FAARC
9 Althea St.
St. Augustine, FL 32084
pilbeamsue@aol.com

In the January 2003 issue of Nursing 2003, published by Lippincott Williams & Wilkins, Cheryl L. Mee, RN, BC, MSN and Eileen Robinson, RN, MSN wrote an article titled "What's Different About This Nursing Shortage?" The ideas they shared seem to parallel our respiratory therapist shortage. It seems appropriate to summarize their findings for educators who may see the shortage in terms of students but who also realize student shortages produce staff shortages.

Those of you who have been in respiratory care a long time have probably noticed that, as in the past, staff therapists are putting in longer hours, caring for more patients, and trying to keep up. They're waiting for reinforcements - new therapists or traveling therapists - to ride into town. However, relief may not be on the way this time. Staff may have to keep up this pace indefinitely. Welcome to the new respiratory therapy shortage.

Today's shortages in allied health and nursing are unlike the kind of shortages we've seen in the past, experts say. Unique trends in the demographics of our population, reimbursement trends in health insurance and Medicare, and unusual labor and population trends are causing huge disruptions in the supply of nurses and therapists. At the same time the need for health care workers is skyrocketing.

More Patients, Fewer Workers

"There are two population groups moving in opposite directions: patients and nurses..." say Mee and Robinson. You could easily substitute "respiratory therapists" for "nurses" in that statement. More people are surviving serious illnesses and living longer with chronic disease, while at the same time more nurses and therapists are leaving the field or retiring or going into non-staff positions such as management or sales.

Fewer new people are going into health care as well, report the authors. "Other professions are doing a better job of attracting the new generation of workers, men and women alike." Is it any wonder, when you look at the events affecting health care in the U.S.? Consider the following:

* Hospital restructuring and cost cutting have eliminated a lot of staff positions, leaving those who remain working overburdened.
* Fewer students are entering health care professions such as respiratory care. During the period 1998-2002 fewer RT students resulted in fewer graduates.
* Fewer new therapists are available to fill vacant hospital positions.
* Respiratory therapy has never had a high-profile public image. But even nursing's public image "hasn't caught up to reality," say Mee and Robinson.

Tired of "Making Do"

Mee and Robinson note that increasingly heavy patient loads have made many nurses tired of settling for less and simply "making do." In a 2001 study of 43,000 nurses, more than 40% of hospital employed nurses in the United States reported dissatisfaction with their jobs. Only 34% reported their facilities had enough nurses to provide high-quality care. Only 43% reported enough support services to get the work done. And only 29% reported a responsive administration. You might suspect that a survey of therapists might yield similar results, as all these issues are familiar to staff therapists as well.

Widespread Dissatisfaction

The authors go on to discuss the myriad factors contributing to the widespread dissatisfaction among today's nurses. Many of these sound all too familiar:

* Lack of a strong professional practice environment
* Lack of respect from physicians, employers, and other health care providers
* High nurse (therapist)/patient staffing ratios
* Excessive or mandatory overtime
* Unsafe working conditions leading to errors
* Abusive work environments
* Poor use of advanced technology
* Inadequate compensation for additional skills and education
* Poor standards of care that lead to below-par care and poor patient outcomes

No Quick Fix

Mee and Robinson found no quick fix to the shortage. Because of its unique characteristics we'll have to dig deeper. "Addressing the core retention issues will also address the key recruitment issues that keep candidates from entering the profession," they write.

Summary

At least we're not alone in our struggle to recruit and retain students and staff. And there may be a bright side. The economy has certainly seen no improvement. This may be the salvation for health care, at least in the short term. As the ranks of the unemployed swell and the glamour of the computer industry fades along with the NASDAQ stock average, there may be a silver lining. The job-hungry may start looking for the security of the health care industry. In the meantime, we must continue to do what we can to come up with innovative ideas that will make our profession more attractive to the public, improve job conditions for those working in our area, and lead to new ways to grow and strengthen our position in the health care environment.

For more information about the Nursing article and Nursing journal, see the web sites http://www.nursing2003.com and http://www.nursingcenter.com. [Top]

Respiratory therapists enter the workforce with a wide variety of expectations and goals for their careers. Some are looking for an opportunity to move into management, become an educator, or become an advanced practitioner in a staff position. However, a common thread has developed over the past 3 or 4 years regarding these new employees' knowledge, skill, and ethics.

The majority of new practitioners seem to need the most training and mentoring in concepts regarding mechanical ventilation. Students have spent most of their time trying to learn ventilator-specific items, terms, and functions, but little investment has been made in learning the concepts of pressure, flow, and time. I do understand that student therapists will not have had exposure to all the ventilators they may face in the workplace. However, with a firm foundation in general mechanical ventilation concepts the new employee can easily learn how the specific functions alter flow, pressure, and time.

Skill varies from student to student. Much of the new employee's initial skill level depends on the clinical rotation(s) the student had in school and the exposure the student had to various procedures. Initiation of mechanical ventilation is a subject that usually requires additional training and hands-on experience, including attaching the circuit and choosing appropriate settings based on the patient's age, size, and disease process. Also, even though it is a basic skill, many new employees require additional training for sterile gloving and suctioning, since they have only done closed-system suctioning during clinical rotation (excluding lab time).

Concerning work ethic, new employees often lack initiative. The new employee who goes above and beyond the assigned duties or spends extra time to practice a skill stands out in the profession. However, lack of initiative is not always indicative of a poor work ethic. Some employees lack initiative because of a lack of confidence. If that's the situation, knowledge and skill can be enhanced by written and competency assessments. As the employee gains experience, confidence grows, which typically increases initiative. If lack of initiative remains an issue after providing resources to increase the employee's knowledge and skill, the employee may have a professionalism issue or a behavior that needs modifying.

Another common thread is lack of commitment to the profession. Not all therapists enter respiratory care to achieve the objectives mentioned above. The turnover rate remains high in the health care industry as a whole. This is nothing new. Attempts have been made to recognize and publish predictors of performance and longevity among respiratory therapists. Also, commitment or professionalism is often associated with involvement in local, state, and national professional associations. Retention must be a priority for departments, and they must reward those who commit to the organization. The respiratory schools must emphasize the opportunities that exist within the respiratory profession.

In the next newsletter we will discuss how to address or correct these issues and look at which tools are most valuable for a new employee to bring to the workplace. Stay tuned! [Top]

Hospitals are facing severe shortages of health care providers and are anticipating long-term shortages in the years ahead. The American Hospital Association's Commission on Workforce for Hospitals and Health Systems studied and addressed this problem in a report titled "In Our Hands: How Hospital Leaders Can Build a Thriving Workforce."1 The report attributes the shortages to an aging labor force, few potential workers, a less attractive view of a career in health career, and the dissatisfaction of the current health care workforce. In addition, the demand for health care services continues to grow.

The report includes many recommendations for government, hospital leaders, educators, professional associations, and other organizations to deal with the workforce crisis. One recommendation is to develop partnerships and collaborative programs with educational institutions. The report indicates, "Community colleges and universities educate most of the hospital workforce. However, the link between these educational institutions and hospitals is too often weak or non-existent."1 The report recommends building stronger relationships with area colleges and universities through investment of time, personnel, and funds.

Shortages of well-trained health professionals require program directors of health career training programs and health facility administrators to be aware of the mutual benefits of student placement in training facilities. Most health career education programs include structured clinical education experiences in which students develop and demonstrate clinical competencies. Clinical education requires the participation and collaboration of health care program educators and health care facilities. Health career training programs provide both tangible and intangible benefits to the employees and facilities in which training occurs.

Cost containment in health care is an ongoing issue. Phelan et al indicate that clinical education provides such tangible benefits as savings in recruiting of students.2 They also reveal that the cost of clinical education was most often cited as lost staff time. However, two studies of health care training found that the loss of staff time was covered by the revenues and productivity generated by students.3,4 Clinical education can revitalize staff, provide supervisory experience to staff, increase job satisfaction, increase professionalism and work quality, and provide workload support when students become proficient in clinical skills.5,6 Research indicates that the cost savings of hiring students trained in the health care facility include saving the time and expense of new employee orientation, advertising, interviewing, recruiting, and overtime for coverage of a vacant position.7-9

College and university health science programs are collaborating with health care facilities to address the health care workforce shortages. A survey by the National Network of Health Career Programs in Two-Year Colleges found that collaborations and partnerships were being implemented to address the national shortages of health care providers, students for programs, and clinical sites for students.10 These collaborative efforts include tuition reimbursement programs, stipends, grants to fund the start-up costs of new programs, funding for equipment and facilities, funding for faculty in high-demand areas, and joint appointments of faculty members.

The American Hospital Association report recommends offering scholarships, internships, and externships to students. The report also suggests collaborative efforts for professional development, partnering to increase enrollments and clinical site availability, and developing local or regional task forces to elicit dialogue and feedback between educators and employers. Collaborations are being forged in an effort to ease the health care employee shortage, to encourage enrollment in health care career programs, and to address health care faculty shortages. These partnerships are strengthened by the common goal of providing quality health care through the preparation of quality health care providers. Health care practitioners, educators, and administrators are encouraged to build collaborative partnerships between higher education institutions and health care facilities to strengthen and support the development of quality health care providers.

References

1. In Our Hands: How Hospital Leaders Can Build a Thriving Workforce. (2002). AHA Commission on Workforce for Hospitals and Health Systems. Washington DC: American Hospital Association.
2. Phelan, S. E., Daniels, M. G., Hewitt, L. (1999). Clinical Education Benefits. Laboratory Medicine.
3. Douce, F. H. Vieth, K. P. (1985). Benefits and costs to hospitals affiliating with a respiratory therapist educational program. Respiratory Care, 30, pp. 686-690.
4. Davis, M. R., Morhart, R. E. Vidmar, G. C. Rhyne, R. R. (1988). Evaluation of cost-productivity of hospital-based general practice residency programs. Special Care in Dentistry, pp. 220-223.
5. Hammersberg, S. S. (1997). Who will train tomorrow's technologists? Laboratory Medicine, 28(9), 564-566.
6. Jones, B., Murtaugh, M., Durkin, Z. A., Bolden, M. C., & Majewski, T. (2002). Clinical education in two-year colleges: Cost-benefit issues. Journal of Allied Health, 29 (2), pp. 109-112.
7. Harmening, D. (1998). Department of Medical and Research Technology, University of Maryland School of Medicine. Benefits of a Clinical Affiliation. DMRT and DH Publishing, 1-6.
8. Snyder, J. R. (1992). Manpower needs in the year 2000: Medical Technology education. Laboratory Medicine, 23(6), 416-419.
9. Best, M. L. (1990). Lab administrators' role in retaining professionals. Medical Laboratory Observer, August, 46-50.
10. National Network of Health Career Programs in Two-Year Colleges.
(2002). Community College-Hospital Collaboration Survey. (Retrieved from http://www.NN2.org, February 28, 2003)[Top]

The asthma educator certification examination was launched on September 19, 2002. As of February 2003 over 250 individuals had completed the examination process. Approximately 75-80% of the candidates have successfully achieved the AE-C designation. The examination is available 5 days a week at the same testing sites (run by Applied Measurement Professionals Inc.) that are used for the National Board for Respiratory Care (NBRC) examinations. Online registration is available at the National Asthma Educator Certification Board (NAECB) web site: http://www.naecb.org. The NAECB plans to post on the web site the number of certified asthma educators available in each state.

As candidates prepare for the examination they can turn to resources listed in the candidate handbook and on the web site. The examination matrix is also available in the candidate handbook. The matrix is based on a national job analysis. Several preparatory courses for the examination are available as well, including one sponsored by the AARC specifically for respiratory therapists. Prior to attending a preparatory course, review its contents for consistency with the examination matrix. It is also helpful to determine the success rate of those who have attended the course.

The NAECB will provide two oral presentations at the Asthma 2003 Conference in Washington, DC, in June 2003. The presentations will cover the asthma educator job analysis study and an update of NAECB activities. The NAECB will complete a statistical analysis of the examination in late 2003. Multiple variables will be examined, including the optional demographic questions on the candidate application.

The Education Section can support the success of respiratory therapists sitting for the exam, through preparatory courses, review materials, and post-graduate courses. Two areas of the examination matrix may specifically benefit from input from respiratory care educators. The first section includes the patient/family education needs assessment process, planning the education session, implementation, and outcome assessment. The other area is in program management and outcome assessment. Other opportunities exist for certified asthma educators to serve as item writers or on NAECB committees.

The web site is a valuable resource for updated information. An announcement of the Linda Ford, MD Asthma Educator Scholarship Program and application criteria will be forthcoming. Please contact the NAECB for further information and opportunities to participate in this exciting process to improve the care for individuals with asthma. I will also be glad to provide additional information. You may contact me at: sblonshine@aol.com.[Top]

For the second year in a row at least 40 states are facing a legislative budget shortfall. Since state constitutions often include a balanced budget clause, legislators and governors are being forced to make difficult choices, and health funding has not been spared the cuts. Unfortunately, a number of states have also looked to their revenue stream from the 1998 Master Settlement Agreement (MSA) - commonly known as the tobacco settlement - as a short-term fix, using current settlement funds for general operation purposes and sacrificing decades of future payments for smaller up-front payments through securitization.

The trend to sell off the rights to future MSA payments in return for a lump sum payment continues. Budget deficits provide the greatest impetus for these decisions, but legislators also cite fears that MSA payments will dry up in the future as people quit smoking. The most negative effect of securitization may be its impact on health programs. Most states fund tobacco prevention and other important health initiatives with MSA revenue. Once that revenue is sold off it will become more difficult to find funds in the future.

In Louisiana a Millennium Trust Fund was established as a permanent trust fund into which a portion of the settlement funds are deposited. Only investment earnings on the trust can be spent. All earnings are credited, one third each, to three funds within the Millennium Trust Fund: the Education Excellence Fund, the Health Excellence Fund, and the Tuition Opportunity Program for Students (TOPS) Fund. Louisiana is funding only $500,000 per year to tobacco control and prevention programs. The Centers for Disease Control Best Practices Minimum for state spending calls for $27,130,000.

Please investigate the spending of the MSA in your own state. Get involved, get educated, and lobby for adequate tobacco control and prevention. Your local Lung Association is a valuable resource. Please contact them and help us eliminate tobacco-related lung disease in future generations. [Top]

Typical assessments of learning include pencil-and-paper exams, laboratory, and clinical evaluation. Education research has shown these methods are inadequate to determine what the student truly understands and conceptualizes about a given topic. Nontraditional methods, such as concept mapping, interviewing, Vee diagrams, and protocol analysis, have been shown to be effective in identifying concepts and gaps in student understanding. The present study evaluated the use of a word-list tool (Fig. 1) to assess understanding of lung pathology.

Fig. 1. Word-list tool.

Using only 2 words, describe the pathophysiology of each of the following diseases:

Asthma
______________ ______________
Emphysema
______________ ______________
Chronic bronchitis
______________ ______________
Cystic fibrosis
______________ ______________
Interstitial lung disease
______________ ______________
Pneumonia
______________ ______________
Pulmonary edema
______________ ______________
Pulmonary emboli
______________ ______________
ARDS
______________ ______________
Bronchiectasis
______________ ______________

The study included 152 participants. Each was given a list of 10 lung disease terms and carefully instructed to describe each term using 1 or 2 words. Emphasis was placed on having participants use only 1 or 2 descriptive terms for each disease. Completed word-lists were divided into 3 study groups, based on the participant's years of experience (novice, intermediate, and expert).

Qualitative analysis was used to process the data. The number of alternative concepts (AC), misconceptions (MC), and concepts (C) were identified for each disease by study group. The totals were: AC 257, MC 70, and C 647. Averages for each participant in each study group were: novice AC 1.5, MC 0.5, C 4.1; intermediate AC 1, MC 1, C 5; and expert AC 2.4, MC 1, C 7.3. The number of times participants encountered a term they were unable to describe were: novice 16, intermediate 26, and expert 16. Table 1 shows a sample of the data.

Table 1. Sample Responses from Word-List Tool

Emphysema
Novice: Loss of tissue (AC), Increased DLCO (MC)
Intermediate: Airway obstruction (AC), Increased mucus (MC)
Expert: Pink puffer (AC), Wheezy lungs (MC)
Pulmonary Edema
Novice: Wet lungs (AC), Pink sputum (AC), Lung hyperinflation (MC)
Intermediate: Fluid overload (AC), Inflamed pleural (AC), Inflammation (MC)
Expert: Wet lung (AC), Lung swelling (MC), Fluid hypertrophy (MC)
Pulmonary Emboli
Novice: Blocked bronchiole (MC)
Intermediate: Air accumulation (AC)
Expert: Increased airway resistance (MC)

This easy-to-administer word-list tool was effective in quickly assessing understanding of diseases. The study's results revealed a number of important misconceptions and gaps in understanding, and this type of tool can help educators identify the concepts and topics students need to study. In addition, the word-list provides the instructor additional data to rethink how the lung disease course needs to be taught. Data from this tool could be triangulated with other sources of assessment to improve instruction and student evaluation. [Top]

Ruth M. Kleinpell, RN, PhD, from Rush University College of Nursing in Chicago, Illinois, wrote a guest editorial in the September 2002 issue of the American Journal of Critical Care (Volume 11, No 5) titled, "Rediscovering the Value of the Journal Club." As would be expected, the article was slanted toward the nursing profession, but I decided to take her ideas and explore the use of a journal club in a respiratory therapy program.

Dr. Kleinpell's article defines a journal club as, "an educational meeting in which a group of individuals discuss current articles, providing a forum for a collective effort to keep up with the literature." Most journal clubs meet weekly or monthly.

The primary value of a journal club is to keep its members up-to-date on the latest knowledge and techniques in their profession. Members can discuss the pros and cons of new technologies and decide how they fit into their practice. For both professionals and students the journal club can promote awareness of new research findings and help the members apply research findings in clinical practice.

Journal clubs can also be used for: critiquing research and looking at its validity; learning good (versus inadequate) research procedures; and student practice in explaining new concepts to their peers. Participants can discuss the reports' benefits, problems, and impact on respiratory care practice. Journal clubs can also have a professionalism objective, in that they teach students the need to keep up with new concepts by reading journal articles. The experience will set a pattern for them to follow as they pursue their careers.

I surveyed 20 four-year respiratory therapy programs across the nation to assess their use of journal clubs. I received 9 responses. In every case the institution recognized the need for and benefits of a journal club, but none of the programs were using the journal club format at the time of the survey. However, all of the programs did use some facsimile of a journal club tied to specific course work on which the student was graded. Some programs have the students research literature in a research methods course in order to determine the validity of research projects they were assigned to read and critique. Others used literature searches tied in with clinical case studies to strengthen students' knowledge of a disease process or therapeutic technique.

In our program's student journal club the student chooses (with instructor approval) a topic or articles are assigned. The articles present something new in the profession, and the student must present their understanding of the article to their classmates. The presenter must be able to discuss the article, showing how it is beneficial or harmful to the patient, and must be able to answer questions from the students or the faculty.

The student, the profession, and the patient all benefit from journal clubs in respiratory care programs, and all programs should have some version of a journal club so that students are aware of recent developments and get in the habit of keeping up with the literature.[Top]

[Editor's Note: The following article is reprinted from AARC Times.]

In many hospitals today there is a serious shortage of qualified respiratory therapists, and many full time positions remain unfilled. This shortage translates to overworked therapists, which increases the potential for medical errors. In addition, many health care education programs are seeing fewer applicants each year. As well, the incidence of respiratory-related diseases is on the increase. The baby boom generation, the largest generation ever born, is becoming the largest geriatric population in history. Complex medical conditions, often respiratory-related, usually accompany advancing age. Thus, there is a shortage of health care professionals just before the time when demand for health care workers will be at an all-time high.

Some RC education programs provide full-time faculty to oversee their students in the hospital setting, but many programs can only provide part-time faculty overseers and therefore must depend on clinical preceptors to supervise students. More and more frequently, directors of clinical education are being told there is not enough staff available to take on respiratory care students. It is widely assumed that students are slow, that students require close supervision, and that students are more often "in the way" than helpful. But those assumptions are not fully justified.

Respiratory care students are the future of respiratory care. So let's examine some of the advantages of having student trainees in respiratory care departments. To begin with, one clinical preceptor plus one or two students can do the work of one full-time employee. Students actually do as much work as they create, and the cost (to the department) of having students is usually zero. After an initial training period, students begin to pull their weight, providing free help to overloaded staff. While students go through their various clinical rotations the department managers and supervisors can observe their work habits and thus get the first opportunity to recruit the best students. Students are oriented to the policies and procedures of each department and thus are job-ready and capable of functioning fairly independently when they go to work full time. There are personal advantages for the preceptors as well. Because teaching is one of the best ways to learn, training students is an excellent way to get respiratory care staff to review and perhaps improve their own procedures. Students bring in new perspectives and ask questions that staff may not have thought about, so preceptors brush up on procedures and theory, which re-energizes the life-long learning process.

Some colleges or universities pay clinical preceptors, but others do not have funding to pay instructors. Such universities can offer formal, albeit non-paid, clinical faculty appointments to preceptors. These appointments give preceptors access to university facilities and services, and may even provide them with the opportunity to sit in on ongoing classes free of charge, to enhance their knowledge base or prepare for an advanced credential, such as the registry exam or pulmonary function technology exam. RC department managers can give staff incentive for preceptorship by making it a positive part of the employee evaluation. Thus preceptors may advance up the career ladder more quickly if they participate in training future respiratory therapists.

What can hospital respiratory therapy departments do to solve the mounting problem of staff shortages in the face of an increasing demand for health care workers? Many departments are offering sign-on bonuses for new employees who agree to give 1 or 2 years of service in exchange for a monetary bonus. Others have begun to award scholarships to students nearing the end of their respiratory therapy education, in exchange for a commitment to work for that department after graduation. Respiratory care departments could consider providing associate degreed respiratory therapists with financial support and the opportunity to return to school to complete their baccalaureate degrees, as well as encourage certified therapists to earn their registry credentials. That would prompt therapists to seek the highest levels of training and thus promote the highest level of patient care. When advanced level respiratory therapists practice the critical thinking skills necessary to determine how best to treat their patients, limited health care resources can be more efficiently allocated and unnecessary procedures can be eliminated.

Another solution to health care personnel shortages may lie in scholarships of another kind. Why not offer scholarships "up front" as an incentive to enter the field of respiratory care, in exchange for a 1 or 2 year work commitment? Higher education gets more expensive all the time, and students who have not made a final career choice might be influenced to choose respiratory care if some of their education expenses are paid by a scholarship. If departments have resources to offer sign-on bonuses and scholarships to graduating RT students, they may be able to allocate some of these resources to offer scholarships to attract students into the field and thus into their own departments.

When hospital respiratory therapy departments provide respiratory therapy staff with financial resources to advance their educations, and when they award scholarships to entering respiratory care students, 3 problems can be addressed: that of hospital department staff shortages; that of misallocation of respiratory therapy resources; and that of declining enrollment in respiratory care education programs. Sounds like a win-win situation to me![Top]

If I were to pick the single most important thing that I saw in my student clinical experience that altered my perception of life it would be the first time I watched a patient die. It happened during my last critical care rotation. I had 2 patients that day, and from the start I knew 1 of them was probably not going to make it through the day.

My patient was a very elderly lady suffering numerous ailments and disease processes. She was in multiple-organ failure, which would take her life that day. The nurse made me aware of the situation, telling me that this woman was likely to expire at any moment. Sure enough, about 30 minutes into my day, her heart rate began to drop and got progressively worse, then hovered around 30-40 beats per minute. She was receiving non-invasive ventilatory support via face mask, but it most certainly was not enough to sustain her life.

The nurse explained the concept of comfort care to me and said the ventilator was part of it. I remember the nurse pulling the bed sheets up over the lady's shoulders to make her as comfortable as possible, and I heard the nurse say to her, as she was dying, "Everything is going to be okay; just rest."

Of course, the lady was non-responsive, but we still talked to her and explained everything we were doing. A call had already been placed to the family to let them know that the end was near. Her daughter and granddaughter arrived, and I watched them have their last moments with their loved one. We were still able to monitor her vital signs from the monitor in the room and we watched as her heart rate dropped to single digits. Now it would only be a matter of minutes before she expired.

Finally, when she flat-lined, I went into the room and took the mask off of her face so the family would not have to look at her that way. I had learned in school about "agonal breathing," which looks almost like a fish attempting to breath when it is out of water. This happens because the brain is starving for oxygen after the heart has stopped. It was kind of disturbing seeing this for the first time, because the breaths were extremely shallow and purposeful, and I knew in my heart that this lady no longer had a heartbeat. I can still picture the scene in my mind. I stood back and watched as the family grieved over her death.

There is an important request I would like to make to our clinical educators. You have observed and dealt with dying over and over in your careers, but please remember that most students have probably not seen death before, at least not in this setting, and the student may not want to let any kind of emotion show. Educators, please be available to answer student questions and provide comfort when a patient is dying.

In the end I found myself wondering what this dying lady was like when she was healthier and aware of her surroundings. Maybe this was my way of grieving over the first time I was ever exposed to death in this way. I have been to wakes and funerals, but nothing compares to seeing a person die right before your eyes. It is something I will never forget. It can definitely change a person's outlook on life and how precious life is. It certainly changed mine.[Top]

Orientation day and the first week of classes was an uncomfortable time for me, but not for obvious reasons. Along with my classmates I took my turn introducing myself and sharing my previous work experience. But even though I was proud of my previous experience I hesitated to share it, mostly because I feared my classmates' reactions. I did not want anyone to influence me regarding my decision to come into this profession.

You see, I graduated cum laude with a bachelor of science degree in chemistry and had worked for 10 years as a chemist, in a manufacturing setting. I was employed by a company that is a pillar of the manufacturing community, and I was highly respected and highly rewarded in my field, with a salary that approached $80,000 per year. Repeatedly, classmates, friends, and strangers would stare in disbelief upon hearing I had left "so much" for the profession of respiratory care. With this increasing opposition to my decision, I began to question myself as well.

This question haunted me throughout the early part of my first semester. I wandered through the halls of the hospital, wondering what had brought me to this point. My instructor had entered the profession many years earlier because she had wanted to wear a white lab coat. I had worn a white lab coat for the past 10 years, so that had not influenced my decision. Some of my classmates wanted to improve their status, socially or economically. My career as a chemist was rewarding; I had a great deal of responsibility, I had determined production schedules, formulated new products, researched and developed, and supervised and lead crews of production personnel. I had achieved financial stability and social acceptance. Nevertheless, I knew I was searching for something different, something that would soothe my soul.

I was drawn to infants and children during my first clinical rotation. I was always the first to volunteer to take care of the babies, and one day I was sent to give a nebulizer treatment to a premature baby girl who had a multitude of problems. When I bounced into the room I was not aware of how that helpless little girl, Gwyneth, would help me. She was tiny, and her little body struggled with each breath. She appeared to be gasping for air. The treatment worked like a miracle. Afterwards, I wrapped her in her blankets and watched with wonder. She rested peacefully, no flaring nostrils, no intercostals retraction ... just a tiny little girl, finally sleeping.

All those previous doubts suddenly left me; the burden had been lifted; there was no turning back. I was a future Registered Respiratory Therapist! It was difficult to leave Gwyneth that day; she had touched my heart, changed my life, and soothed my soul.[Top]

For Those Who Are Physically Challenged

During February 2003, Education Section members were asked to offer (on the e-mail list) their thoughts about a person who had applied to an RC program. The applicant was a bright individual with a bachelor of science degree, but the applicant also had a physical handicap. John Blewett (Albuquerque TVI Community College, Albuquerque, New Mexico), one of the many individuals who responded, sent a message that describes the situation for a lot of us. He wrote:

"I have had students in the past with hearing impairments and even had one with no vision in one eye and less than perfect vision in the other, yet these students not only passed my program, they became licensed and now work as RTs. It seems that if the desire is there, people whom we perceive to have 'deficiencies' often show us just how wrong we are; they are testimony to the strength of the human spirit and the ability to adapt. I also firmly believe that students have the right to try and even the right to fail."

Teaching Tip

In a recent e-mail list exchange Stephen F. Wehrman, RRT (Kapi'olani Community College, Honolulu, Hawaii) shared the following teaching tip. "I want to share a simple but powerful teaching tool I have been using for some time. I got it from the book Classroom Assessment Techniques (2nd edition, by Angelo and Cross, published by Jossey Bass Inc, 1993), which is invaluable!

Every class session I give each student a 3x5 card. At the end of the session I ask them to identify one concept that was especially clear and one that was 'muddy', unclear, or needed more explanation. I collect the cards and reply via e-mail, further explaining the subject and/or giving references for further reading. This system gives me direct feedback on my teaching. If the same questions keep coming up on a specific topic, it means I need to work on how I teach that subject.

Students love this technique and it takes only 1-2 minutes of class time and about 20 minutes to make a reply. Cheap, easy, effective."[Top]

An educator from Missouri submitted this question: "What is rise time and when should it be used?"

Rise time is used to indirectly adjust flow rate for pressure control (PC) or pressure support (PS) breaths. To understand why rise time is used, first consider how the ventilator adjusts flow for a traditional PC or PS breath.

At the onset of inspiration the ventilator's microprocessor determines a rate of flow delivery sufficient to increase the pressure in the patient circuit to the predetermined level. The flow rate depends on the patient's lung mechanics and ventilatory demand. The practitioner does not directly control the peak flow during these breath types, unlike a volume control (VC) breath, in which peak flow is pre-set.

A variable peak flow is desirable to prevent patient-ventilator asynchrony, but there may be incidences when flow rate becomes excessive and creates an "overshoot" or flow spike. Some clinicians report that this can lead to uneven gas distribution, sheer stress, and patient-ventilator asynchrony. Thus, the use of rise time indirectly controls flow rate. The term "rise time" accurately reflects what this control performs. By adjusting rise time, a "rise" to the desired pressure is effected by either accelerating or slowing the flow to the patient. Thus, a rapid or high rise time value results in faster flow acceleration than a slower rise time.

If one wants to provide the greatest flow delivery available during a PC or PS breath, a higher rise time should be selected. This is often used with patients who have high inspiratory flow demands, such as ARDS patients, pediatric patients, or those with heightened neurological ventilatory drive. In these situations a muted rise to set pressure is desirable (for example, patients with obstructive airways disease) and a lower rise time may be desirable.

Adjusting rise time requires that the clinician monitor patient-ventilator synchrony, mandatory and spontaneous tidal volumes, and ventilatory rates. The ideal rise time will provide patient-ventilator synchrony and the highest tidal volume delivery at the lowest breathing frequency. Rise time is typically not treated as a static control, but is often frequently adjusted to patient dynamics and ventilatory needs.[Top]

In February I sent a message to the Education Section e-mail list seeking input on issues section members think the section should address. The following topics were suggested (not necessarily in order of importance):

We would like to hear from you. If you did not have the opportunity to respond to the initial request on the e-mail list, please contact me at pilbeamsue@aol.com with your comments.[Top]

Each year, the Lambda Beta Society awards four $500 scholarships to recognize and encourage academic excellence in the profession of respiratory care. Applicants must meet the criteria detailed below and the applications must be postmarked by August 1, 2003.

Candidates must submit a scientific/research paper relating to respiratory care. Essays entitled, "What does it mean to be a respiratory care professional?" will no longer be accepted. Winners will be notified by early-to-mid September and scholarships will be awarded during the Lambda Beta Reception during the AARC International Respiratory Congress in Las Vegas, Nevada. Individuals with questions about the scholarships should contact the Executive Office.

Requirements

In case of a tie, grades (from the respiratory care curriculum only) will be used for final determination of the recipient, and a telephone interview may be required. For complete information and applications please contact: Glenda Hocker, Executive Secretary, Lambda Beta Honor Society, PO Box 15945-292, Lenexa, KS 66285. (913) 541-9077. e-mail: GHocker@goamp.com.[Top]

It's not unusual for respiratory care education programs to offer scholarships for newly enrolled students and for those who have successfully completed part of the RC program. But the following letter from an anonymous educator to Section Chair Sue Pilbeam has an unusual twist to the scholarship idea.

Dear Ms Pilbeam,

What if educators encouraged the following? Instead of, or in addition to, scholarships that help students meet expenses during the time spent in a respiratory care program, scholarship money would be released to the student after graduation and only when the graduate provided proof of passing the CRT exam and having applied for the RRT exam within 2 years after graduation. This would be reimbursement only and would not be based on the graduate passing the registry.

This would solve the problem of awarding a $500 scholarship to the student who is doing well but doesn't complete the program. If the graduate exceeds the time limit (procrastination) or decides that the RRT credential is not necessary, the money can be awarded to a current student. This would also solve the rare but not unheard-of problem of a good student using scholarship money inappropriately.

I wonder what the effect would be of awarding five $400 reimbursements to the first five members of a graduating class who pass the CRT and apply for the RRT exam? I've heard of one school that considered having students pay money into a fund every semester to pay for the CRT and RRT exams. According to the faculty there, that fee is considered a normal fee that the successful student has to bear.

Nothing in my personal experience disagrees with the notion that department managers can be a key part of encouraging graduates to strive for the RRT credential. When I was in school the department manager told me to skip the CRT and just become registered, which is just what I did. Though the option of skipping the CRT is not available today, it is correct to advise students to consider the RRT credential as the stopping point, not the CRT.

But the current discussions among educators about the graduate therapist's procrastination and the debate as to whether the RRT credential is really worth the time, trouble, and expense may be misplaced. When educators try to come up with a solution we may be out of line.

What are we telling the graduate? You are now trained. You are capable. You are in a worthy profession. Be a problem solver who applies critical thinking. And if you need motivation to obtain the highest credential that you went to school and worked for, someone or something (a manager, a coworker, a big pay raise, small fees for tests) will be there to encourage you.

As educators we know that not every graduate is capable of critical thinking. We can encourage students to think but we can't guarantee that they will. Don't the behaviors of sitting on the CRT credential and procrastination simply identify those who don't think things through? Ultimately, you and I obtain the RRT credential by personal choice. It's their choice. They've graduated. Let go of their hands.[Top]

National Coalition for Health Professional Education in Genetics (NCHPEG)
Linda Van Scoder, EdD, RRT, is the AARC representative to the NCHPEG. Find out more about the organization at: http://www.nchpeg.org. (Click on "Educational Resources").

Free Respiratory Care Research Manual
A book describing how to conduct respiratory care research projects is available free of charge in PDF format for members. Nonmembers may order the book at the AARC online store for $60 plus $7.50 shipping. Go here: http://www.aarc.org/resources/handbook/index.asp to find out more.

National Respiratory Care Week Outreach Kit
National Respiratory Care Week is October 19-25, 2003. Go here: http://www.aarc.org/members_area/resources/kit.asp to access an RC Week kit and sample press release that will help you get started on planning local public relations events.

Photo Gallery
Royalty-free photos of therapists and equipment are available for use in recruitment, presentations, ads, or wherever you need a photo of a professional doing his or her job. Here's the link: http://www.aarc.org/members_area/photo_gallery/.

Respiratory Care Education Annual
You can now access back issues of the Education Annual, beginning with the 1996 issue, at: http://www.aarc.org/resources/rcea/. Future issues will be added as they are published. All back issues are indexed in the CINAHL Database.

New Sample Curriculum
The AARC Education Committee has developed a new sample curriculum for a post-graduate course in placement and management of an intravenous line. This offers respiratory care education programs a high-quality addition to their RT training programs. It is designed for use by respiratory care education programs in conjunction with their clinical affiliates. A course following this curriculum will augment training programs for respiratory therapists, with thorough instruction in intravenous line placement and management. It will also be suitable for CRCE credit approval. The course should take 4-8 hours. Practitioners who receive this training will add value to their workplaces and enhance the concept of skill-building, which is vital to the future of the respiratory care profession. The new sample curriculum package contains everything an education facility needs to establish a complete intravenous line course: lesson outlines, checklists, and references. The intravenous line course materials are available now. AARC Education Section members can receive these course materials at no cost. Other AARC members can obtain the materials for $25. The price for non-members is $35. For more ordering information contact the AARC at (972) 243-2272.

World Tuberculosis Day 2003
In 1993 tuberculosis was declared a global emergency by the World Health Organization. Since then 10 million patients have been treated with the DOTS (directly observed treatment short-course) strategy. "DOTS cured me. It can cure you too!" is the theme for this year's World Tuberculosis Day, with particular emphasis on patients. The objectives of World Tuberculosis Day 2003 are (1) to educate the general public on the symptoms and treatment of tuberculosis, (2) to encourage people to seek testing at a DOTS clinic if they think they might have tuberculosis, and (3) to persuade people to comply fully with the DOTS treatment strategy. Momentum is building up and many countries around the world have packed agendas for World Tuberculosis Day 2003. For more information visit http://www.iuatld.org or http://www.stoptb.org.

"CoughAssist" CD-ROM available free from JH Emerson Co.
JH Emerson Company has created a CD-ROM to accompany the "CoughAssist", a noninvasive airway clearance device that can generate peak expiratory cough flows > 6 L/s. The CD-ROM includes step-by-step instructions and clinical guidelines for the device, and is therefore useful as a training aid. To obtain a free copy of the CD-ROM call 1-800-252-1414 or e-mail rob@jhemerson.com.

National Board for Respiratory Care (NBRC) Update for Educators
One of the NBRC Board of Trustees' goals this year is to "promote continued communication and cooperation within the respiratory therapy community." Therefore, the NBRC will continue to provide periodic updates (via e-mail) to program directors of accredited respiratory care education programs, and hopes you find this a helpful and informative means of staying connected to credentialing activities. Visit http://www.nbrc.org for up-to-the-minute information for you and your students.

Electronic Eligibility Database (EED) Annual Enrollment Deadline Passed
At the end of 2002 all program directors of accredited respiratory care education programs received information to renew their annual enrollment in the NBRC's Electronic Eligibility Database (EED). Programs that were not previously enrolled also received information to enroll in the EED for the first time. The EED allows you or designated program officials to transmit graduate information directly to the NBRC, which facilitates processing of your graduates' applications for testing and eliminates the need for them to provide official copies of certificates of completion/graduation to the NBRC. Using the EED helps your graduates qualify for testing as soon as possible after graduation. The EED can also accepts verification of academic degrees and quarter or semester hours of academic credit in lieu of official college transcripts to document eligibility for the RRT examination. The deadline for annual enrollment has passed (it was January 31, 2003) and all passwords were reset on that date, but it is not too late to renew! Complete the enrollment materials and fax the forms to the NBRC Executive Office (fax: 913-541-0156) as soon as possible. If you did not receive EED renewal materials for your program please e-mail the NBRC Executive Office immediately (NBRC-info@nbrc.org) and include your name, institution name, phone number, fax number, and e-mail address. Another set of enrollment forms will be e-mailed or faxed to you. Remember, there is no charge for this service!

CRT and RRT Job Analyses
Survey responses for both the CRT and RRT job analyses have been analyzed and summarized. The NBRC's Ad Hoc Respiratory Therapy Job Analysis Committee met several times in February to review this data. The committee is now working towards new, detailed content outlines and test specifications for both examinations. As with past RRT and CRT job analyses, criterion-related validation studies will be conducted for the CRT examination and written registry portion of the RRT examination in late 2003. A similar study is planned for 2004 for the Clinical Simulation Examination. The first CRT examinations offered under new test specifications are planned for release in July of 2004. The first Written Registry Examinations offered under new specifications are planned for release in late 2004 or early 2005.

Pre-Test Problem Added to the Clinical Simulation Examination
Beginning July 1, 2003, the Clinical Simulation Examination (CSE) will contain 1 additional simulation for pre-testing purposes. Students' performance on this pre-test problem will have no effect on their scores in the Information Gathering and Decision Making sections, nor on their overall CSE pass/fail score. The inclusion of a pre-test simulation on the CSE will allow the NBRC to introduce new simulations to the actual credentialing examination only after they have been tried and proven to have stable test statistics. The duration of the CSE test will remain the same (4 hours). Over 95% of CSE test takers complete the examination with 20 minutes remaining in the testing session, and the average time to complete the CSE is 3 hours. The NBRC will continue to monitor the completion time for candidates attempting the CSE after the pre-test problem is introduced, to ensure that the testing time of 4 hours is sufficient. [Top]