Characterizing the mental health and functioning of Canadian respiratory therapists during the COVID-19 pandemic

ABSTRACT

Introduction: Healthcare professionals (HCPs) appear to be at increased risk for negative psychological outcomes [e.g. depression, anxiety, post-traumatic stress disorder (PTSD), moral distress] and associated impacts on functioning throughout the COVID-19 pandemic. HCPs working on designated COVID-19 units may be further impacted than their colleagues not on these units given added demands of patient care and risk of contracting COVID-19. Little is known, however, about the mental health and functioning of specific professional groups beyond nurses and physicians, including respiratory therapists (RTs), over the course of the pandemic. Accordingly, the purpose of the present study was to characterize the mental health and functioning of Canadian RTs and compare profiles between RTs working on and off designated COVID-19 units.

Methods: Canadian RTs completed an online survey between February and June 2021, including demographic information (e.g. age, sex, gender,) and measures of depression, anxiety, stress, PTSD, moral distress and functional impairment. Descriptive statistics, correlation analyses and between-groups comparisons were conducted to characterize RTs and compare profiles between those on and off COVID-19 units.

Results: Two hundred and eighteen (N = 218) RTs participated in this study. The estimated response rate was relatively low (6.2%) Approximately half of the sample endorsed clinically relevant symptoms of depression (52%), anxiety (51%) and stress (54%) and one in three (33%) screened positively for potential PTSD. All symptoms correlated positively with functional impairment (p's < .05). RTs working on COVID-19 units reported significantly greater patient-related moral distress compared to those not on these units (p < .05).

Conclusion: Moral distress and symptoms of depression, anxiety, stress and PTSD were prevalent among Canadian RTs and were associated with functional impacts. These results must be interpreted with caution given a low response rate, yet raise concern regarding the long-term impacts of pandemic service among RTs.

HIGHLIGHTS

• Research on RTs’ mental health prior to and during the COVID-19 pandemic is scant, especially in comparison to other HCPs.

• RTs in the present study reported experiencing moral distress and clinically significant symptoms of depression, anxiety and PTSD, with associated functional impairment.

• One in three RTs screened positive for likely PTSD on the PCL-5.

• There is a need to provide RTs with adequate mental health supports and to understand the long-term impacts of pandemic service among RTs.

Introducción: Los profesionales de la salud (PSs) parecen estar expuestos a un mayor riesgo para desarrollar resultados psicológicos negativos, ej. depresión, ansiedad, trastorno de estrés postraumático (TEPT), angustia moral y su impacto deletéreo en el funcionamiento durante la pandemia de COVID-19. Además, investigaciones preliminares sugieren que los PSs que trabajan en unidades designadas para COVID-19 pueden verse más afectados negativamente que sus colegas que no trabajan en estas unidades dadas las demandas adicionales de atención a estos pacientes y el riesgo de contraer COVD-19. A pesar de este conocimiento y exposición a eventos altamente estresantes y traumáticos pre-pandemia, poco se sabe sobre la salud mental y funcionamiento de grupos específicos de profesionales que no sean enfermeras y médicos, incluidos los terapeutas respiratorios (TRs), durante el curso de la pandemia. En consecuencia, el propósito de este estudio fue caracterizar la salud mental y funcionamiento de los TRs canadienses durante la pandemia de COVID-19 y comparar los perfiles de TRs que trabajan dentro y fuera de las unidades designadas para COVID-19.

Métodos: Los TRs completaron una encuesta en línea entre Febrero y Junio del 2021, incluyendo información demográfica básica (p. ej., edad, sexo, género, estado civil) y medidas psicométricas validadas de depresión, ansiedad, estrés, TEPT, angustia moral y deterioro funcional. Se realizaron estadísticas descriptivas, análisis de correlación y comparación entre grupos para caracterizar los TRs y comparar perfiles funcionales entre aquéllos dentro o fuera de las unidades de COVID-19.

Resultados: Doscientos dieciocho (N = 218) TRs participaron en este estudio. La tasa de respuesta estimada fue relativamente baja (6,2%). Aproximadamente la mitad de la muestra dio positivo en el tamizaje para síntomas clínicamente relevantes para depresión (52%), ansiedad (51%) y estrés (54%) y un tercio (33%) dio positivo para posible TEPT. Todos los síntomas correlacionaron positivamente para deterioro funcional (p's < 0.05). En promedio, los TRs reportaron dificultades funcionales presentes por 9 días en el último mes. Los TRs trabajando en unidades COVID-19 reportaron una angustia moral relacionada a pacientes significativamente mayor comparado con aquéllos que no estuvieron en esas unidades (p < 0.05).

Conclusión: La angustia moral y los síntomas de depresión, ansiedad, estrés y TEPT fueron prevalentes entre los RTs canadienses y se asociaron con impactos funcionales entre Febrero y Junio del 2021. A pesar de la necesidad de interpretar estos resultados con precaución, debido a una baja tasa de respuesta, estos resultados elevan preocupaciones respecto a los impactos a largo plazo de servicios pandémicos en TRs y apuntan a la necesidad de una adecuada prevención, detección temprana y esfuerzos de intervención para apoyar la salud mental y funcionamiento de TRs en Canadá. Los TRs trabajando en unidades designadas para COVID-19 pueden beneficiarse particularmente de apoyos relacionados con la angustia moral relacionada al nivel de pacientes.

简介：在整个 COVID-19 疫情期间，医疗保健专业人员 (HCP) 出现负性心理结果 [例如抑郁、焦虑、创伤后应激障碍 (PTSD)、道德困扰]及其对功能有害影响的风险似乎有所增加。 此外，初步研究表明，考虑到对患者护理的额外要求和感染 COVID-19 的风险，在指定 COVID-19 单位工作的 HCP 可能比不在这些单位工作的同事受到更大的负面影响。尽管知道这些和疫情前高度有压力和创伤性事件暴露，但对于除了护士和医生之外、包括呼吸治疗师 (RT) 的特殊职业群体在疫情期间的心理健康和功能知之甚少。 因此，本研究旨在描述加拿大 RT 在 COVID-19 疫情期间的心理健康和功能，并比较在指定 COVID-19 单位工作的 RT 之间的概况。

方法：加拿大 RT 在 2021 年 2 月至 2021 年 6 月期间完成了一项在线调查，包括基本人口统计信息（例如，年龄、性别、性别、婚姻状况）和经心理测量验证的抑郁、焦虑、压力、创伤后应激障碍、道德困扰和功能损伤的测量。 进行了描述性统计、相关性分析和组间比较，以刻画并比较RT在 COVID-19 单元和非 COVID-19 单元之间的心理和功能概况。

结果：218名 RT (N = 218) 参与了本研究。 估计的反应率相对较低 (6.2%) 。大约一半的样本对抑郁 (52%)、焦虑 (51%) 和压力 (54%) 的临床相关症状筛查呈阳性，三分之一 (33%)对可能的PTSD筛查呈阳性。 所有症状都与功能损伤呈正相关 (p < .05)。 平均而言，RT 报告在过去一个月中存在 9 天的功能困难。 在 COVID-19 单位工作的 RT相较于不在这些单位的人相比，报告了显著更多的患者相关道德压力 (p < .05)。

结论：在 2021 年 2 月至 2021 年 6 月期间，道德困扰和抑郁、焦虑、压力和 PTSD 症状在加拿大 RT中普遍存在，并且与功能影响相关。尽管因反应率较低需要谨慎解释这些结果，这些结果引起了人们对疫情服务对RT长期影响的关注，并指出需要采取充分的预防、早期侦察和干预措施，以支持加拿大 RT 的心理健康和功能。 在指定的 COVID-19 单位工作的 RT 可能特别受益于与患者层面道德困扰相关的支持。

KEYWORDS:

• Respiratory therapists
• COVID-19
• mental health
• PTSD
• healthcare

PALABRAS CLAVE:

• Terapeutas Respiratorios
• COVID-19
• Salud Mental
• TEPT
• Atención Sanitaria

关键词:

• 呼吸治疗师
• 新冠肺炎
• 心理健康
• PTSD
• 医疗保健

The COVID-19 pandemic has exacerbated workplace stressors and potentially traumatic circumstances in healthcare settings across the globe, placing healthcare professionals (HCPs) at heightened risk for a host of negative psychological outcomes, including depression, anxiety, stress, post-traumatic stress disorder (PTSD) and moral distress (Benfante et al., 2020; Cai et al., 2020; Chew et al., 2020; Donkers et al., 2021; Shanafelt et al., 2020). Research on respiratory therapists’ (RTs’) mental health during the pandemic, however, is lacking, where the majority of investigations have focused on other frontline workers (e.g. physicians and nurses; Di Tella et al., 2020; Kang et al., 2020; Lu et al., 2020; Mosheva et al., 2021; Xiao et al., 2020). RTs are HCPs who specialize in the cardiopulmonary system and are key team members in end-of-life care (Mahan, 2019). As experts in mechanical ventilation, RTs have played a vital role on the frontlines caring for COVID-19 patients (Rajan et al., 2021; Sawadkar & Nayak, 2020). With pre-pandemic evidence suggesting that moral distress, death anxiety and PTSD may be relevant concerns among RTs given high exposure to death and dying in their occupation (Brown-Saltzman et al., 2010; Burr et al., 2020; Collins et al., 2015; Mahan, 2019), there is reason to suspect that RTs, like their colleagues, may be negatively impacted by added stressors and exposures during the COVID-19 pandemic. Moreover, RTs providing care on designated COVID-19 units may be further impacted than their counterparts on non-COVID units given added demands of patient care and risk for contracting COVID-19, as demonstrated among other HCP groups (Di Tella et al., 2020; Said & El-Shafei, 2021; Wozniak et al., 2021). To date, however, RTs in Canada have not exclusively been studied during the COVID-19 pandemic. To provide RTs with adequate, evidence-informed supports and resources necessary to ward against the anticipated negative outcomes associated with their service during the pandemic, there is a need to characterize the psychological and functional profile of this population. Accordingly, the primary purpose of the present study was to characterize the mental health and functioning of RTs who worked during the COVID-19 pandemic in Canada. Secondarily, this study aimed to explore potential differences in mental health and functioning profiles between RTs working on and off COVID-19 units. This investigation will provide a needed baseline from which to monitor RTs mental health and functioning moving forward.

Research on HCPs’ experiences during the pandemic highlights the impact that COVID-19 has had on multiple domains of HCPs’ wellbeing (Billings et al., 2021). HCPs have reported fear for personal and family safety, concerns surrounding patient mortality and shortages in personal protective equipment as key stressors during the pandemic (Cai et al., 2020; Hall, 2020; Shanafelt et al., 2020). Elevated symptoms of depression, anxiety, stress, PTSD and moral distress have been reported by HCPs across the globe and throughout the COVID-19 pandemic (Chew et al., 2020; Di Tella et al., 2020; Donkers et al., 2021; Du et al., 2020; Huang & Zhao, 2020; Kang et al., 2020; Lai et al., 2020; Miljeteig et al., 2021; Vizheh et al., 2020). For example, among 1257 HCPs who worked during the first wave of the pandemic in China, Lai et al. (2020) found that approximately half of participants (mostly nurses and physicians) reported symptoms of depression and anxiety, a third reported symptoms of insomnia and almost three-quarters reported symptoms of distress. In a systemic review and meta-analysis, pooled prevalence rates revealed high endorsement of anxiety (23.2%), depression, 22.8% and insomnia (38.9%) among healthcare workers during the COVID-19 pandemic (Pappa et al., 2020). Finally, within Canada, Wilbiks et al. (2021) reported mild depression severity in a sample of 86 Canadian HCPs (mostly female hospital technicians in New Brunswick), with approximately 75% of participants in need of clinical follow-up.

There is some evidence to suggest that providing care on a designated COVID-19 unit/hospital (Di Tella et al., 2020; Said & El-Shafei, 2021) or working directly with COVID-positive patients in the ICU (Wozniak et al., 2021) is associated with heightened risk for adverse psychological impacts in comparison to HCPs not working in these COVID-designated areas. For example, Di Tella et al. (2020) found that Italian medical doctors and nurses (N = 145) who worked on designated COVID-19 units reported greater levels of depression and PTSD symptoms in early 2020 compared to those providing care on other units. Relatedly, Said and El-Shafei (2021) reported higher stress levels among nurses working at a designated COVID triage centre in Egypt in April 2020 compared to nurses at a general, non-COVID hospital. Nurses at the designated COVID-19 hospital reported stress primarily related to workload and dealing with death and dying (Said & El-Shafei, 2021). In addition, Wozniak et al. (2021) found significant differences between intensive care unit (ICU) HCPs and HCPs on other units where those in the ICU reported poorer well-being, and greater symptoms of anxiety, depression and peritraumatic stress. These findings suggests that HCPs working directly with COVID-19 patients may be in need of additionally mental health supports given their unique location on the forefront of the pandemic. Contrarily, Tiete et al. (2021) reported no significant differences in the mental health (i.e. burnout, insomnia, depression, anxiety and stress) of 1244 Belgium physicians and nurses in the spring of 2020. Given conflicting results, further research is needed to understand the relation between working on COVID-19 unit and elevated risk for adverse outcomes.

At the time of writing, only a handful of studies have exclusively investigated RTs during the COVID-19 pandemic. This research suggests that RTs experience negative psychological outcomes similarly to other HCPs. For example, Miller et al. (2021b) found high levels of burnout among their sample of 3010 RTs. Rajan et al. (2021) found that RTs reported a ‘negative psychological impact’ related to working on the frontlines of the pandemic, with a high level of concern over bringing COVID-19 home to family as a specific factor related to this impact (Rajan et al., 2021). Notably, there are limitations to these RT-specific studies as author-generated questionnaires were used rather than psychometrically validated measures of burnout or negative psychological impacts. Finally, in an investigation of anxiety among HCPs during the pandemic in Saudi Arabia, Alenazi et al. (2020) reported that individuals with the highest levels of anxiety were most likely to be nurses, workers in radiology and RTs. Comparatively, understandings of RTs experiences during the pandemic are poor and an investigation of the role of working on a COVID-19 unit among RTs is absent.

The paucity of literature surrounding RTs’ experiences during COVID-19 is in keeping with the limited studies investigating RTs’ mental health prior to the pandemic. Prior to COVID-19, the majority of RT-exclusive research was not mental-health-related, covering instead topics such as tobacco/smoking cessation training (Gordon & Mahabee-Gittens, 2011; Jordan et al., 2011), critical thinking skills (Goodfellow, 2001) and patient care provided by RTs (Shelledy et al., 2009; Wong et al., 2014). The limited empirical research related to RTs’ mental health prior to the COVID-19 pandemic points to the need to better understand RTs’ experiences given frequent exposure to potentially traumatic events, including providing end-of-life care and in some cases withdrawing life support (Brown-Saltzman et al., 2010; Mahan, 2019; Rocker et al., 2005). Of note, exposure to death ranks as one of the key features required for a DSM-5 conferred diagnosis of PTSD (American Psychiatric Association, 2013) and such exposures have likely only increased during the COVID-19 pandemic with increases in critically ill COVID-19 patients. Indeed, pre-pandemic literature, though scant, demonstrates the relevance of death anxiety (Collins et al., 2015), end-of-life care (Brown-Saltzman et al., 2010; Mahan, 2019), moral distress (Schwenzer & Wang, 2006) and secondary traumatic stress or PTSD (Burr et al., 2020) among RTs. It is probable that these mental health impacts have been exacerbated during the COVID-19 pandemic as workplace stressors have increased (e.g. longer hours, increased patient load, changing policies and procedures, fear of contracting the virus; Billings et al., 2021). Indeed, in a letter to the editor, Sawadkar and Nayak (2020) described how RTs in India spent approximately 4–10 h per day caring for COVID-19 patients alone at the outset of India's third wave, playing a crucial role in bedside management of critically ill patients with high acuity need and high risk for medically invasive, even painful procedures and death. Adverse psychological impacts may be especially pronounced among RTs directly caring for COVID-19 patients on designated COVID-19 units as seen among some other HCP groups (Di Tella et al., 2020; Said & El-Shafei, 2021; Wozniak et al., 2021).

The relative paucity of literature on RTs during the COVID-19 pandemic, and prior data to suggest that that RTs are confronted with widespread stressors and trauma exposure, warrants the characterization of this population during the pandemic period. This knowledge will be central to efforts to provide adequate prevention, early detection and intervention support to RTs in Canada and beyond. Accordingly, the objective of the present study was to characterize the mental health and functioning of Canadian RTs during the COVID-19 pandemic and to compare profiles between those working on and off COVID-19 units. In line with the extant literature on HCPs’ experiences during the pandemic, we hypothesized that RTs would report elevated adverse psychological symptoms and functional impairment and that RTs working on COVID-19 units would report significantly greater symptoms than their counterparts not on these units. To our knowledge, this is the first study to exclusively investigate Canadian RTs' mental health during the COVID-19 pandemic. The results of this investigation will provide a baseline from which future research can build from to better understand RTs’ experiences and needs during the pandemic period.

1. Methods

1.1. Procedure

This study is a part of a broader, multiple-methods investigation of Canadian HCPs’ experiences during the COVID-19 pandemic and was approved by the Hamilton Integrated Research Ethics Board (#12667). Eligibility criteria for the present study required that RTs be at least 18 years of age and have contributed to patient care during the COVID-19 pandemic in Canada. Recruitment involved an email sent from the Canadian Society for Respiratory Therapists (CSRT; representing approximately 4875 RTs in Canada), posters shared from consenting hospitals across Canada, conference presentations and social media (i.e. Facebook and Twitter) advertisements. Interested participants accessed the survey via Research Electronic Data Capture (REDCap) software (Harris et al., 2009, 2019). Participants provided electronic informed consent if they wished to participate. The survey took approximately 30-45 min to complete. Upon completion of the survey, participants had the opportunity to enter into a draw to win a $25.00 (CAD) gift card.

The time of data collection (February to June 2021) roughly corresponds to the second wave of the COVID-19 pandemic in Ontario, Canada, during a declared state of emergency (Elliott, 2022). Approximately 3000 cases of COVID-19 were recorded in Ontario in February, peaking at 9300 in April and dropping to 1500 in June (Canadian Institute for Health Information, 2021; Elliott, 2022). This time period included increasing availability of vaccines (mainly first-dose among healthcare staff and vulnerable individuals) and associated political and social tension, restricted international travel, restricted shopping at non-essential retailers and the introduction of mask mandates (Canadian Institute for Health Information, 2021; Elliott, 2022). Moreover, in interviews that our research group conducted with HCPs at this time, we heard about divided opinions amongst staff, increasing workloads, burnout, strife with management, abuse from patients, fear of contamination (subsiding with vaccinations), anxiety about getting vaccines for family, anger about the way the vaccines were rolled out (e.g. prioritization of some workers over others) and stress related to not knowing if spouses could go to work and if their children would be in school.

1.2. Measures

1.2.1. Demographics

Participants were asked to provide basic sociodemographic (e.g. sex, gender identity, current province/territory of residence; Table 1) and occupational information (e.g. years practicing occupational setting, if they worked on a COVID-19 unit; Table 2).

Table 1. Participant sociodemographic characteristics.

Variable		% (N = 218)
Age
	20–29	24.3%
	30–39	33.9%
	40–49	23.9%
	50+	18.0%
Sex /Gender Identity^a
	Female	84.9%
	Male	14.7%
Sex Orientation	Heterosexual or straight	87.6%
	LGBTQ^c	<5%
Marital Status
	Legally Married, Common Law, or Domestic Partnership	68.8%
	Single, Never Married	23.4%
	Separated, Divorced or Widowed	7.3%
Ethnicity^b
	Caribbean	0.5%
	East Asian	4.6%
	First Nations	3.2%
	Latin American	1.4%
	Middle Eastern	0.9%
	South Asian	1.4%
	Southeast Asian	1.4%
	European	87.6%
	Other	4.6%
Province/Territory
	Ontario	35.3%
	Alberta	19.7%
	British Columbia	17.4%
	Quebec^c	<5%
	Other province and territories^c	<5%
Education	College diploma (community or technical)	39%
	University degree (e.g. Bachelors, Masters, PhD)	50%
	Some higher education^c	<5%
Income
	$100,000 and over	50.5%
	$80,000 – $99,000	19.8%
	$60,000-$79,000	11%
	$40,000-$59,000^c	<5%
	Less than $39,000^c	<5%

^a The entire sample was cis-gendered. Sex and gender were collapsed to remove redundancy.

^b Participants were permitted to select multiple options.

^c The confidential cells are supressed (Brackstone & White, 2002).

Table 2. Participant occupational characteristics.

Variable		% (N = 218)
Occupational Setting^a
	Hospital	87.2%
	Acute	85.8%
	Acute Care Units	82.6%
	Chronic Care Units	33%
	Outpatient Clinics	18.8%
	Anesthesia Assistant	7.3%
	Rehabilitation	5%
	Community	15.6%
	Respiratory equipment vendor/Home O2 vendor	6.9%
	Primary Care/Long Term/Provincial Home Care	8.8%
Years Practiced
	Student^b	<5%
	0–5 Years	25.2%
	6–10 Years	17.4%
	11–15 Years	17.0%
	16–20 Years	12.8%
	21–25 Years	11.5%
	26–30	6.4%
	Over 30 Years	6.0%
Role	Staff therapist	80.3%
	Educator	16.1%
	Senior therapist/leadership	10.1%
	Management/Consultant/Sale	5.5%
	Student^b	<5%
Unit	COVID-19	71.1%
Patient populations^a
	Adult Care	96.8%
	Pediatric	53.7%
	Neonatal	50.5%
Employment Status^a
	Full-Time	68.3%
	Part-Time	19.3%
	Casual	8.3%
	Self-Employed or Unemployed^b	<5%

^a Participants were permitted to select multiple options.

^b The confidential cells are supressed (Brackstone & White, 2002).

1.2.2. Depression, anxiety and stress scale (DASS-21)

The DASS-21 was used to assess the presence and severity of symptoms of depression (i.e. dysphoria, hopelessness, devaluation of life, self-deprecation, lack of interest/involvement, anhedonia and inertia), anxiety (i.e. autonomic arousal, skeletal muscle effects, situational anxiety, subjective experience of anxious affect) and stress (i.e. difficulty relaxing, nervous arousal, being easily upset, agitated, irritable, over-reactive and impatient; Lovibond & Lovibond, 1995). Participants rated their degree of agreement with 21 statements (7 items per subscale) about their experience over the past week on a scale from 0 (Never) to 3 (Always). Scores for each subscale were calculated by summing the 7-items corresponding to the construct and multiplying the sum by 2. Cut-off scores greater of 9, 7 and 14 were used to indicate clinically relevant symptoms of depression, anxiety and stress (Lovibond & Lovibond, 1995).

1.2.3. PTSD checklist for DSM-5 (PCL-5)

The PCL-5 was used to assess the presence and severity of PTSD symptoms (Weathers et al., 2013). Participants rated their degree of agreement with 20 statements about their experience over the past month on a scale ranging from 0 (Not at All) to 4 (Extremely). A total score was calculated by summing the ratings of the 20 items, where greater scores indicate a greater presence and severity of PTSD symptoms. A cut-off score of 33 was used to define participants with a potential diagnosis of PTSD (Weathers et al., 2013).

1.2.4. Measure of moral distress healthcare professional (MMD-HP)

The MMD-HP was used to assess moral distress (Epstein et al., 2019). The MMD-HP measures the frequency and intensity of moral distress experienced by HCPs across three levels: patient (e.g. ‘Feel pressured to order or carry out orders for what I consider to be unnecessary or inappropriate tests and treatments,’ or ‘Witness HCPs giving ‘false hope’ to a patient or family’), team (e.g. ‘Watch patients suffer because of a lack of provider continuity,’ or ‘Feel unsafe/bullied among my own colleagues’) and system (e.g. ‘Be unable to provide optimal care due to pressures from administrators or insurers to reduce costs,’ or ‘Be required to care for more patients than I can safely care for’; Epstein et al., 2019; Petrişor et al., 2021). Participants rated 27 statements of morally distressing events for both frequency and intensity experienced (or would be experienced if not actually experienced) on a scale from 0 (Never/None) to 4 (Very Frequently/Very Distressing). Total scores were calculated by summing the product of the frequency and distress ratings for each item, where greater scores indicate greater distress (Epstein et al., 2019).

1.2.5. World health organization disability assessment scale 2.0 (WHODAS)

The WHODAS was used as a brief assessment of functional impairment (World Health Organization, 2010). The WHODAS is a 7-domain (e.g. cognition, mobility, self-care, getting along, life activities and participation) assessment instrument based on the conceptual framework of the International Classification of Functioning, Disability and Health (ICF). Only core questions and difficulty effect questions are included in this study. Participants rated the level of impairment experienced with 12 functions on a scale ranging from 0 (None) to 4 (Extremely or Cannot Do). Simple scoring was utilized whereby the 12 items were summed. Greater scores indicate greater functional impairment (World Health Organization, 2010). Participants were also asked to report how many days in the past month functional difficulties were present.

1.3. Data preparation

Three-hundred and four (N = 304) survey data entries from RTs were received between February and June 2021. The response rate of approximately 6.2% (estimated based on CSRT recruitment reach), though low, is not surprising given the short time span of data collection during a critical point during the pandemic, as described above. With most participants residing in Ontario, we posit that this response rate reflects the experiences of RTs at this point in time where work and home demands, stress and potentially traumatic exposures resulted in a lack of motivation or ability to participate in survey research.

After removing data entries from RTs who either did not provide consent, consented but did not complete any part of the survey, or consented and completed the demographics but not at least one scale of interest, 218 RTs were included in data analysis. Patterns of missing data were assessed via the naniar package on R software (Tierney et al., 2019) to elucidate differences between RTs who completed the demographics only and dropped out of the study compared to RTs who completed the demographics in addition to at least one scale of interest to this study (see Supplementary Materials). Little's MCAR test (Little, 1988) was used to assess missingness in the final dataset, revealing no pattern of missingness between questionnaires (${\chi }^2$ = 3144, p-value = .955). A pattern of missingness was, however, observed within the MMD-HP survey (${\chi }^2$ = 912, p-value = .0001). The mice package on R software (van Buuren & Groothuis-Oudshoorn, 2011) was used for multiple imputation to handle missing data within the MMD-HP survey (only items that contributed to the total score). The original and imputed datasets were compared before analysis revealing that the summary statistics did not change after imputation.

1.4. Data analysis

Data analysis was conducted on R software (R Core Team, 2021). To characterize RTs’ mental health and functioning, descriptive statistics (i.e. means and standard deviations) were run. To understand the association between psychological and functional impacts, a series of bivariate correlation analyses were conducted between WHODAS total scores and DASS-21, PCL-5 and MMDH-HP scores, respectively. To investigate the impact of working on a designated COVID-19 unit, a series of Wilcoxon tests (due to violation of normality) were conducted on DASS-21, PCL-5, MMD-HP and WHODAS scores between those working and not working on COVID-19 units. We hypothesized that RTs working on designated COVID-19 units would report greater moral distress and symptoms of depression, anxiety, stress, PTSD and functional impairment relative to their colleagues who were not working on these units (Di Tella et al., 2020; Said & El-Shafei, 2021; Wozniak et al., 2021) based on the assumption of greater burden and stressful exposures associated with directly caring for COVID-positive patients. All statistical analyses were conducted using SPSS with a significance level of α = .05.

2. Results

2.1. Sample

Two hundred and eighteen (N = 218) RTs were included in data analysis. Most participants were registered RTs (93.8%; 6.2% graduate, student and recently retired RTs). Almost three quarters (71.1%) of the participants reported working on a designated COVID-19 unit. Sociodemographic information, along with additional occupational information, are provided in Table 1 and Table 2, respectively. Variable levels with 0 responses are not shown; variable levels were collapsed where counts were less than 5 to protect anonymity.

2.2. Characterization

Descriptive statistics and Cronbach's alpha values are reported in Table 3. The average depression, anxiety and stress scores in the sample each corresponded to mild symptom endorsement. According to predefined severity cut-offs (Lovibond & Lovibond, 1995) approximately half of the sample scored outside of the normal range for symptoms of depression (52%), anxiety (51%) and stress (54%). Further, 18%, 20% and 16% of the sample scored in the severe to extremely severe severity levels for depression, anxiety and stress, respectively. One third (33%) of the participants scored at least 33 or greater on the PCL-5, indicative of a potential diagnosis of PTSD. Almost one in five (18%) of the participants scored above the cut-offs for depression, anxiety, stress and PTSD, collectively.

Table 3. Descriptive statistics of psychological and functional symptoms.

Scale	Measure	Cronbach's α	Min-Max	M	SD
DASS-21
	Depression	0.91	0–42	12	9
	Anxiety	0.81	0–40	9	7
	Stress	0.86	0–42	16	9
PCL-5
	PTSD	0.95	0–74	23	16
MMD-HP
	Total	0.93	6–34	138	77
	Patient	0.87	0–96	42	23
	Team	0.89	0–185	57	41
	System	0.81	0–128	39	25
WHODAS
	Functional Impairment	0.89	6–26	11	5

2.3. Associated functional impairment

On average, participants (n = 178) reported functional difficulties present for 9 days (SD = 9.3) in the past 30 days. In the past 30 days, participants (n = 178) were totally unable to carry out their usual activities or work because of a health condition for an average of 1.5 days (SD = 4.1). On average, the sample (n = 178) reported 4.1 days (SD = 6.2) where they had to cut back or reduce usual activities or work due to any health condition (excluding days where they were totally unable to carry out usual responsibilities). WHODAS scores were positively, significantly correlated with all DASS-21 scores, PCL-5 and MMD-HP scores (p's < .001), such that greater endorsement of these psychological symptoms was associated with a greater endorsement of functional impairment (Table 4).

Table 4. Bivariate correlations between negative psychological impacts and functioning.

	Measure	1	2	3	4	5	6	7	8	9
1	WHODAS	–
2	DASS-21 Depression	.536**	–
3	DASS-21 Anxiety	.481**	.601**	–
4	DASS-21 Stress	.468**	.740**	.642**	–
5	PCL-5	.505**	.663**	.648**	.669**	–
6	MMD-HP	.306 **	.369**	.465**	.432**	.570**	–
7	MMD-HP Patient	.248**	.274**	.303**	.349**	.426**	.784 **	–
8	MMD-HP Team	.327**	.365**	.496**	.407**	.573**	.936**	.655**	–
9	MMD-HP System	.259**	.270**	.359**	.358**	.437**	.840**	.482**	.695**	–

**Pearson's Correlation is significant at the p < .001 level (two-tailed).

2.4. COVID-19 units

Depression, anxiety and stress, PTSD and functional impairment scores did not significantly differ between those on and off COVID-19 units (p's > .05). Patient-level moral distress scores significantly differed between RTs working on and off designated COVID-19 units (Figure 1), such that RTs on COVID-19 units (M = 45.7, SD = 22.7) reported significantly greater patient-related moral distress than those not on these units (M = 32.5, SD = 20.2; p < .001).

Figure 1. Moral distress compared between COVID-19 units.

An exploratory comparison of full- and part-time RTs revealed that only PTSD scores significantly different between groups, such that those working full-time (M = 12.3, SD = 9.5) reported elevated symptoms of PTSD compared to those working part-time (M = 9.5, SD = 9; p = 0.038).

3. Discussion

The primary purpose of this study was to characterize the mental health and functioning of RTs during the COVID-19 pandemic in Canada. Canadian RTs reported moral distress and clinically relevant symptoms of depression, anxiety, stress and PTSD associated with functional impairment between February and June of 2021. Although it is difficult to make symptom comparisons between geographical regions given variability in sociocultural contexts, preparedness of healthcare systems and regional COVID-positive counts, the present results appear consistent with reports from other HCPs (Demartini et al., 2020; Di Tella et al., 2020; Hennein et al., 2021; Latimer, 2021; Lenzo et al., 2021; Pappa et al., 2020; Plouffe et al., 2021; Wilbiks et al., 2021). For example, Chew et al. (2020) reported that 10.6%, 15.7% and 5.2% of 906 HCPs in Singapore and India screened positively for depression, anxiety and stress symptoms, respectively, according to the DASS-21 (Lovibond & Lovibond, 1995). Relatedly, in a study of 1092 HCPs in the United States, 15.6% of the 170 HCPs surveyed screened positively for probable Generalized Anxiety Disorder (as per the GAD-7), 13.9% screened positively for major depression and 23% screened positively for PTSD (as per the PHQ-9; Hennein et al., 2021). Di Tella et al. (2020) reported 26.2% of their sample of Italian medical doctors and nurses met the 33-point cut-off of the PCL-5. Interestingly, 3.8% of the 371 HCPs in a study in China reported symptom scores consistent with a likely diagnosis of PTSD on the PCL-5 (Yin et al., 2020). Reports of PTSD symptoms may be relatively low in Yin et al.’s (2020) sample as they intentionally surveyed HCPs immediately after the COVID-19 outbreak and research from the Severe Acute Respiratory Syndrome outbreak in the early 2000s demonstrates that HCPs were most impacted by the events once the crisis was over (Billings et al., 2021). While there are no norms for the MMD-HP, moral distress scores reported by our sample of RTs are comparable to that of hospital nurses on COVID-19 units in the United States (Latimer, 2021) and Canadian HCPs (Plouffe et al., 2021) during the pandemic period.

Heightened endorsement moral distress and symptoms of depression, anxiety, stress and PTSD were significantly associated with a higher level of functional impairment among RTs in the present study. The present findings are consistent with an investigation of hospital-based HCPs in Nepal, where depression and anxiety scores correlated positively with functional impairment (Shrestha et al., 2021) along with reports of an association between negative psychological impacts and insomnia among HCPs during the pandemic (Lai et al., 2020; Pappa et al., 2020). Overall, the present characterization of psychological and functional profiles among Canadian RTs appear consistent with reports from other HCPs during the COVID-19 pandemic.

The results of the present study suggest the need for adequate mental health supports for Canadian RTs. Notably, RTs are excluded from presumptive legislation surrounding PTSD in some Canadian provinces. In Canada's largest province, Ontario, Bill 163, ‘Supporting Ontario's First Responders Act (PTSD)’ led to a section amendment of the 1997 Workplace Safety Insurance Act (WSIA) in 2018 to include a statutory presumption that employment is assumed to be the cause of PTSD unless there is evidence to indicate otherwise among ‘other designated workers’ in addition to first responders (WSIB, 2018). This policy allows eligible individuals to access benefits and treatment for PTSD and was amended in 2018 to include nurses who provide direct patient care (WSIB, 2018). Registered RTs, however, are not included in this legislation. Although a work-related trauma was not explicitly referenced, our findings suggest that 1 in 3 RTs may experience elevated symptoms of PTSD and benefit from supports and treatments. Moving forward, research on PTSD among RTs specifically related to work events is needed to further explore the consideration of RTs as designated workers for presumptive legislation. Importantly, the WSIA's presumptive legislation in Ontario only considers PTSD and does not acknowledge other deleterious impacts associated with healthcare service, such as depression, anxiety, stress and moral distress, as demonstrated in this study. Here, it is critical to ensure that RTs, alongside their healthcare colleagues, receive adequate mental health supports, including targeted prevention, early intervention and treatment. It will be critical for provincial and federal governments to ensure RTs and other HCPs are supported during and well beyond the COVID-19 pandemic to ensure the continuity of healthcare in our country.

The secondary aim of this study was to explore potential differences in psychological and functional outcomes between RTs working on and off COVID-19 units. RTs in our study working on COVID-19 units reported higher levels of patient-related moral distress (e.g. following family's insistence to continue aggressive treatment despite believing it to be futile and prolong patient suffering; Epstein et al., 2019) than those not working on COVID-19 units. This finding is consistent with reports of high rates of exposure to death and dying and the involvement of RTs in invasive care procedures (at times perceived as futile) during the pandemic (Ritchie et al., Under Review). Our data were collected at a time when vaccines were beginning to be rolled out in Ontario and the best course of action for treating COVID-19 patients was not clear. Here, RTs on COVID-19 units may have been exposed to more frequent instances of patient-level moral distress (e.g. contributing to futile care, providing care that they do not believe is in the patient's best interest) given uncertainty about treatment outcomes. Further, our exploratory analysis of full- and part-time employees revealed that RTs working full-time may be at risk for PTSD symptoms to a greater extent than those working part-time, perhaps due to greater frequency to traumatic exposures. In interviews our research group conducted with Canadian HCPs in parallel to the present study's data collection, RTs described novel patient-related distress when family members made treatment decisions for patients over the phone, without being in the hospital seeing the invasive and painful nature of the potentially life-saving procedures. Here, adequate supports that address patient-level moral distress must be established and made readily available.

Aside from moral distress, mental health and functioning reports did not differ between RTs working on and off COVID-19 units in the present study. Though contrary to our hypothesis, this result adds to the conflicting literature surrounding the added burden of working on a COVID-19 unit. in an investigation of burnout and resilience among RTs during the pandemic, Miller et al. (2021a) reported that, despite 73% of the sample (N = 221) reporting burnout, the prevalence of burnout did not differ significantly between those working and not working in COVID-19 hotspots. Further, in an exploration of the socio-ecological predictors of mental health outcomes among American HCPs during the pandemic, working directly on the frontlines did not affect the odds of negative outcomes, such as depression, anxiety or PTSD (Hennein et al., 2021). Notably, across our sample of RTs, self-reported moral distress, depression, anxiety, stress, PTSD and functional impairment were relatively high. It is not clear if COVID-19 units across Canada were implemented consistently (e.g. designated wards) or if existing units, such as the ICU, were responsible for taking COVID-positive patients. As such, it is possible that not working in a designated COVID-19 unit does not bring less risk and exposure to distressing events, especially at our point of data collection in a declared state of emergency. We posit that a lack of significant differences between RTs on and off COVID-19 units may be related to inconsistencies in the definition or creation of COVID-19 units across the country. We can also not rule out that the symptoms reported on the survey may be related to personal life traumas or pre-COVID events, limiting conclusions of the comparisons between RTs on and off COVID-19 units. Future research should account for work-related, COVID-19 specific index traumas to better understand differences among RTs working in different areas.

Although the psychological and functional profiles presented in this study cannot be causally linked to events during the COVID-19 pandemic, the pandemic context has presented an opportunity to consider RTs’ experiences, which has previously been overlooked in comparison to other HCPs. With limited knowledge of psychological and functional outcomes among RTs prior to and during the COVID-19 pandemic, two important conclusions can be made from our findings. First, RTs experience moral distress, depression, anxiety, stress, PTSD and functional impair and are in need adequate supports. Second, research is urgently needed to understand the risk and protective factors for adverse outcomes among Canadian RTs during and beyond the current pandemic period.

4. Limitations

Several limitations should be considered in the interpretation of the results. An inherent limitation to this study is its cross-sectional design. The results of the present study provide a snapshot of RTs’ mental health and functioning early 2021 and must be interpreted in this context. Without comprehensive knowledge on RTs’ mental health at other time points in the pandemic and before the pandemic, the contextualization of these findings is limited. Follow-up studies with Canadian RTs are needed to understand the long-term mental health and functional impacts of COVID-19 healthcare service in this profession. Additionally, the present study did not control for history of mental illness and the PCL-5 was used without reference to a specific Criterion A trauma. As such, it must not be assumed that scores indicative of potential PTSD are linked solely to events that occurred during the COVID-19 pandemic. As such, it is not clear to what extent the symptoms of depression, anxiety, stress and PTSD reported by our sample of RTs were present prior to the onset of the pandemic. Finally, the present study is limited by its response rate and biased sample (e.g. majority female RTs residing in Ontario). The present findings may thus not be generalizable to the population of Canadian RTs. Responders may have been more likely to have elevated moral distress and negative psychological and functional outcomes. Replication of the present study is warranted with a more representative sample of Canadian RTs.

5. Conclusion

The present study illustrates that symptoms of depression, anxiety, stress, PTSD and moral distress were prevalent among RTs in Canada between February and June 2021 and were associated with functional impairment. As the pandemic persists, RTs will continue to face stressful and potentially traumatic circumstances, thus having the potential to further elevate existing symptoms and associated functional impacts. Here, it will be imperative to ensure that RTs, alongside other HCPs, have access to prevention, early intervention and long-term treatments aimed at stabilizing the mental health and well-being of this critical healthcare workforce that has given vital service at enormous personal cost during the COVID-19 pandemic.

Acknowledgements

The authors would like to acknowledge the heroic efforts of RTs across Canada as they serve on the frontlines of the COVID-19 pandemic, including Fatima Foster and Kelley Hassall who contributed greatly to this study. In addition, we would like to thank the Canadian Society for Respiratory Therapists for their willingness and cooperation in recruitment.

Data availability statement

The data used in this study come from the McKinnon Trauma and Recovery Research Unit at McMaster University. All interested researchers may apply for access to these data through online application subject to review by the Data Access Committee, ethics approval, and signing of a data sharing agreement. Data are provided only once a data sharing agreement is in place between McMaster University (the custodian of the data) and the researchers’ institution. For more information about data access please contact https://www.thetraumaandrecoverylab.com/contact.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This study was supported by a contract to M.C.M. and R.L. from the Veterans Affairs Canada-funded Atlas Institute for Veterans and Families, from an IDEAS grant to R.L. and M.C.M. awarded by National Defence, and by a donation to Homewood Research Institute from Homewood Health Inc. M. C.M. is supported as the Homewood Chair in Mental Health and Trauma at McMaster University. A.M. is the Executive Vice President at Homewood Health Inc. H.S. & C.O’C. are service providers at Homewood Health Centre. F.F. & S.R. are employed at the Atlas Institute for Veterans and Families.