Fatima Foster, RRT, CRE

Nancy Garvey, RRT, MAppSc

Tania Del Rizzo, BSc RRT MBA (c)

The American Psychiatric Association (APA) defines Post Traumatic Stress Disorder (PTSD) as the exposure to “actual or threatened death, serious injury or sexual violation.” (1)

Daniel Sundahl DanSunPhotos.com Image used with permission

“Our jobs are a recipe for emotional disaster”

Survey Respondent, April 2019


In 2016, Bill 163 “Supporting Ontario’s First Responder’s Act (PTSD)” amended the Workplace Safety and Insurance Act, 1997 (WSIA) to create a statutory presumption that:

“If a first responder or other designated worker is diagnosed with post traumatic stress disorder (PTSD) and meets specific employment and diagnostic criteria, the first responder or other designated worker’s PTSD is presumed to have arisen out of and in the course of his or her employment, unless the contrary is shown”. (2)

Bill 163 allows for facilitation of access to insurance benefits and treatment for such workers. The diagnosis must be provided by a Psychiatrist or Psychologist in accordance with the APA Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)(1).  RRTs are not among the list of workers covered by Bill 163. The Respiratory Therapy Society of Ontario (RTSO)  is communicating with the Ministry of Labour, advocating for RRT inclusion in future legislation.


Upon review of current literature, a significant gap was noted with respect to RRTs and the incidence of Occupational Stress Injury (OSI) and PTSD.  In effort to gain a better understanding of the level of risk for PTSD and OSI among RRTs secondary to workplace exposures, the RTSO conducted a survey in the Spring of 2019.  The aim of this survey was to assess the prevalence of OSI/PTSD among RRTs and Student Respiratory Therapists (SRTs) working in the province of Ontario.

The survey was created using an APA validated psychometric tool.  This questionnaire is a “self-report measure that assesses the presence and severity of PTSD symptoms that screens for symptom endorsement within the past 30 days.” (3).  This tool is not a stand-alone diagnostic tool.


146 participants: 91% working as RRTs; 6% were SRTs; 3% were currently not working.

Work experience: Less than 5 years 21%; 6-10 yrs 11%; 11-19 yrs  30%;  20+ yrs  32%

Results are scored in two ways. The first is based on total score, and the second is based on “behaviour clustering”. Separately, three key questions of interest suggest respondents need further assessment.

Meeting criteria suggestive of PTSD Symptoms

Based on total score: 30.14%
Based on behaviour cluster only:  33.05%
Combining both methods of scoring:  33.56%
3 key questions: 74.66%
Combining the total score, cluster, and key questions:  25.34%

Several respondents qualified based on total score even though they did not answer every question. This affected their clustered category scores as some respondents avoided answering some questions.

Comments included: concerns regarding exposure to significantly traumatic events, inappropriate staffing and workload creating high pressure situations, moral distress, not having appropriate equipment, a lack of support, and many others. One respondent was denied recovery time while nursing and paramedics were given several months to address symptoms. There were comments made that had we asked to reflect on the past year, they would have answered differently, potentially driving the scores higher.


Daniel Sundahl DanSunPhotos.com Image used with permission

RRTs have a reputation of being the “paramedics” of the hospital.  As specialists of the cardiopulmonary system, RRTs are constantly required to manage competing high-acuity situations in addition to a standard patient caseload.  Within one shift, a therapist can respond to various “STAT” and “code” situations across all age demographics. Often with little or no time to decompress before moving on to the next call while being expected to stay focused and ready to respond. Therapists support various areas in one shift significantly increasing the degree of exposure to “witnessing and/or experiencing actual or threatened death, serious injury or violence” (1). We are continually exposed throughout our careers since adding or withdrawing life support is core to our work.

Exposure to violence or physical injury is also real: direct violence from impaired patients (whether drug related, mental health or cognition), violent visitors, terror situations such as bomb threats or persons with guns, mass casualties, and potential for hostage situations. Pathogen exposure during pandemics such as SARS, treating respiratory patients before identification to find out later an exposure to a harmful pathogen may have occurred.

Exposure is not limited to hospitals. Therapists working in the community must care for patients in neighbourhoods with high crime rates, they enter private homes exposing themselves to potentially dangerous scenarios, nursing homes and even when transporting patients – whether ground or air. These professionals are often working alone with no backup or support at the ready if needed.  These therapists also develop long-standing relationships with patients and experience, not only death, but grief as well.

In all of these situations, RRTs are often overlooked for debriefings, other psychological supports and resources for treatment of work-related OSI which can result in PTSD.

Historically, RRTs have been “groomed” to have a “strong spine, take a deep breath, don’t let them see your emotions and move on”.  Stigma does exist and fear of being perceived weak in a profession that requires a high degree of resilience and strength is real.  The ever-increasing technology and improvements in healthcare protocols, means sicker patients added to increased workloads.  The RRT role has evolved from technician to clinician – therapists who consult, advocate and offer treatment plans for the patients entrusted to our care.  With this, the profession has not kept up at ensuring we take care of our mental wellness in these high stress environments.

Too much trauma, whether large isolated or small repeated ones, numbs emotions until you no longer feel. Author and artist, Daniel Sundahl (Paramedic) states “You can lead a horse to water… but what if he doesn’t know he’s thirsty because his capacity to feel thirst has changed?” Is it conceivable that therapists are keeping silent knowingly because of stigma? Is it possible therapists are completely unaware there is help for what they are feeling OR just numb to feeling at all?

Burnout, disengagement and apathy, are all terms of language common in break rooms. These are symptoms of something bigger.  We routinely advise caregivers to take care of themselves so they can provide better care for their loved ones. As professional caregivers RRTs are not immune to this.  Self-care whether physical or mental is not a privilege, it is a necessity because healthy caregivers make better caregivers.


The survey results demonstrate OSI/PTSD is a relevant issue for the profession.  At best, we are comparable to other professions such as nursing and paramedics, who do have inclusion in Bill 163.  RTSO will, therefore, continue working towards inclusion at the next Bill amendment.

The RTSO is collaborating with the College of Respiratory Therapists of Ontario (CRTO) and a University to study the occupational risk for PTSD in all practicing, licensed Ontario RRTs.  It will be critical to have participation from all Ontario RRTs. Collaboration with our schools will also be critical as we want to measure the risk in current 3rd (clinical) year students.  Together with the CRTO, a recommendation will be put forward to include mental health preparedness in the National Competency Framework for RT as a requirement for entry to practice.

In addition to advocating at the Ministry Level, the RTSO is continually exploring resources to assist RTSO members with recognizing and managing the signs and symptoms of Occupational Stress Injury and Post-Traumatic Stress Disorder.  Resources are available on the RTSO website under the Resources tab (https://www.rtso.ca/osi-ptsd/). A poster is being drafted for submission for the CSRT conference and we are developing a webinar to disseminate the points discussed in this article in greater detail.

It is time to bring mental wellness to the forefront. Raise awareness, prevention, and facilitate treatment.

Thank you to everyone who participated in the original survey.  Without your help we would not have been able to take this initiative forward.

The RTSO provides specialty representation for Ontario RTs based on Ontario needs. RRTs practicing in Ontario, providing relevant support and advocating for you. The strength will be in the numbers – join or renew today.


The authors would like to thank Hassall,K, RRT, MEd, FCSRT and Jones, S, RRT FCSRT LSSBB for their support and assistance in providing proof-reading and editing skills for this writing.  We would also like to recognize the past contributions of the PTSD Working Group. We must also thank artist and authorDaniel Sundahl of www.DanSunphotos.com  for graciously allowing us to use his photo art.


(1) American Psychiatric Association. (2013). Posttraumatic Stress Disorder.
Retrieved from: http://www.dsm5.org/Documents/PTSD%20Fact%20Sheet.pdf

(2) WSIB Ontario Operational Policy “Posttraumatic Stress Disorder in First Responders and Other Designated Workers”
September 2018 Update https://www.wsib.ca/en/operational-policy-manual/posttraumatic-stress-disorder-first-responders-and-other-designated

(3) PCL-5 https://www.ptsd.va.gov/professional/assessment/documents/using-PCL5.pdf

Please direct inquiries or suggestions regarding this initiative to Fatima Foster, RRT, CRE St. Joseph’s Healthcare Hamilton, T8117-50 Charlton Ave E, Hamilton ON, L8N 4A6  ffoster@stjosham.on.ca

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