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OCR for page 159
5
The Role of Eclucat;ional Policy in
Influencing Supply
TF NO STEPS ARE TAKEN to bolster the future supply of personnel in
1 several allied health fields, health care institutions will be hampered in
meeting the public's demand for services. These steps will require coor-
dinated actions by educators and employers, encouraged by modest but
strategic federal, state, and private programs. Many of the recommenda-
tions in this and the following chapter are directed toward educators, em-
ployers, and the allied health professions themselves. Although the committee
believes its recommendations will be beneficial to those parties, it looks to
public intervention to stimulate and amplify their implementation.
This chapter is divided into three sections. The first deals with policies
to influence the decisions of persons choosing careers. The second discusses
the role of educational institutions in maintaining or expanding enroll-
ments. The third addresses concerns about the preparedness of the future
allied health work force.
THE ALLIED HEALTH STUDENT APPLICANT POOL
For most fields the available trend data on allied health programs and
graduations do not signal an imminent crisis requiring dramatic public
intervention. Looking to the future, however, the committee is deeply
concerned that the weak infrastructure of allied health education may
compromise the system's ability to maintain enrollments, let alone increase
the supply of personnel in fields in which employment demand is high. A
key to the viability of allied health education is its capacity to maintain its
159
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160
ALLIED HEALTH SERVICES
share of qualified students from the traditional college-age applicant pool
while tapping into less traditional pools of students, particularly minority
students.
For a number of years, allied health deans and program directors have
expressed concern about the declining number of applicants to their pro-
grams and the implications of this decline for the academic quality of the
student body. Reportedly, spaces in many programs are going unfilled,
and this lack of student interest is jeopardizing the survival of academic
programs. Comprehensive data collection concerning applicants to allied
health programs is not currently being done. However, CAHEA annually
surveys program directors in several allied health fields about whether
applications to their programs are increasing, decreasing, or remaining
1 1 1
stable. In its 1987 survey, program directors in 13 of 22 fields reported
decreases in the number of applicants (CAHEA, 19881.
The clinical laboratory fields in particular were experiencing distress.
For example, almost two-thirds of the medical technology program direc-
tors reported decreases in applicants in 1987. Of the 116 programs that
voluntarily withdrew from CAHEA accreditation between 1983 and 1987,
36 attributed their decisions to a declining applicant pool.
Unpublished survey data from the American Society of Allied Health
Professions suggest that only physical therapy has a large applicant pool
to draw upon, with about five applicants per academic space. Other fields
such as dietetics, medical technology, radiologic technology, and medical
record administration average only slightly more applicants than needed
to fill their classes.
A recent (1987) survey of the College of Health Deans, an organization
composed of allied health administrative units in 20 universities without
medical centers from 17 states, revealed that only 3 out of 17 respondents
reported that all of their professional classes were filled. Although clinical
laboratory programs were those most frequently cited as having excess
capacity, many other fields also reported unfilled classes.
Although the current level of applications worries academic administra-
tors, they are even more concerned about the future because of the pre-
dicted decline in the college-age cohort of the population, an issue discussed
in Chapter 3. This decrease suggests that in the future there may be even
greater competition among schools for technically oriented students than
there is today. Information from annual surveys of college freshmen on
changing occupational preferences shows a slow but steady decline (from
3.3 percent to 1.1 percent) between 1977 and 1985 in women's interest in
careers in laboratory technology and dental hygiene, dietetics and home
economy (from 1.1 percent to 0.4 percent), and health technology (from
3.7 percent to 1.8 percent). Women's interest in the category headed "ther-
apist" has remained relatively stable over the period; men have exhibited
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EDUCATIONAL POLICY'S ROLE IN INFLUENCING SUPPLY
161
gradually increasing interest over the years (Cooperative Institutional Re-
search Program, 1987~.
Academic administrators are also concerned that, with fewer applicants
from which to select, the quality of students will decline. Thus far, except
for the areas of clinical laboratory sciences and radiography, no decrease
in student quality seems to be evident to program directors, as measured
by the CAHEA survey. More objective evidence for assessing quality changes,
such as grade point averages or test scores during students' first year of
professional course work, is not routinely collected. The American College
Testing (ACT) Program test scores of high school juniors who intend to
mayor In allied health fields do not bear out a shift in quality (Table 5-1),
although the downward trend in dental hygiene may deserve some atten-
tion.
Not every allied health field has experienced an applicant deficit, as
evidenced by what has occurred in the physical therapy field. Despite a
rapid increase in the establishment of physical therapy programs, most
directors report that they still have more than an adequate supply of ap-
plicants and can limit enrollment to those with high grade point averages.
It is not unusual to find physical therapy programs with application-to-
acceptance ratios of 10 to 1. In addition to physical therapy a few of the
~ .
_ . 1 ~ '
newer professions sucn as perfusion and diagnostic medical sonography
are also in great demand, with about 60 percent of program directors
experiencing application increases (CAHEA, 19881.
Because they are fewer in number and smaller in size,
it is difficult to
equate the success of programs like perfusion, for example, with programs
in physical therapy. Nonetheless, characteristics of perfusion programs are
worth noting. Some of the students are often drawn from other disciplines
TABLE 5-1 ACT Test Score Means for Students Specifying Academic
Majors
ACT Composite Test Scores
Academic Major
Percentage of
Change,
1980-1981 1983-1984 1985-1986 1986-1987 1980-1987
Dental assisting 13.3 13.2 13.5 13.3 0
Dental hygiene 16.1 15.5 15.4 15.0 - 1.1
Medical technology 18.2 18.2 18.6 18.2 0
Occupational therapy 16.7 16.6 17.5 17.5 -0.8
Physical therapy 17.8 18.0 18.8 18.5 1.0
Radiological technology 14.4 15.4 15.9 15.8 1.4
Nursing (RN) 16.2 15.9 16.3 15.9 -0.3
Pharmacy 20.0 19.8 20.4 20.1 0.1
Overall college-bound
population 18.5 18.2 18.3 18.7 1.1
SOURCE: Unpublished data from the American College Testing Program.
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162
ALLIED HEALTH SERVICES
(respiratory therapy and critical care nursing, for example) and therefore
have had some exposure to the new field. Employment opportunities abound,
and not all graduating students enter the clinical field because other at-
tractive opportunities are often available. For example, manufacturers and
biomedical engineering laboratories hire some perfusionists; some enter
medical school and others choose teaching. Although perfusion is a high-
stress profession, it is also a relatively well-paid one. The average salary for
a graduating student is $35,000, but highly qualified and experienced
perfusionists may earn close to $100,000. Although they are not known to
the general public, perfusionists are respected in the allied health world
for their success in garnering earnings and their relative independence
(Brown, 19871.
Why do some programs fare better than others in attracting students?
Some reasons come readily to mind. Undoubtedly, the positive economic
outlook for physical therapy rising salaries, growing autonomy, and high
levels of demand for graduates has affected student thinking. Also, in
comparison with such fields as clinical laboratory technology, physical ther-
apy has greater public visibility and more patient contact.
There may be lessons to be learned from schools of social work, which
have succeeded in increasing their applicant pool from 2 applicants per
opening in 1983 to 3.5 applicants per opening today. Social work is con-
sidered to be closely related to (if not directly under the umbrella of) allied
health. Deans of schools of social work attribute the revitalization of interest
in social work careers to a wide variety of social and economic factors,
including the following:
· optimism about the status of social welfare programs in the post-
Reagan era;
· a surge (although not as dramatic as during the 1960s) in the sense
of social commitment among students;
· occupational outlook projections of higher-than-average growth in de-
mand;
· growth of independent practices and third-party payment;
· adoption by some schools of "business-like" approaches to marketing
and recruiting students; and
· salaries that, while not high initially, averaged about $27,800 in 1986-
1987 (Health Professions Report, 19881.
Visibility and comparatively high pay are elements that contribute to the
attractiveness of a field, and these in turn contribute to the success of schools
in obtaining high application rates. Some fields that are viewed by the allied
health community as being attractive and offering well-paying careers none-
theless do poorly in attracting students because they lack visibility. For
example, occupational therapy shares many of the attributes of physical
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EDUCATIONAL POLICY'S ROLE IN INFLUENCING SUPPLY
163
therapy, but its role in health care is not well known. Medical record
administrators can earn over $50,000 per year and advance to hospital
executive positions, but that field, too, is little known to the public.
Some allied health occupations (e.g., medical technology and radiogra-
phy) do not offer particularly good economic rewards but seek to attract
scientifically oriented students to work in potentially hazardous environ-
ments in which they may be exposed to contaminated body fluids or ra-
diation. Moreover, although laboratory and radiography employment
prospects may be rebounding after PPS cutbacks, the atmosphere of job
insecurity may still be influencing students' perceptions about those fields.
Student Recruitment
Many of the social factors that influence career choice are beyond the
control of health care institutions or academics. The economic attractiveness
of careers and their work environments are largely in the hands of em-
ployers (a topic that is addressed in Chapter 6) and those who make reim-
bursement decisions.
There are a number of techniques that schools have used to attract
students. Among them are the use of professional recruiters, giving faculty
release time to visit high school counselors and students, the distribution
of videotapes about the school, and undertaking national promotions (e.g.,
Lab Week, fostered by the American Society for Medical Technology).
Unfortunately, such efforts to influence students' career choices toward an
allied health field have not been systematically documented or evaluated.
Many psychological and social theories of career choice and career de-
velopment have emerged over the years to explain how individual career
development unfolds over the life span. These theories suggest the diffi-
culties of intervening in a complex process. Career development is shaped
by an interplay of psychological attributes, knowledge about training re-
quirements, educational and occupational opportunities, genetic and child-
hood influences, evolving personalities, and patterns of traits that individuals
express cognitively and psychologically in their choice behavior. Research
related to career development finds that, like all human behavior, it is a
highly complex process and is part of the total fabric of personality (Lent
et al., 1986~.
Most of the existing approaches to career development are based on
limited samples of relatively privileged persons. The samples typically have
been composed of men rather than of women, and the approaches to
career development in general have been addressed to persons in the
middle range of socioeconomic characteristics. Consequently, these ap-
proaches tend to emphasize the continuous and progressive aspects of
career development that are possible primarily for persons who are rela-
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164
ALLIED HEALTH SERVICES
tively free to choose any career and for whom both psychological and
economic resources are available. Such criteria do not necessarily fit women
and minorities (Fitzgerald and Crites, 1980~.
The impact of several variables (including parental socioeconomic status
ESES1, academic achievement, and sex) on both selection and persistence
in career choice has been investigated in an attempt to determine who is
being recruited into professions in general. These variables were used to
analyze responses from the U.S. Department of Education's 1972 National
Longitudinal Study and recent follow-up surveys. Results showed that chil-
dren of high-SES parents were four times more likely than children of
low-SES parents to engage in professional study at the baccalaureate level
and six times more likely to participate in or complete professional training
at the graduate level. The SES level of parents did not have as much effect
on the aspirations of children, however; children of high-SES families were
only twice as likely to wish for a professional career as their contemporaries
from low-SES families. Researchers have concluded that the idea of sub-
stantial social and economic mobility in the United States has been exag-
gerated and is difficult to achieve. Only 2 percent of young people from
low-SES homes were in graduate-level professional programs 7 years after
high school, despite large federal student aid programs and numerous
corporate and foundation programs to stimulate opportunities in the
professions (Miller, 19861.
In general, the career choice literature does not provide detailed guid-
ance for recruitment efforts. Yet several implications for specific planning
. .
Interventions can he seen.
· The concepts that people are only economic animals and that work is
chosen only for the livelihood it offers are too simplistic. Work also provides
a means for meeting the needs of social interaction, dignity, self-esteem,
self-identification, and other forms of psychological gratification.
· Personal, educational, occupational, or career maturation comprises
complex learning processes that begin in early childhood and continue
.
throughout life.
· Choice occurs not at a point in time but in relation to antecedent
experiences and future alternatives.
· Career information must include not only objective factors such as
earning possibilities, training requirements, and numbers of positions avail-
able but the social and psychological aspects of careers as well.
· Career choice is frequently a compromise between the attractiveness
of an alternative, the likelihood of attaining it, and the costs of attaining it
(Herr and Cramer, 1984~.
In sum, the literature on career choice is suggestive rather than pre-
scriptive for recruitment tactics. Long-range efforts must take into account
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EDUCATIONAL POLICY'S ROLE IN INFLUENCING SUPPLY
165
the need to make individuals aware of careers at an early stage. If women
continue to predominate in many of the allied health fields, we must learn
more about the dynamics of their career choice behavior.
Successful student recruitment efforts generally depend on positive mar-
ket signals emanating from the world of work. In the next chapter the
committee discusses actions that employers must take to improve the cir-
cumstances of allied health personnel in work settings in which the per-
ceptions of unsatisfactory careers accurately reflect reality. However, to the
extent that potential students incorrectly believe that a career is unsatis-
factory, the problem may require improved communication. Local con-
sortia of professional association members, employer representatives, and
educators should be formed to devise recruitment strategies based on com-
munity needs, characteristics, and resources. These consortia should target
nontraditional audiences, tailoring the message and method of commu-
nication to each. A marketing plan geared to attracting newly unemployed
workers from a local industry, for example, should not be the same as one
that seeks to attract displaced homemakers or handicapped high school
students.
The demand for technically oriented people is growing in many sectors
of the economy. One study predicts that
The jobs that will be created between 1987 and 2000 will be substantially different
from those in existence today. A number of jobs in the least-skilled job classes will
disappear, while high-skilled professions will grow rapidly. Overall the skill mix of
the economy will be moving rapidly upscale, with most new jobs demanding more
education and higher levels of language, math and reasoning skills. (Hudson In-
stitute, 1987)
More specifically, more than half of the new jobs created between 1984
and the year 2000 will need some high school education. Nearly a third
will require a college degree; today, only 22 percent of occupations require
a college degree (Hudson Institute, 19871. The health care industry is not
the only industry that is beginning to understand that one of the challenges
of the future will be to position themselves favorably in the competition
for the supply of educated, technically able workers. For some allied health
fields, there are already indications that potential practitioners are being
lost to other professions. It is clear that educators, employers, and the
professional associations must act if they want to maintain or increase their
share of the work force. The process of change is necessarily interactive.
If employers succeed in making allied health employment more attractive,
educational institutions will experience increases in the size and quality of
the applicant pool. Yet, circularly, the extent to which employers are able
to alter the conditions of employment depends in part on the education
that workers have received.
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166
ALLIED HEALTH SERVICES
The committee recommends that educational institutions, in close col-
laboration with employers and professional associations, organize for the
recruitment of students. They should seek persons from less traditional
applicant pools minorities, older students, career changers, those al-
ready employed in health care, men (for fields in which they are under-
represented), and individuals with handicapping conditions.
Minorities
Two major societal problems underlie concerns about minority partici-
pation in allied health careers, leading the committee to devote special
attention to this issue.
First, as several recent public policy documents have stated, minority
populations in the United States have comparatively poor health statuses
and use fewer health care resources relative to their needs (U.S. Department
of Health and Human Services, 1985~. Although a causal relationship be-
tween the supply of minority practitioners and improved minority health
care and health status is difficult to validate, minority health care workers
are more likely to work in geographic areas and at delivery sites that serve
minority and other disadvantaged patients. Officials interviewed at three
inner-city hospitals, including two public hospitals, said that minorities are
at least 50 percent of their total allied health work force. Moreover, data
extracted from facility records show that this pattern is relatively uniform
across such different fields as clinical laboratory technology, physical and
occupational therapy, dietetics, and medical records (Booker, 1987~.
Second, there is a lack of parity throughout American society between
whites and nonwhites in professional positions. To the extent that the allied
health fields can provide improved career opportunities for minorities, a
double benefit will occur: education programs will be better able to maintain
enrollments, and personnel shortages may be alleviated in underserved
geographic areas and institutions that serve poor minority populations.
To supplement a review of the literature on the representation of mi-
norities in allied health fields, the committee conducted extensive interviews
with deans and faculty of 10 schools active in the National Society for Allied
Health (an organization committed to increasing the participation of black
and other disadvantaged minorities in allied health practice, education, and
administration). Other schools were added in an attempt to broaden the
information base. A school known to have a predominantly Hispanic stu-
dent body and structured activities to recruit Hispanics to allied health
programs was selected, as was a school in an area with a large American
Indian population. Finally, a nonminority school in the South was added
because it boasts the largest number of allied health programs on a single
campus and has been actively involved in minority allied health recruitment
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EDUCATIONAL POLICY'S ROLE IN INFLUENCING SUPPLY
167
and retention efforts for some time (Booker, 1987~. Pertinent information
from these interviews will be referred to in our discussion of minorities in
allied health education.
Table 5-2 presents estimates of racial and ethnic characteristics of allied
health personnel based on the results of an analysis of the 1980 census.
The data show that minority personnel are underrepresented, relative to
their representation in the U.S. labor force, in the 10 allied health fields
studied by the committee and particularly in the fields requiring higher
education.
CAHEA reports that over the entire range of the fields it accredits the
racial mix of students enrolled during 1986-1987 generally mirrored the
racial mix of the U.S. population. Blacks represented 11 percent of total
enrollments, Hispanics, 6 percent, and American Indians, about 2 percent.
What these data fail to reveal is that minorities are overrepresented in fields
requiring less education and underrepresented in fields requiring more
education. The extent to which minorities have a higher departure rate
from programs and careers is not known. Several professional associations
in fields requiring baccalaureate and advanced degrees have commented
on the need for greater efforts to increase the number of minority students.
For example, the 1984 Study Commission of the American Dietetics As-
. . .
soaatlon noted:
While no effort has been made in the past to restrict other racial groups, or males,
from the profession, little has been done to make the profession more attractive
to them, nor has any strong effort been made to recruit them. The 1984 Study
Commission believes such an effort is overdue.
TABLE 3-2 Distribution of Personnel (Percentage) in Selected Allied
Health Occupations by Race or Ethnic Origin, 1980
Minority
White (not of White Other
Occupation Spanish origin) Black (Spanish origin) Minoritya
Laboratory technician 79.5 11.1 3.3 6.2
Dental hygienist 95.4 1.6 1.6 1.3
Dietitian 84.6 6.7 1.9 8.0
Medical record technician 84.4 9.5 2.2 3.9
Occupational therapist 94.7 2.1 0.9 2.4
Physical therapist 93.4 3.3 1.1 2.0
Radiologic technician 86.2 7.7 3.7 2.4
Respiratory therapist 82.1 10.0 4.9 3.1
Speech and hearing therapist 92.9 4.3 1.5 1.3
aThese figures include American Indians, Japanese, Chinese, and other Asians or Pacific
Islanders.
SOURCE: Health Resources and Services Administration (1984).
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ALLIED HEALTH SERVICES
Past Efforts to Increase Minority Participation
The Federal Government
The federal government first initiated programs to encourage "culturally
or economically disadvantaged individuals" to enter allied health as part
of the 1970 health manpower legislation (P.L. 91-519~. This statute was
extended in 1973 by the Comprehensive Health Manpower Act (P.L. 92-
157) and the Health Programs Extension Act (P.L. 93-45) and in 1976 by
the Health Professions Educational Assistance Act (P.L. 94-484~. Later, an
administrative decision was made to provide support for projects that em-
phasized the recruitment and retention of minorities as well as the disad-
vantaged (Carpenter, 1982~.
Between fiscal years 1972 and 1977 approximately $20 million of a total
of nearly $191 million of grants awarded for allied health were allocated
for programs targeting minority and disadvantaged populations. Between
1978 and 1981, under P.L. 94-484, a larger share of the total but a smaller
amount was awarded for project activities to assist disadvantaged allied
health students (Carpenter, 1982~.
By fiscal year 1982 the only federal funding of any magnitude that was
available for minority recruitment and retention in allied health training
was the Health Careers Opportunity Program (HCOP). HCOP has five
objectives: (1) recruitment, (2) preliminary education (noncredit), (3) fa-
cilitation of entry, (4) retention, and (5) information dissemination. Ex-
amples of HCOP activities include career fairs; faculty counseling; tutoring;
summer enrichment programs to enhance mathematics, science, and com-
munication skills; and linkage arrangements among undergraduate schools
such as historically black colleges and universities (HBCUs), community
colleges, and high schools.
Between fiscal years 1982 and 1987 the number of allied health grants
under HCOP increased steadily, as did the funds that were awarded. Of
the $60 million or more awarded since fiscal year 1985, $5.37 million has
gone to allied health programs. The proportion awarded each year to allied
health r~rncrr~m~ race. from .6 percent to nearly 10 percent during this 3-
year period (W. Holland, Division of Disadvantaged Assistance, Health
Resources and Services Administration, personal communication, 1987~.
The Area Health Education Centers (AHEC) Program assists health
professions schools in improving the distribution, supply, quality, utiliza-
tion, and efficiency of health care personnel in the health care service
delivery system by encouraging the regionalization of professional edu-
cation. The program has no legislative mandate to recruit and retain mi-
norities, but it has explicitly encouraged such activities. In fiscal year 1987,
AHECs in Arizona, New Mexico, Texas, California, Oklahoma, and at three
black medical schools Drew (Los Angeles), Meharry (Nashville), and
11~_~$ r ~_~4 shiv ~ eve _ ~ ~
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EDUCATIONAL POLICY'S ROLE IN INFLUENCING SUPPLY
169
Morehouse (Atlanta) were cited by AHEC officials as having active com-
mitments to training professionals to serve Hispanic, Indian, and black
populations. The AHEC financial investment in the recruitment and re-
tention of minority allied health students and workers was not obtainable
from available program data (Area Health Education Centers Program,
1987).
States
The health professions education programmatic resources of most states
have been devoted to increasing the supply of minority physicians and
dentists, but a few states support initiatives for minorities in allied health
training. For example, Connecticut funds the Health Sciences Cluster Pro-
gram, which exposes high school students to allied health professions;
economically disadvantaged students in allied health in Georgia are eligible
for a small grant program, the Regents Opportunity Grant Program (Man-
dex, Inc., 1987~. New York State has developed an action plan to improve
minority access to the licensed professions (including dental hygiene, speech-
language pathology and audiology, physical therapy, and occupational
therapy), the core of which is a comprehensive effort to improve curriculum
development and teaching in mathematics and science in grades 7 through
12. In addition, the state offers financial assistance to allied health students
willing to work in state agencies after graduation (New York State Education
Department, Bureau of Higher and Professional Education Testing, 1985~.
Allied health is rarely specifically identified in state legislation for targeted
funding. Several investigators report being unable to ascertain the amount
spent for allied health education because these funds are not distinguished
from appropriations for "medical education." Of the 13 allied health pro-
gram officials interviewed (Mandex, 1987), only one reported that the
program received funds for minority recruitment and retention through
a line item in the state budget.
Private Foundations
Private organizations also see merit in encouraging minorities to select
health care careers. The Josiah Macy, Jr., and Robert Wood Johnson foun-
dations have been quite active in these efforts. However, Robert Wood
Johnson Foundation staff report that current activities do not include allied
health professions. Macy has sponsored some allied health professions
training, but its primary focus, after more than 20 years of involvement
in minority health professions education, is still physicians. The Macy ex-
perience is worth describing in some detail because of its potential appli-
cability to allied health education. (The following description is taken from
Bleich L1986, 19871.j
.
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EDUCATIONAL POLICY'S ROLE IN INFLUENCING SUPPLY
195
investigate models in which academic institutions have succeeded in
broadening their financial base through such mechanisms as faculty prac-
tice plans, extension courses, and industry relationships. The national
organizations should also hold workshops to help institutions implement
the models and to disseminate information.
In undertaking revenue-generating enterprises, however, allied health
deans will confront and possibly exacerbate a problem they have faced
before. Faculty resources currently are stretched thin to control costs, and
the excessive teaching load leaves little time for faculty to engage in scholarly
activity, research, and college committee work. Yet these activities constitute
a major portion of the traditional evaluation criteria for faculty promotion
and tenure. Consequently, they are the preferred nonteaching activities
pursued by faculty wishing to advance their academic careers. Maintaining
state-of-the-art clinical competence further adds to the faculty's already
excessive work load. Indeed, the committee heard a number of deans
complain of the difficulties their faculty members face in maintaining clin-
ical skills and of the concomitant impact of these difficulties on preparing
students for the labor market.
To ensure that the clinical competence of allied health faculty is main-
tained, the institutional award system must accommodate clinical compe-
tence because faculty allocate what little nonteaching time they have to
those activities that are highly rewarded. The committee recommends that
institutions that offer allied health academic programs reward and en-
courage faculty clinical competence. Clinical practice that sustains this
competence should be made a requirement for promotion.
It is noteworthy that this concern about the reward system is also one
that medical educators have been forced to confront. As the president of
the Association of American Medical Colleges has observed, "Despite the
realization that teacher-clinicians are essential ingredients of medical fa-
cilities, the need is often not recognized by the parent universities whose
appointments and promotion policies leave no niche for the clinician-
teacher to receive proper recognition" (Petersdorf, 1987~.
Preparing Students for Tomorrow's,iobs
In principle, sound educational planning would dictate that academic
institutions base their program offerings on an understanding of the knowl-
edge, skills, and socialization required of their graduates not only for
today's health care labor market but for the future as well. By extension,
statewide higher education planning should take into account the mix and
distribution of personnel at different educational levels that will be needed
across the state. Confounding efforts at such rational planning, however,
are a lack of clear signals from the labor market about future human
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196
ALLIED HEALTH SERVICES
resource needs and continuing controversy about matching education to
the requirements of the health care delivery system.
Reflecting this controversy, an allied health education advisory committee
in Texas highlighted a series of concerns that often surface when such
groups view the broad spectrum of allied health fields (Allied Health Ed-
ucation Advisory Committee, 1980~:
.
· the growing amount of narrow specialization at all degree levels;
· the requirements of some professional groups for higher levels of
training for professional entry credentials;
· difficulties with the transfer of credits to implement the career ladder
concept;
· the most appropriate levels of training for various kinds of allied health
personnel; and
· differences in the programs needed to prepare practitioners, master
clinicians, teachers, researchers, and managers.
Ironically, these issues are of concern today because, in the past, edu-
cational institutions have responded to student and employer demands.
Associate degree and certificate programs were developed to provide stu-
dents who were unwilling or unable to spend 4 years in school before
entering the work force an opportunity to enter a field in which those
workers with traditional higher credentials were in short supply. Academic
health centers and 4-year colleges, in addition to community colleges, sought
to meet the needs of their own and local hospitals with 2-year programs.
Students with baccalaureates in other than health care fields were accom-
modated with certificate programs so they could pursue allied health ca-
reers. Students who were interested in careers in respiratory therapy, dental
hygiene, and radiography, which were principally offered at the associate
degree level, found themselves able to enroll in programs that also allowed
them to obtain baccalaureate degrees. The result of these developments
was the opening of allied health occupations to a wider range of partici-
pants.
Having accommodated the needs of different student markets and em-
ployers who were either experiencing shortages in some personnel cate-
gories or who were attempting to structure their staffing with personnel
of different educational levels, the educational system is now faced, not
surprisingly, with a state of untidiness that planners find uncomfortable.
Further complicating matters is the growing availability of graduate train-
ing. Although advanced degrees have long been accepted as appropriate
preparation for faculty, administrators, and researchers, there is greater
skepticism about graduate work when it comes to the elevation of a field's
entry-level qualifications or efforts to develop specialities.
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EDUCATIONAL POLICY'S ROLE IN INFLUENCING SUPPLY
197
The committee acknowledges this great diversity in educational quali-
fications but finds that a public policy problem requiring attention may not
exist. The diversity in and of itself is not a problem. The test of whether
specialization and changing qualifications or standards are dysfunctional
is twofold: (1) Is there wastefulness in student educational investments? (2)
Is the educational system responsive to society's need for a manpower
supply that permits the health care system to function efficiently and pro-
vide care of the desired quality?
Educational Investments by Students
To open a new education program and admit a class implies a contract
with students that contains certain assurances. No school can guarantee a
student a job nor can it guarantee that skills and knowledge acquired in
its programs will be marketable in perpetuity. Nevertheless, the committee
believes that schools have the responsibility to ensure that (1) professional
education is training for a specific, "real" occupation at the end of the line;
(2) the program's general education content is sufficiently balanced by
occupation-specif~c skills; (3) if, and when, students wish career advance-
ment through education, there is a relatively efficient pathway to follow;
and (4) there is a realistic balance between the role aspirations of professions
with the realities of day-to-day work. In fulfilling their responsibilities to
students, educational decision makers face a number of dilemmas.
"Real" fobs There are numerous job titles under the umbrella of allied
health. Not all of them need to have separate, formal academic programs.
Yet educators must be sensitive to changing technology and disease patterns
that may warrant such recent developments as genetic counselors and MRI
. .
tec unmans.
The Southern Regional Education Board (1980) has recommended-
and the committee concurs that academic institutions contemplating the
development of new allied health specialities ask themselves three practice-
related questions:
· Are there any legal or professional restrictions on the new practitioners
that will tend to inhibit employers from hiring these graduates?
· Is the new speciality sufficiently different from existing specialities to
justify the development of a new educational program?
· What degree of liability does the supervisor of the new practitioners
assume?
Liberal Education Faculty in professional or technically oriented pro-
grams in higher education face a continuing struggle to reconcile the de-
mands of academia for scholarship and general education with pressures
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198
ALLIED HEALTH SERVICES
from employers and accrediting bodies to prepare students for technolog-
ically demanding jobs. The argument on the side of liberal education is
that the educational program ought to be providing preparation for life
and not just for a specific job. Graduates must be prepared to respond to
the inevitable changes that will occur in society.
Many educators feel the pressure that is exerted by employers (especially
employers in fields that require familiarity with instrumentation) to influ-
ence programs to produce graduates who do not need extensive orienta-
tion. Even at the community college level, which has had a strong tradition
of job orientation, there is concern about the appropriate mix of general
education and technical/clinical course work. In one small survey, 25 allied
health community college deans reported proportions of general education
to technicallclinical course work credits that ranged from 8 percent to 35
percent, with an average of 22 percent (Kaminski, 19871. In the name of
responsiveness to a changing society, general education courses compete
with pressures to incorporate such areas of study as geriatrics, computer
applications, multicompetency, and clinical experience in alternative sites
of care.
The committee is sympathetic to the dilemmas faced by curriculum plan-
ners. Yet it is also concerned that students receive an educational foun-
dation on which they can build a career if they so desire. Part of this
foundation entails developing the capacity for and an interest in lifelong
learning. A further, important benefit of such a foundation is that, if
current skills become obsolete, practitioners have a base on which they can
develop an alternative career.
Articulation Allied health dean Elizabeth King from Eastern Michigan
University describes two hypothetical students to illustrate the personal
dimensions of the problems of articulation, the process by which students
achieve upward educational transitions among academic programs (King,
1985~. One student, having worked 7 years as a certified occupational
therapy assistant "with a love of the profession and a conscious decision to
build upon her current skills," is confused and disillusioned when denied
the opportunity to transfer her professionally related course work toward
an occupational therapy degree. Meanwhile, another student with an as-
sociate degree in general studies, hearing about the good job prospects for
occupational therapists but having little knowledge about what occupational
therapists do, is advised by the senior college that all of his courses will
transfer and he can complete the degree in 2 years.
In general, states have strongly promoted the concept of multiple entry
and exit points in health careers to minimize the loss of student time in
moving through certificate, associate, and baccalaureate programs. Without
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Representative terms from entire chapter:
health education
EDUCATIONAL POLICY'S ROLE IN INFLUENCING SUPPLY
199
strong mandates or incentives, however, such programs have difficulty
overcoming some inherent barriers. King discusses a number of them. For
example, curricular problems occur in judging the compatibility of didactic
and clinical program content, which makes it difficult to assess advanced
placement. There is also, at times, a lack of communication between aca-
demic affairs and admissions offices to work out problems regarding credit
transfer policies. Finally, and perhaps most important, faculty professional
biases, in King's view, "the most insidious barrier," create an environment
of"undiscussable tension." These biases label community college students
as "technically" trained and lacking in problem-solving experiences.
The committee recommends that alternative pathways to entry-level
practice be encouraged when feasible. State higher education coordinat-
ing authorities and legislative committee.; .c;holil~l inelet ^^ Fl~v;~:l:~. :_
~1~:~1 ~ _L.1' ~ _ ~ ~
mu '''uo''~y between community colleges and baccalaureate pro-
grams.
Role Congruence
There is continuing tension between health care ad-
ministrators and professional groups over the tendency of a field to assume
more sophisticated or broader responsibilities and the perception of em-
ployers (or payers) as to the legitimate and vale fi,nctionc chat no tm
be performed for patients.
D~:~1 ~~ I ~
o ~ ,~ * ~11~ LllCtL 11~ Lo
Rena associations and program faculty see their responsibilities
.. . ~ . . . .
"O L11~ =~1111111~, mu ~~111t, of tilelr alsclpllne. 1 nls process is reflected in
curriculum content and reinforced by accreditation. Health care admin-
istrators become concerned when they believe curriculum is being used as
a precursor to expanding the legal scope of Rhino and r~imh,~r~f~r
· , · . ~ . ~
;~; Infix n~t1nlr~rr q - ^ car Ar ~1~;~ Al ~~ Al ~~ ~1_-_
~ ~ ~^~.—~~ ~~11L
witnout recognition ot: what Is possible or likely In practice. They also
become concerned when they believe that an occupation is at the same
time abandoning "hands-on" patient care for "nrr~f,~ion~l" r~~
200
ALLIED HEALTH SERVICES
resources it needs to function well. Indeed, the rationale for the committee's
support of public intervention in allied health supply issues is based on its
belief that the link between services and education needs to be strength-
ened.
In determining their program offerings, allied health educators are cau-
tioned by state higher education leaders and health care administrators to
avoid overtraining in both curriculum content and in length and level of
preparation. On the other side are the professions who caution against too
little training and who strive to elevate educational standards through li-
censure, program accreditation, and reimbursement standards.
The committee has heard arguments by the first group that raising
educational qualifications is not only expensive to the student but to the
educational and health care systems as well, both of which are attempting
to control costs. Furthermore, proponents of this view contend that "ed-
ucation creep" exacerbates shortages by lengthening the time required to
prepare an individual for work. They also contend that there is little evi-
dence to suggest that current levels of education are creating care problems.
Counterarguments are most often based on the expanding knowledge
base that practitioners need to master and the limited time available in the
curriculum for such mastery. New sites of care, such as in the home or in
independent office practice, require a level of judgment that can only be
achieved with increased education. Those concerned with an adequate
supply of practitioners point to the higher labor force participation rates
and longer tenure of those who have already attained the higher credential.
This committee encountered a number of these types of controversies
among the allied health fields. Some examples include physical therapists
attempting to establish the master's degree as the entry-level standard, role
delineation debates among baccalaureate medical technologists and 2-year
medical laboratory technicians, proposals to limit the educational routes to
entry-level dietetics, and the movement of respiratory therapy to a bac-
calaureate entry-level standard. The case for promoting a single optimal
level of education is an exceedingly difficult one to make on empirical
grounds. For example, when an IOM committee explored the controversy
over the three educational tracks leading to the registered nurse credential
(associate degree, diploma, and baccalaureate), it was unable to find con-
vincing evidence on the difference of performance among the graduates
(Institute of Medicine, 1983~.
The committee neither endorses nor refutes the position of parties on
either side of these debates. In view of the lack of objective empirical
evidence and the limited scope of the present study, the committee could
not justify offering conclusions that might influence the outcome of these
controversies. The committee does suggest, however, that those making
. .
EDUCATIONAL POLICY'S ROLE IN INFLUENCING SUPPLY
201
decisions ensure that changing existing practice will not limit the supply
of practitioners nor make care excessively costly.
From the committee's perspective the only sensible response to the mov-
ing targets of health care system change and the lack of certainty about
how to match education to future needs is a continuing feedback loop
between education and practice. Graduate follow-up studies that incor-
porate employer perceptions are the most direct measures of how well the
curriculum is preparing students. The aim of these studies, however, need
not be solely to tailor education to employer perceptions of need. Rather,
it should be the start of a dialogue. If students are not applying their
educational experiences fully, the problem may at times rest with the work
environment. A dialogue could potentially lead to a mutually beneficial set
of activities involving more participation from health care managers in
curriculum design and greater involvement of educators in health services
research with practical application to clinical settings.
Various models are available for institutionalizing such interactions. In
some education programs, allied health education and services are jointly
administered by the same corporate entity. An example is Rush University
in Chicago where education and services are unified. Where this is not
feasible, the industry advisory boards common to many community colleges
can be used. Faculty practice plans or clinical affiliations may also be a
starting point to stimulate collaboration.
In those fields in which instrumentation plays a major role in job func-
tioning, industry/faculty collaboration provides a largely untapped re-
source. Manufacturers ultimately have a stake in human resources because
investments by health facilities in technological innovations may be seriously
jeopardized if there is a lack of adequately prepared personnel. Manufac-
turers should consider collaborating with educational institutions in creative
ways for example, the use of equipment, faculty-industry research proj-
ects, short-term employment opportunities as a means of ensuring an
appropriate human resource infrastructure to assist technology transfer.
Yet some stimulus is necessary to overcome the inertia of dealing with
these difficult issues of collaboration. The committee sees a role both for
states and private foundations in providing that stimulus. State legislatures
should establish special bodies whose primary purpose would be to ad-
dress state and local issues in the education and employment of allied
health personnel. Private foundations should support university-based
centers for allied health studies and policy to provide a critical mass of
researchers and resources to advance technology assessment, health care
services research, and human resource utilization.
States have a major role in allied health education by virtue of their
support of public colleges and universities. In addition to this influence,
202
ALLIED HEALTH SERVICES
they are frequently drawn into debates over licensure issues that involve
changing scopes of practice and the licensing of new occupations. (These
regulatory issues are discussed in Chapter 7.)
Private foundations could have a major impact on the future of allied
health education and practice by creating centers of excellence in a few
academic institutions. Many advantages might be gained by coalescing a
core research faculty that also provides services. These mutually reenforc-
ing activities would enhance the quality of research and patient care. Fur-
thermore, these centers might then be a resource to other allied health
education programs regionally or nationally.
The committee believes that the interest of state legislatures and private
foundations in the endeavors we describe will be kindled and sustained
only by a continuing federal presence in the concerns of allied health
education and practice. For this reason, the committee makes the following
recommendation about the federal leadership: The Depa'-l~nent of Health
and Human Services should maintain an organizational focal point on
allied health personnel to implement the grant programs recommended
in this report, to coordinate the recommended work of the interagency
data task force (recommended in Chapter 2), and to facilitate commu-
nication between state legislative committees and the federal government.
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