ABSTRACT. Work in the United States has changed in the decades since the Occupational Safety and Health Act was passed in 1970. American workplaces and the workers employed there are in the midst of profound changes that will persist well into the next century. In recognition of that fact, the National Institute for Occupational Safety and Health, which plays a central role in the education and training of occupational safety and health (OSH) professionals, asked the Institute of Medicine to analyze these changes in detail, assess the supply of, demand for, and knowledge, skills, and abilities of occupational safety and health professionals, and identify personnel needs, skills, and curricula needed for the coming decades.
The committee responsible for this report found that the American workforce is becoming more diverse in age, gender, race, and nationality, and that the products of work are increasingly services rather than goods. A smaller percentage of workers are employed in large fixed industries, and a higher proportion are employed in small firms, temporary jobs, or at home. More work is now contracted, outsourced, and part time. These changes complicate implementation of workplace health and safety programs and argue for more comprehensive curricula, multidisciplinary training, and new types of training programs and delivery systems. These innovations will strengthen the traditional university-based model of four primary OSH disciplines that has guided education and training in the field to date.
The report concludes that the continuing burden of largely preventable occupational diseases and injuries and the lack of adequate OSH services in most small and many larger workplaces indicate a clear need
for more OSH professionals at all levels. The authoring committee also concludes that OSH education and training needs to place a much greater emphasis on injury prevention and that current OSH professionals need easier access to more comprehensive and alternative learning experiences. In addition, provision of adequate training for the majority of American workers will depend upon the discovery of new and improved ways of reaching small and mid-sized industries with increasingly decentralized and highly mobile workforces. Ten recommendations address current and future OSH workforces and training programs.
Each day, more than 16,000 Americans are injured on the job (over 6 million each year) and 20 more die as a result of job-related injuries (over 7,000 each year) (Bureau of Labor Statistics, 1998a). The incidence of occupational illness is more difficult to estimate, but a recent study placed the number of new cases in 1992 at 860,000 and the number of deaths as a result of occupational illnesses at 60,000 annually (Leigh et al., 1997). The economic costs of these job-related injuries ($145 billion) and illnesses ($26 billion) are much higher than those for AIDS and Alzheimer’s disease and are on par with those for cancer and for circulatory diseases (Leigh et al., 1997).
The U.S. Congress passed the Occupational Safety and Health Act of 1970 to assure “every working man and woman in the United States safe and healthful working conditions.” This mandate gave rise to the Occupational Safety and Health Administration (OSHA) and the National Institute for Occupational Safety and Health (NIOSH). Over the last 30 years, OSHA and NIOSH have implemented education and training programs for employers, workers, and occupational safety and health (OSH) professionals, and these programs are essential tools in reducing the burden of occupational injury and illness.
The work environment has changed considerably in the decades since the Occupational Safety and Health Act was passed. Injuries and illnesses that were unrecognized at that time now contribute significantly to the present OSH burden. The workforce has also changed, with more women, minorities, and persons with a disability in the workforce now than ever before. In addition, the numbers of workers over 50 years of age and workers under 18 years of age are also increasing. Workplaces have also evolved dramatically as a result of the U.S. economy’s transition from a manufacturing base to services, and now to information and information technology. There have also been profound changes in the way in which work is organized. Distributed work arrangements, flexible matrix- and team-based organizational structures, and nonstandard work arrange-
ments, among others, have become commonplace, challenging the traditional model for the provision of OSH programs. Important changes are also occurring in the health care system, most notably the increased emphasis on managed care and other means of reducing costs. As yet unexplored are the implications of this new care delivery system for occupational physicians, as well as possible changes in the roles of primary care physicians, nurse practitioners, and physician assistants who may be treating workers.
From a regulatory standpoint, OSHA has added job safety standards over the years that include requirements that “qualified,” “designated,” or “competent” persons ensure their enforcement at the work site, but there has been no agreement as to what type of training might enable such personnel to meet these requirements. OSHA also mandates training of workers in more than 100 of its standards, but it does not speak to the quantity, quality, or efficacy of that training. Few if any standards call for the training of employers or of managers responsible for workplace safety and health.
Given the widespread changes affecting nearly every aspect of workplace safety and health, NIOSH, with support from OSHA, the National Institute of Environmental Health Science (NIEHS), and the U.S. Department of Veterans Affairs, asked the Institute of Medicine to characterize and assess the current U.S. workforce and work environment and forecast the demand and need for, and supply of, qualified OSH professionals. The goal of the assessment was to identify gaps in OSH training programs that could be filled by either public or private programs and to identify the critical curricula and skills needed to meet these evolving occupational safety and health concerns.
CHARGE TO THE COMMITTEE
The charge to the committee was fourfold, calling for analyses of both the adequacy of the current OSH workforce and training and adjustments that might be required in the future because of changes in the workforce, the workplace, the organization of work, and health care delivery.
Assess the demand and need for OSH professionals as well as the adequacy of the OSH professional supply by sampling members of the OSH community (industry, small business, labor, academia, professional organizations, health providers, contract services, and governmental agencies). This assessment would determine the number and type of personnel currently employed; their professional duties, skills, abilities, and knowledge; and shortfalls in these categories.
Analyze changes in the workforce and work environment that are
affecting the roles of OSH professionals now, and how they are likely to affect these roles over the next decade.
Identify gaps in current OSH education and training. For example, determine whether training programs provide an appropriate number of personnel and a matrix of knowledge, skills, and abilities at appropriate levels. Determine which disciplines and skills will be most effective in addressing OSH needs over the next decade.
Identify the critical curricula and skills needed to meet these evolving OSH concerns.
The remainder of this summary, and the report itself, generally follow the four elements of the charge. They begin by describing OSH professionals—who they are and what they do and do not do. The following four sections then describe changes in the work environment that affect OSH and the education and training of OSH professionals. The report then describes current education and training programs and suggests changes in light of trends in the work environment.
OCCUPATIONAL SAFETY AND HEALTH PROFESSIONALS
Without a massive survey of U.S. employers, it is impossible to estimate or describe the full spectrum of OSH personnel who provide services to the U.S. workforce. However, the committee was able to describe the four traditional, or core, OSH professions—occupational safety, industrial hygiene, occupational medicine, and occupational health nursing—as well as three other disciplines that are likely to play a substantial role in the workplace of the future: ergonomists, employee-assistance professionals, and occupational health psychologists.
Although each of the four traditional OSH professions emphasizes different aspects of the field, all four share the common goal of identifying hazardous conditions, materials, and practices in the workplace and helping employers and workers eliminate or reduce the attendant risks. Occupational safety professionals, although concerned about all workplace hazards, have traditionally emphasized the prevention of traumatic injuries and fatalities. Similarly, industrial hygienists, although they do not ignore injuries, focus on the identification and control of health hazards associated with acute or chronic exposure to chemical, biological, or physical agents. Occupational medicine physicians and occupational health nurses provide clinical care and programs aimed at health promotion and protection and disease prevention. These services include not only diagnosis and treatment of work-related illness and injury, but also pre-placement, periodic, and return-to-work examinations, impairment evaluations, independent medical examinations, drug testing, disability
and case management, counseling for behavioral and emotional problems that affect job performance, and health screening and surveillance programs.
Approximately 76,000 Americans are active members of the professional societies representing the core OSH disciplines. The literature suggests that as many as 50,000 more are eligible for membership by virtue of their current employment. The committee therefore estimates the current supply of OSH professionals at between 75,000 and 125,000. The committee could not find good, independent data to support an estimate of demand (i.e., the number of positions available), but the overall supply seems to be roughly consonant with employer demand. However, the committee notes that considerable need exists beyond the current demand for OSH professionals by employers. Doctoral-level safety educators are needed to teach and train injury prevention and safety professionals or their number will decrease, and both occupational medicine and occupational health nursing clearly need more specialists with formal training. Most important, a large proportion of the American workforce is outside the sphere of influence of OSH professionals, particularly those whose focus is primarily prevention, principally because few of those professionals are employed by small businesses and establishments, and, in some sectors of the economy like agriculture and construction, the workplace and the workforce are often transient.
CHANGING DEMOGRAPHICS OF THE WORKFORCE
Projected changes over the next decade will result in a workforce with a larger proportion of individuals over age 55, women, African Americans, Hispanics, and Asians. The special characteristics of these populations will need to be taken into account. For example, women and older workers have lower injury and illness rates than the labor force as a whole, although injured older workers take longer to return to work. In addition, the Americans with Disabilities Act of 1990 mandated reasonable accommodation for workers with a disabling condition, and as a result, the number of employed persons with a disability has increased sharply in the 1990s.
The committee concludes that all aspiring OSH professionals must be made aware of ethnic and cultural differences that may affect the implementation of OSH programs. In addition, the committee believes that health and safety programs are social as well as scientific endeavors and that OSH disciplines and OSH professional groups should reflect the social makeup and diversity of thought and experience of the societies
they serve. Thus, the training and recruitment of OSH professionals should include all racial and ethnic groups. Further, all OSH education will need to include instruction on changes in the physical and cognitive abilities of older workers, the interaction of disabilities and chronic diseases with workplace demands, and in communication skills needed to reach minority workers, workers with low levels of literacy, and those for whom English is a second language.
The industrial and occupational components of the U.S. economy changed significantly during the decade ending in 1998. Among goods-producing sectors, only construction added jobs, while manufacturing and mining both lost jobs. The service-producing sector, on the other hand, led by retail trade and business and health services, has grown dramatically. Four occupational groups—the executive, professional, technical, and service groups—are projected to grow more rapidly than the overall economy and, consequently, to increase their share of employment as this trend continues. Although there are some important exceptions, the rate of occupational injuries has been higher in declining industries, such as manufacturing, than in the industries that are expected to grow, such as retail trade. The majority of U.S. workers are now employed by firms with less than 100 employees; small firms showed the greatest growth in employment in the 1990s, and that trend is expected to continue. More work will be contracted, outsourced, or done on a parttime basis in the coming years. Substantial numbers of workers will hold multiple jobs, and they will change jobs more frequently. An increasing number of workers will work at home. In many sectors, the number of workers represented by unions is falling.
The committee concludes that these changes, as a whole, describe a workplace that is very different from the large fixed-site manufacturing plants in which OSH professionals have been most frequently employed. The changes complicate the implementation of OSH programs and argue for training and delivery systems that are different from those that have been relied upon to date. Simply increasing the numbers or modifying the training of OSH professionals will not be sufficient to meet these challenges, since the primary difficulty will be provision of training to either underserved workers or underserved workplaces. Extensive new regulation is possible but seems unlikely. Other problems not susceptible to site- or group-specific interventions (e.g., smoking, seat belt use, and drunk driving) have been attacked with broad public education campaigns. Future OSH professionals will need to be knowledgeable
about and willing to work with mass media to reach workers at home as well as at work. The committee calls for systematic exploration of new models for implementing OSH programs for the full spectrum of American workers.
CHANGING ORGANIZATION OF WORK
Globalization, technology and other work design factors, and organizational design innovations also present training needs for OSH professionals. Increasing reliance on computer technology, distributed work arrangements, the increased pace of work, and the increased diversity of the workforce create several challenges for OSH personnel. First, new hazards could potentially emerge, both through the introduction of new technologies and through the performance of work in a more dispersed or virtual organization. Second, businesses are becoming smaller and “flatter” (i.e., fewer levels of management) and are redefining the content of work and the nature of the employment relationship. They are under pressure to compete for talent, innovate, provide exceptional quality, and bring products and services to market quickly at competitive prices. The effects of these business developments on workers include demands for new skills and continuous learning, expanded job scopes, an accelerated work pace, and the need to deal with changing workplaces. Workers also face uncertainty in employment relationships, increased interaction with both customers and coworkers, and more involvement with information and communications technologies. Further, societal developments like the increasing numbers of single parents, dual-career households, and aged dependents challenge workers to manage multiple and competing interests in their work and home lives. These factors are a major source of time conflict and carry the potential for causing dysfunction and distress in America’s workforce and workplaces.
The committee concludes that OSH personnel must be well aware of the effects that these changing structural and contextual work conditions have on workers’ well-being and health. They need to be able to recognize and react to effects of these work organization factors on cognitive and behavioral functioning, including stress-related conditions and their link to health, safety, and performance. Finally, OSH personnel need to have a basic competence in prevention and intervention strategies.
CHANGING DELIVERY OF HEALTH CARE
Physicians and nurses specializing in occupational health, and the institutions within which they work, must operate as part of a health care
system that has been undergoing profound changes during the 1990s. One of the most striking features of health care reform has been the dramatic growth of managed care, a major element of which is tighter control on the utilization of health services. This has led to an emphasis on caregivers seeing more patients (vs. providing preventive services, receiving and providing additional education, and performing research), the increased use of primary care physicians and paraprofessionals instead of specialty-trained physicians, and a consolidation of small practices and clinics into large occupational health clinics and integrated systems providing full-time coverage (24 hours a day, 7 days a week) of workers and their families.
The committee concludes that all health care professionals need to be more familiar with workers’ compensation law, and that aspiring OSH professionals need training in the principles of health care organization and financing, managed care, and multi-disciplinary health care.
EDUCATION AND TRAINING PROGRAMS
Any consideration of the future OSH workforce must include an analysis of the educational “pipeline” from which these professionals emerge. The committee used a variety of sources to assemble estimates of the annual number of master’s-level graduates in the four core OSH disciplines. Twenty-nine U.S. schools offer such degrees in occupational safety, and they graduate about 300 students annually. This number is extremely low, given the incidence of workplace injuries, but employers’ apparent willingness to hire graduates with baccalaureate degrees in occupational safety (about 600 annually) limits the demand for master’s-level safety professionals. Less than 10 students are awarded doctoral degrees in occupational safety each year, a level low enough to threaten the future viability of academic departments of occupational safety. The committee estimates that approximately 400 master’s-level industrial hygienists graduate each year, a volume roughly equal to employer demand in the industrial sector that has most commonly used them. Forty institutions offer occupational medicine residencies, and they produce about 90 graduates annually, a number that is insufficient to replace existing occupational medicine specialists when they leave practice. Attracting applicants to this field is a major problem, since the field draws a large proportion of its practitioners from among established physicians, for whom a return to full-time student status is not feasible. A similar situation exists in nursing. Twenty-one schools of nursing and public health award only about 50 master’s-level degrees in occupational health nursing each year. Curricula in all four OSH disciplines are predominantly
technical and science based, with an engineering and physical science emphasis in safety and industrial hygiene and a biological, health, and programmatic emphasis in nursing and medicine. NIOSH training programs provide grants totaling approximately $10 million per year in support of OSH professional education, resulting in approximately 500 OSH-related degrees (or completed residencies) annually. Occupational medicine receives the most funding, reflecting the high cost of postgraduate specialist training for licensed physicians. Industrial hygiene is a close second, with occupational health nursing (at about 55% of the level of occupational medicine’s funding), and occupational safety (at about 33% of the level of occupational medicine’s funding), receiving considerably less support. The committee also reviewed worker and manager training provided by OSHA and others. No degrees are associated with this training, which takes many forms, from simple handouts and videotape viewings to 1–2 weeks of classroom and hands-on instruction. The committee did not attempt an exhaustive survey, but it is clear that tens of thousands of hours of worker training are done, largely in response to OSHA mandates.
The committee concludes that current problems in the education and training of OSH professionals include an insufficient emphasis on the prevention of traumatic injury, which is reflected most clearly in the very small number of doctoral-level graduates in occupational safety; the limited support for relevant research in departments other than those that grant OSH degrees; and an inability to attract physicians and nurses to formal academic training in OSH. An existing problem likely to be exacerbated by the many changes under way in the work environment is the narrow focus of education and training programs on OSH personnel who have traditionally served large, fixed-site manufacturing industries. A problem in terms of responding to changes in the future workplace is a lack of research and training in a number of areas of increasing importance: behavioral health, work organization, communication, management, team learning, workforce diversity, information systems, prevention interventions, and evaluation methods, among others. Additional topics in need of attention include methods for effective training of adult workers; the physical and psychological vulnerabilities of members of the workforce stratified by age, gender, and socioeconomic, and cultural background; the resources available to help with injury prevention and analysis; business economics and values; health promotion and disease prevention; community and environmental concerns; and the ethical implications of technological advances such as the mapping of the human genome.
The committee also concludes that health and safety training for workers, although abundant, is of unknown quality and efficacy, and that OSH training for managers is rarely demanded, offered, or requested.
ALTERNATIVES TO TRADITIONAL EDUCATION AND TRAINING
A substantial portion of the current OSH professional workforce consists of people who do not have advanced degrees or, in some cases, even baccalaureate degrees. These people were attracted to OSH well after beginning their working lives, when full-time attendance in traditional education programs was not a viable option. Now, however, techniques such as distance education and alternative training programs allow students to continue their education outside the confines of a traditional classroom. Distance education is a planned and structured means of learning that uses electronic technology involving audio, print, video, and Internet media, alone or in combination. Limited but impressive data on the popularity and effectiveness of distance education in preparing physicians for occupational medicine board-certification examinations point to its potential as a means of facilitating education and certification of the many practicing OSH personnel without formal specialty training in the area.
The committee concludes that although traditional approaches remain indispensable for some types of instruction, NIOSH should develop incentives to promote the use of distance education and other nontraditional approaches to OSH education and training. An integral part of these innovative programs should be a thorough evaluation of both program content and the performance of their graduates on, for example, credentialing examinations and in job placement compared to that of graduates of traditional programs.
SUMMARY OF FINDINGS AND RECOMMENDATIONS
The charge to the committee called for analyses of both the adequacy of the current OSH workforce and training and adjustments that might be required in the future because of changes in the workforce, the workplace, the organization of work, and health care delivery.
Current OSH Workforce and Training
The current supply of OSH professionals, though diverse in knowledge and experience, generally meets the demands of large and some
medium sized workplaces. However, the burden of largely preventable occupational diseases and injuries and the lack of adequate OSH services in most small and many medium-sized workplaces indicate a need for more OSH professionals at all levels. The committee also finds that OSH education and training should place more emphasis on injury prevention and that current OSH professionals need easier access to more comprehensive and alternative learning experiences.
To address the critical need to mitigate the enormous and continuing impacts of acute and chronic injuries on worker function, health, and well-being, to develop new leaders in this neglected field, and to strengthen research and training in it at all levels:
Recommendation 1: Add a new training initiative focused on prevention of occupational injuries.
NIOSH should develop a new training initiative focused on the prevention of occupational injuries, with special attention to the development of graduate-level faculty to teach and conduct research in this area. Possible approaches would include regional Occupational Injury Research, Prevention, and Control Centers as an entirely new program or by modification of the existing NIOSH training programs or collaboration with the Centers for Disease Control and Prevention’s National Center for Injury Prevention and Control.
To enhance needed multidisciplinary research in injury prevention and in occupational safety and health in general:
Recommendation 2: Extend existing training programs to support of individual Ph.D. candidates.
NIOSH should extend existing training programs to support individual Ph.D. candidates whose research is deemed of importance to the prevention and treatment of occupational injuries and illnesses, independent of academic department or program. Restricting support to students in Education and Research Centers or Training Project Grants–affiliated departments or disciplines deprives the OSH field of individuals who may have innovative responses to changing circumstances.
To address the lack of formal training among OSH professionals:
Recommendation 3: Encourage distance learning and other alternatives to traditional education and training programs.
NIOSH should encourage the use and evaluation of distance education and other nontraditional approaches to OSH education and training, especially as a means of facilitating education and certification of the many practicing OSH personnel without formal specialty training in the area.
Recommendation 4: Re-examine current pathways to certification in occupational medicine.
The American Board of Preventive Medicine should reexamine the current pathways to certification in occupational medicine. Specifically, it should consider
extending eligibility for its existing equivalency pathway to include physicians who graduated after 1984 and
developing a certificate of special competency in occupational medicine for physicians who are board certified in other specialties but who have completed some advanced training in occupational medicine.
Future OSH Workforce and Training
Expected changes in the workforce and in the nature and organization of work in the coming years will result in workplaces that will be quite different from the large fixed-site manufacturing plants in which OSH professionals have previously made their greatest contributions. The delivery of OSH services will become more complicated, and additional types of OSH personnel and different types of training than have been relied upon to date will be needed. Simply increasing the numbers or modifying the training of occupational health professionals will not be sufficient, since the primary difficulty will be to provide training to underserved workers and underserved workplaces. Traditional OSH programs must be supplemented by a new model that focuses on these workers and work sites.
To help ensure high-quality occupational safety and health programs for the full spectrum of American workers:
Recommendation 5: Solicit large-scale demonstration projects that target training in small and mid-sized workplaces.
NIOSH, in collaboration with OSHA, should fund and evaluate large-scale demonstration projects that target training in small and midsized workplaces. These innovative training programs should encourage the use of new learning technologies, should include a recommended core of competencies, and could lead to the creation of a new category of health and safety personnel—OSH managers.
Recommendation 6: Evaluate current worker training and establish minimum quality standards.
OSHA should join together with NIOSH, NIEHS, unions, industries, and employer associations to evaluate the efficacy of OSHA and other worker training programs and better define minimum training requirements.
Recommendation 7: Solicit demonstration projects to create model worker training programs for occupational safety and health trainers.
NIOSH, in collaboration with OSHA, should fund demonstration project grants that target specific employment sectors as an incentive to develop model training programs for another category of health and safety personnel—OSH trainers.
To address the challenges posed by the increasing diversity of the U.S. workforce:
Recommendation 8: Increase attention to special needs of older, female, and ethnic/cultural minority workers.
All aspiring OSH professionals must be made aware of ethnic and cultural differences that may affect implementation of OSH programs. In addition, because OSH programs are social as well as scientific endeavors, NIOSH, OSHA, NIEHS, other federal and state agencies, educational institutions, unions, employers, associations, and others engaged in the training of OSH personnel should foster and/or support efforts to provide a body of safety and health professionals and trainees that reflects age, gender, and ethnic/cultural background of the workforces that they serve. These organizations should also foster meaningful instruction on the aging process, the interaction of disabilities
and chronic diseases with workplace demands, and communication skills to interact with minority and workers with low levels of literacy and those for whom English is a second language.
To prepare present and future OSH professionals to address continuing changes in the U.S. workforce, in the workplace, and in the organization of work itself as major determinants of workplace safety, health, and well-being:
Recommendation 9: Examine current accreditation criteria and standards.
Boards and other groups that accredit academic programs in the OSH professions, in conjunction with appropriate professional organizations, should carefully examine their current accreditation criteria and standards, paying special attention to the needs of students in the areas of behavioral health, work organization, communication (especially risk communication), management, team learning, workforce diversity, information systems, prevention interventions, healthcare delivery, and evaluation methods.
Recommendation 10: Broaden graduate training support to include behavioral health science programs.
NIOSH should broaden its graduate training support to include the behavioral health sciences (e.g., psychology, psychiatry, and social work) by developing and maintaining training programs in work organization and the prevention and treatment of physical and mental effects of work-related stress.
BOX 1 SUMMARY OF RECOMMENDATIONS
Current OSH Workforce and Training
Future OSH Workforce and Training