week 6-42

HEALTHCARE PROFESSIONALS

Kenneth R. White, PhD, FACHE; Dolores G. Clement,

DrPH, FACHE; and Kristie G. Stover, PhD

CHAPTER

4

71

Learning Objectives

After completing this chapter, the reader should be able to

• understand the role of healthcare professionals in the human resources management function of healthcare organizations;

• define the elements of a profession, with an understanding of the theoretical underpinnings of the healthcare professions in particular;

• describe the healthcare professions, which include the majority of healthcare workers, and the required educational levels, scopes of practice, and licensure issues for each;

• relate knowledge of the healthcare professions to selected human resources management issues and systems development; and

• comprehend the changing nature of the existing and emerging healthcare professions in the healthcare workforce, particularly the impact of managed care.

Introduction

Healthcare professionals are central to the delivery of high-quality healthcare services. Extensive training, education, and skills are essential in meeting the needs and demands of the population for safe, competent healthcare. These specialized techniques and skills that healthcare professionals acquired through systematic programs of intellectual study are the basis for socialization into their profession. Additionally, the healthcare industry is labor intensive and is distinguished from other service industries by the number of licensed and reg- istered personnel that it employs and the variety of healthcare fields that it pro- duces. These healthcare fields have emerged as a result of the specialization of medicine, development of public health, increased emphasis on health promo- tion and prevention, and technological advances and growth.

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C o p y r i g h t 2 0 0 8 . H e a l t h A d m i n i s t r a t i o n P r e s s .

A l l r i g h t s r e s e r v e d . M a y n o t b e r e p r o d u c e d i n a n y f o r m w i t h o u t p e r m i s s i o n f r o m t h e p u b l i s h e r , e x c e p t f a i r u s e s p e r m i t t e d u n d e r U . S . o r a p p l i c a b l e c o p y r i g h t l a w .

EBSCO Publishing : eBook Academic Collection (EBSCOhost) - printed on 2/1/2022 4:15 PM via WESTERN KENTUCKY UNIVERSITY AN: 237620 ; Fottler, Myron D., Fried, Bruce.; Human Resources in Healthcare : Managing for Success Account: s8993066.main.ehost

Because of this division of labor within medical and health services de- livery, many tasks that were once the responsibility of medical providers have been delegated to other healthcare personnel. Such delegation of duties raises important questions for the industry: Should healthcare providers other than those specifically trained to practice medicine be considered professionals in their own right? To what extent should their scope of practice be extended?

In this chapter, we respond to the aforementioned questions by defin- ing key terms, describing the healthcare professions and labor force, explain- ing the role of human resources in healthcare, and discussing key human re- sources issues that affect the delivery of healthcare.

Professionalization

Although the terms “occupation” and “profession” often are used inter- changeably, they can be differentiated.

An occupation enables workers to provide services, but it does not re- quire skill specialization. An occupation is the principal activity that supports one’s livelihood. However, it is different from a profession in several ways. An occupation typically does not require higher skill specialization. An individual in an occupation is usually supervised, adheres to a defined work schedule, and earns an hourly wage rate. An individual in an occupation may be trained for a specific job or function and, as a result, is less able to move from one organ- ization to another.

A profession requires specialized knowledge and training that enable professionals to gain more authority and responsibility and to provide service that adheres to a code of ethics. A professional usually has more autonomy in determining the content of the service he or she provides and in monitoring the workload needed to do so. A professional generally earns a salary, requires higher education, and works with more independence and mobility than do nonprofessionals.

The distinction between an occupation and a profession is important because the evolving process of healthcare delivery requires professionals who are empowered to make decisions in the absence of direct supervision. The proliferation of knowledge and the skills needed in the prevention, diagnosis, and treatment of disease has required increasing levels of education. Under- graduate- and/or graduate-level degrees are now required for entry into vir- tually every professional field. Some professions, such as pharmacy and phys- ical therapy, are moving toward professional doctorates (i.e., PharmD and DPT, respectively) for practice.

A countervailing force against the increasing educational requirements of the healthcare professions is ongoing change in the mechanisms for deliv- ery and payment of services. With consolidation of the healthcare system and

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the rise of managed care, along with its demands for efficiency, fewer financial resources are available. As a result, healthcare organizations are pressured to replace highly trained—and, therefore, more expensive—healthcare profes- sionals with unlicensed support personnel. Fewer professionals are being asked to do more, and those with advanced degrees are required to supervise more assistants who are functionally trained for specified organizational roles.

Functional training produces personnel who can perform tasks but who may not know the theory behind the practice; understanding theory is essential to becoming fully skilled and able to make complex management and patient care decisions. Conversely, knowing the theory without having the ex- perience also makes competent practice difficult. When educating potential healthcare professionals, on-the-job training or a period of apprenticeship is needed, particularly in addition to basic coursework. Dreyfus and Dreyfus (1996) contend that both theoretical knowledge and practiced response are needed in the acquisition of skill in a profession. These authors lay out five stages of abilities that an individual passes as he or she develops a skill:

1. Novice. At this stage, the novice learns tasks and skills that enable him or her to determine actions based on recognized situations. Rules and guidelines direct the novice’s energy and action at this stage.

2. Advanced beginner. At this stage, the advanced beginner has gained enough experience and knowledge that certain behaviors become automatic, and he or she can begin to learn when tasks should be addressed.

3. Competent. At this stage, the competent individual has mastered the practiced response of definable tasks and processes and has acquired the ability to deal with the unexpected events that may not conform to plans.

4. Proficient. At this stage, the proficient individual has developed the ability to discern a situation, intuitively assess it, plan what needs to be done, decide on an action, and perform the action more effortlessly than possible in the earlier stages.

5. Expert. At this stage, the expert can accomplish the goals without realizing that rules are being followed because the skill and knowledge required to reach the goal have become second nature.

Theoretical understanding is melded with practice in each progressive stage. Functional training can help an individual progress through the first three stages and can provide the individual with calculative rationality or inferential rea- soning ability to be able to apply and improve theories and rules learned. For skill development at the proficient and expert levels, deliberative rationality or ability to challenge and improve theories and rules learned is required. Healthcare pro- fessionals need to become experts in fields where self-direction, autonomy, and decision making for patient care may be required (Dreyfus and Dreyfus 1996).

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Healthcare Professionals

The healthcare industry is the largest and most powerful industry in the United States. It constitutes more than 6.5 percent of the country’s total la- bor force and nearly 15 percent of the gross domestic product. Healthcare professionals include physicians, nurses, dentists, pharmacists, optometrists, psychologists, nonphysician practitioners such as physician assistants and nurse practitioners, healthcare administrators, and allied health professionals. The allied health professions are a huge group that consists of therapists, medical and radiologic technologists, social workers, health educators, and other ancillary personnel. Healthcare professionals are represented by profes- sional associations. Table 4.1 provides a sample of professional associations in healthcare.

Healthcare professionals work in a variety of settings, including hospi- tals; ambulatory care centers; managed care organizations; long-term-care or- ganizations; mental health organizations; pharmaceutical companies; commu- nity health centers; physician offices; laboratories; research institutions; and schools of medicine, nursing, and allied health professions. According to the Bureau of Labor Statistics (BLS 2007), healthcare professionals are employed by the following:

• hospitals (34.5 percent), • nursing and personal and residential care facilities (23.0 percent), • physician offices and clinics (17.1 percent), • home health care services (6.9 percent), • dentist offices and clinics (6.3 percent), and • other health service sites (12.2 percent).

The U.S. Department of Labor recognizes about 400 different job ti- tles in the healthcare sector; however, many of these job titles are not included in our definition of healthcare professionals. For example, almost one-third of those employed in the healthcare sector probably belong in the support staff category—that is, employees who are part of the patient care team or involved in delivering health services. These approximately 2.2 million nursing aides, home health aides, and personal attendants are critical to the delivery of healthcare services (BLS 2007).

The primary reasons for the increased supply and demand for health- care professionals include the following interrelated forces:

• technological growth, • specialization, • changes in third-party coverage, • the aging of the population, and • the proliferation of new and diverse healthcare delivery settings.

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Organization Target Audience Website

Health Professions

Pew Health Professions Future health http://futurehealth Commission professions .ucsf.edu

American College of Future healthcare www.healthmanage Healthcare Executives: managers and mentcareers.org Health Management Careers administrators

Accrediting Organizations

Accreditation Association for Ambulatory healthcare www.aaahc Ambulatory Health Care facilities .org

Accreditation Council for Graduate medical www.acgme Graduate Medical Education education programs .org

American Osteopathic Osteopathic hospitals www.osteopathic Association and health systems .org

Commission on Accreditation Rehabilitation facilities www.carf.org of Rehabilitation Facilities

The Joint Commission Hospitals and health www.joint systems commission.org

National Committee for Health plans http://web Quality Assurance .ncqa.org

American Association of Blood banks www.aabb.org Blood Banks

American College of Surgeons www.facs.org Surgeons

American College of Cancer programs www.facs.org/ Surgeons: Commission cancer on Cancer

College of American Clinical laboratories www.cap.org Pathologists

Professional Associations

American College of Healthcare Healthcare executives www.ache.org Executives

National Association of African-American www.nahse.org Health Services Executives healthcare executives

Institute for Diversity in Health Healthcare managers, www.diversity Management students, organizations, connection.org

diversity programs

TABLE 4.1 Resource Guide for the Healthcare Professional

(Continued)

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Organization Target Audience Website

Medical Group Management Physician practice www.mgma.com Association managers and

executives

American Hospital Association: Healthcare human www.hrleader.org American Society for resources Healthcare Human Resources professionals Administration

American College of Physician Physician executives www.acpe.org Executives

American College of Health Long-term-care www.achca.org Care Administrators administrators

Association for Healthcare Medical www.ahdionline.org Documentation Integrity transcriptionists

American Association of Nurse anesthetists www.aana.com Nurse Anesthetists

American Association for Respiratory therapists www.aarc.org Respiratory Care

American Health Information Medical records www.ahima.org Management Association and information

management professionals

American Medical Technologists Medical technologists www.amt1.com

American Nurses Association Registered nurses www.ana.org

American Association for Homecare www.aahomecare Homecare administrators .org

American Occupational Occupational www.aota.org Therapy Association, Inc. therapists

American Organization of Nurse executives www.aone.org Nurse Executives

National League for Nursing Nurse faculty and www.nln.org educators

American Physical Therapy Physical therapists www.apta.org Association

American Society for Clinical Pathologists and www.ascp.org Pathology laboratory

professionals

American Society of Health- Health system www.ashp.org System Pharmacists pharmacists

TABLE 4.1 Continued

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Organization Target Audience Website

American Society of Radiologic Radiologic www.asrt.org Technologists technologists

American Speech-Language- Speech-language www.asha.org Hearing Association pathologists;

audiologists; and speech, language, and hearing scientists

Healthcare Financial Controllers, chief www.hfma.org Management Association financial officers,

and accountants

Healthcare Information and Health information www.himss.org Management Systems Society and technology

managers

National Cancer Registrars Cancer registry www.ncra-usa.org Association professionals

Trade Associations

American Hospital Association Hospitals, health www.aha.org systems, and personal membership groups

Federation of American Investor-owned www.fah.org Hospitals hospitals and health

systems

Association of American Teaching hospitals www.aamc.org/ Medical Colleges: Council of and health systems members/coth Teaching Hospitals and Health Systems

Catholic Health Association Catholic hospitals www.chausa.org of the United States and health systems

America’s Health Insurance Health insurers www.ahip.org Plans

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TABLE 4.1 Continued

This chapter focuses primarily on nurses, pharmacists, selected allied health professionals, and healthcare administrators.

Nurses

The art of caring, combined with the science of healthcare, is the essence of nursing. Nurses focus not only on a particular health problem but also on the whole patient and his or her response to treatment. Nurses work in many

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different areas, but the common thread of nursing is the nursing process, which has five steps (ANA 2008):

1. Assessment. This involves collecting and analyzing physical, psychological, and sociocultural data about a patient.

2. Diagnosis. This entails making a judgment on the cause, condition, and path of the illness.

3. Planning. This revolves around creating a care plan that sets specific treatment goals.

4. Implementation. This includes supervising or carrying out the actual treatment plan.

5. Evaluation. This focuses on continuous assessment of the plan.

Nurses also serve as patient advocates, multidisciplinary team members, managers, executives, researchers, and entrepreneurs.

Nurses make up the largest group of licensed healthcare professionals in the United States. According to the “National Sample Survey of Registered Nurses (NSSRN),” the United States has 2.9 million registered nurses (RNs), of whom more than 1.8 million (83.2 percent) are employed in healthcare or- ganizations (HRSA 2006a). Approximately 56 percent of employed RNs, or 1.6 million, work in hospitals, while 15 percent, or 435,000, work in commu- nity or public health settings. Complementing this workforce are 749,000 li- censed practical nurses, or licensed vocational nurses as they are known in some states (BLS 2006).

According to the demographic profiles from the NSSRN (HRSA 2006a), most nurses are women. In 2004, the average age of a nurse was 46.8 years old, nearly two years older than in 1997, when the average age was 44.5 years. The aging of the workforce is also reflected in the demographics of nurses: The RN population under 30 years old dropped, from 25 percent in 1980 to 8 percent in 2004. Meanwhile, the percentage of nurses older than 54 years increased to 25.2 percent in 2004, compared to 20.3 percent in 2000 and 16.9 percent in 1980. Only 5.8 percent of RNs are men, and only 11 per- cent of RNs come from racial/ethnic minority backgrounds.

All U.S. states require nurses to be licensed to practice. The licensure require- ments include graduation from an approved nursing program and successful completion of a national examination. Educational preparation distinguishes the two levels of nurses.

RNs must complete an associate’s degree in nursing (ADN), a diploma program, or a baccalaureate degree in nursing (BSN) to qualify for the licen- sure examination. ADN programs generally take two years to complete and are offered by community and junior colleges, and hospital-based diploma programs can be completed in about three years. The fastest growing avenue for nursing education is the baccalaureate preparation, which typically can be

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Registered Nurses and

Licensed Practical

Nurses

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completed in four years and is offered by colleges and universities. Licensed practical nurses (LPNs), on the other hand, must complete a state-approved program in practical nursing and must achieve a passing score on a national examination. Each state maintains regulations and practice acts that delineate the scope of nursing practice for RNs and LPNs.

Among employed RNs, about 34 percent hold associate’s degrees, 20 percent have hospital-based program diplomas, and 34 percent possess BSN degrees. In 2004, 13 percent of nurses reported having a master’s de- gree or a doctoral degree (HRSA 2006a). In addition to licensure and educa- tional achievements, some nurses obtain certification in specialty areas such as critical care, infection control, emergency nursing, surgical nursing, and ob- stetric nursing. The nursing field comprises many specialties and subspecial- ties; certification in these areas requires specialty education, practical experi- ence, and successful completion of a national examination. Some nurses obtain certification in these specialty areas because certification helps them maintain their professional associations. To remain certified, continued em- ployment, continuing education units, or reexamination may be required.

An advanced practice nurse (APN) is a nurse with particular skills and creden- tials, which typically include basic nursing education; basic licensure; a grad- uate degree in nursing; experience in a specialized area; professional certifica- tion from a national certifying body; and, if required in some states, APN licensure (National Council of State Boards of Nursing 2006). The APN spe- cializes as a nurse practitioner, certified nurse midwife, certified registered nurse anesthetist, or clinical nurse specialist.

The APN role is defined by seven core competencies or skillful per- formance areas. The first core competency of direct clinical practice is central to and informs all of the other areas, as follows (Hamric 2005):

• Direct clinical practice (central) • Expert guidance and coaching of patients, families, and other care providers • Consultation • Research skills, including use and implementation of evidence-based

practice, evaluation, and conduct • Clinical and professional leadership, which includes competence as a

change agent • Collaboration • Ethical decision-making skills

Additional core competencies may be needed in each specialty area that an APN pursues. The largest number of APNs is made up of nurse practition- ers (NPs), who may further specialize in acute care or community settings or for particular client groups such as adults, children, women, or psychiatric/ mental health populations.

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Advanced Practice Nurses

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Each state maintains its own laws and regulations regarding recogni- tion of an APN, but the general requirements in all states include licensure as an RN and successful completion of a national specialty examination. Some states permit certain categories of APNs to write prescriptions for certain classes of drugs. This prescriptive authority varies from one state to another and may be regulated by boards of medicine, nursing, pharmacy, or allied health. Some states require physician supervision of APN practices, although some managed care plans now include APNs on their lists of primary care providers.

Certified nurse midwives (CNMs) specialize in low-risk obstetric care, includ- ing all aspects of the prenatal, labor and delivery, and postnatal processes. Cer- tified registered nurse anesthetists (CRNAs) complete additional education to specialize in the administration of various types of anesthesia and analgesia to patients and clients. Often, nurse anesthetists work collaboratively with sur- geons and anesthesiologists as part of the perioperative care team. Clinical nurse specialists (CNSs) hold master’s degrees, have successfully completed a specialty certification examination, and are generally employed by hospitals as nursing “experts’’ in particular specialties. The scope of the CNS is not as broad as that of the NP; CNSs work with a specialty population under a some- what circumscribed set of conditions, and the management authority of pa- tients still rests with physicians. In contrast, NPs have developed an au- tonomous role in which their collaboration is encouraged, and they generally have the legal authority to implement management actions.

Pharmacists

In the foreseeable future, the pharmacy profession will continue to undergo extensive change. Until the 1970s, pharmacists performed the traditional role of preparing drug products and filling prescriptions. In the 1980s, however, pharmacists expanded that role. Pharmacists now act as an expert for clients and patients on the effects of specific drugs, drug interactions, and generic drug substitutions for brand-name drugs.

To be eligible for licensure, pharmacists must graduate from an accred- ited bachelor-degree program in pharmacy, successfully complete a state board examination, and obtain practical experience or complete a supervised internship. After passing a national examination, a registered pharmacist (RPh) is permitted to carry out the scope of practice outlined by state regula- tions. The trend in pharmacy has been to broaden education to include the terminal degree Doctor of Pharmacy (PharmD). Many pharmacy schools of- fer this program for those interested in research careers, teaching, higher ad- ministrative responsibility, or being part of the patient care team. This educa- tional preparation also requires successful completion of a state board examination and other practical clinical experience, as outlined by state laws.

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APN Specialization

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Allied Health Professionals

The term “allied health professionals” is generally not well understood be- cause of its ambiguous definition (O’Neil and Hare 1990) and a lack of con- sensus about what such a role constitutes. In general, allied health profession- als complement the work of physicians and other healthcare providers, although one may also be a provider. The U.S. Public Health Service defines an allied health professional as follows (Health Professions Education Exten- sion Amendments of 1992, Section 701 PHS Act):

. . . a health professional (other than a registered nurse or a physician as- sistant) who has received a certificate, an associate’s degree, a bachelor’s degree, a master’s degree, a doctoral degree, or post-baccalaureate train- ing in a science related to health care; who shares in the responsibility for the delivery of health care services or related services, including (1) serv- ices relating to the identification, evaluation and prevention of disease and disorders, (2) dietary and nutrition services, (3) health promotion serv- ices, (4) rehabilitation services, or (5) health systems management serv- ices; and who has not received a degree of doctor of medicine, a degree of doctor of osteopathy, a degree of doctor of veterinary medicine or equiv- alent degree, a degree of doctor of optometry or equivalent degree, a de- gree of doctor of podiatric medicine or equivalent degree, a degree of bachelor science in pharmacy or equivalent degree, a graduate degree in public health or equivalent degree, a degree of doctor of chiropractic or equivalent degree, a graduate degree in health administration or equiva- lent degree, a degree of doctor of clinical psychology or equivalent degree, or a degree in social work or equivalent degree.

A debate on the exclusiveness and inclusiveness of this definition con- tinues. Some healthcare observers consider nursing, public health, and social work to fall under the umbrella of allied health, but these professions are of- ten categorized as separate groups. Figure 4.1 lists the major categories that compose the allied health profession and the job titles and positions that nor- mally fall under each category.

According to the “2006 National Occupational and Wage Estimates for Healthcare Personnel,” the allied health professions constitute 45.5 per- cent of the healthcare workforce in the United States (BLS 2007). This num- ber excludes physicians, nurses, dentists, pharmacists, veterinarians, chiroprac- tors, and podiatrists. The allied health profession is the most heterogeneous of the personnel groupings in healthcare.

The National Commission on Allied Health (1995) broadly divided allied health professionals into two categories of personnel: (1) therapists/ technologists and (2) technicians/assistants. Some of the job titles presented in Figure 4.1 may not fit into these two categories. In general, the therapist/ technologist category represents those with higher-level professional training

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Behavioral Health Services

• Substance abuse counselor • Community health worker • Home health aide • Mental health assistant • Mental health aide

Clinical Laboratory Sciences

• Laboratory associate • Laboratory microbiologist • Laboratory technician • Chemist (biochemist)

• Microbiologist • Associate laboratory microbiologist

Dental Services

• Dental assistant • Dental hygienist • Dental laboratory technologist

Dietetic Services

• Dietitian • Assistant director of food service • Dietary assistant • Associate supervising dietitian

Emergency Medical Services

• Ambulance technician • Emergency medical technician

Health Information Management Services

• Director of medical records • Senior analyst of medical records • Assistant director of medical records • Health information manager • Medical record specialist • Data analyst

• Coder

Medical and Surgical Services

• Electroencephalograph technician • Medical equipment specialist • Electroencephalograph technologist • Electrocardiograph technician • Operating room technician • Dialysis technologist • Biomedical equipment technician • Surgical assistant • Biomedical engineer • Ambulatory care technician • Cardiovascular technologist

Occupational Therapy

• Occupational therapist • Occupational therapy aide • Occupational therapy assistant

Ophthalmology • Ophthalmic technician • Optician • Optometric aide

FIGURE 4.1 Major

Categories of the Allied

Health Profession and

Professional Titles

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Physical Therapy

• Physical therapist • Physical therapy assistant

Radiological Services • Nuclear medicine technician • Nuclear medicine technologist • Radiation technician • Diagnostic medical sonographer • Ultrasound technician • Radiologic (medical) technologist • Medical radiation dosimetrist

Rehabilitation Services • Art therapist • Music therapist • Exercise physiologist • Dance therapist • Recreational therapist • Rehabilitation counselor • Recreation therapy assistant • Rehabilitation technician • Addiction counselor • Sign-language interpreter • Addiction specialist • Psychiatric social health technician

Orthotics/Prosthetics

• Orthopedic assistant

Respiratory Therapy Services

• Respiratory therapist • Respiratory therapy technician • Respiratory therapy assistant

Speech-Language Pathology/Audiology Services

• Audiology clinician • Staff audiologist • Staff speech pathologist • Speech clinician

Other Allied Health Services

• Central supply technician • Medical illustrator • Podiatric assistant • Veterinary assistant • Health unit coordinator • Chiropractic assistant • Home health aide

and who are often responsible for supervising those in the technician/assistant category. Therapists/technologists usually hold a bachelor’s or a higher-level degree, and they are trained to evaluate patients, understand diagnoses, and develop treatment plans in their area of expertise. On the other hand, technicians/assistants are most likely to have two years or less postsecondary education, and they are functionally trained with procedural skills for speci- fied tasks.

FIGURE 4.1 Continued

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Educational and training programs for the allied health profession are sponsored by a variety of organizations in different academic and clinical set- tings. They range from degree offerings at colleges and universities to clinical programs in hospitals and other health facilities. Before 1990, one-third of al- lied health programs were housed in hospitals, although hospitals graduated only 15 percent of their students (O’Neil and Hare 1990). The Association of Schools of Allied Health Professions (ASAHP 2007) includes these among its membership: 112 academic institutions, 2 professional associations, and approximately 200 individual members. Junior or community colleges, voca- tional or technical schools, and academic health centers can all sponsor allied health programs. These programs can also be stand-alone when aligned with an academic health center, or they can be under the auspices of the school of medicine or nursing if a specific school of allied health professions does not exist. Dental and pharmacy technicians/assistants may or may not be trained in their respective schools or in a school of allied health professions.

A vast number of the undergraduate allied health programs are accred- ited by the Commission on Accreditation of Allied Health Education Programs (CAAHEP), a freestanding agency that in 1994 replaced the American Med- ical Association’s Committee on Allied Health Education and Accreditation. The formation of CAAHEP was intended to simplify the accrediting process, to be more inclusive of allied health programs that provide entry-level educa- tion, and to serve as an initiator of more far-reaching change. Some key allied health graduate programs, such as physical therapy and occupational therapy, are accredited through specialty professional accreditation organizations.

Healthcare Administrators

Healthcare administrators organize, coordinate, and manage the delivery of health services; provide leadership; and guide the strategic direction of health- care organizations. The variety and numbers of healthcare professionals they employ; the complexity of healthcare delivery; and environmental pressures to provide access, quality, and efficient services make healthcare institutions among the most complex organizations to manage.

Healthcare administration is taught at the undergraduate and graduate levels in a variety of settings, and these programs lead to a number of different degrees. The settings include schools of medicine, public health, healthcare business, and allied health professions. A bachelor’s degree in health adminis- tration allows individuals to pursue positions such as nursing home administra- tor, supervisor, or middle manager in healthcare organizations. Most students who aspire to have a career in healthcare administration go on to receive a mas- ter’s degree. (For a detailed description of various career paths and options, see Haddock, McLean, and Chapman 2002).

Graduate education programs in healthcare administration are ac- credited by the Commission on Accreditation of Healthcare Management

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Education. Most common degrees include the master of health administra- tion (MHA), master of business administration (MBA) with a healthcare em- phasis), master of public health (MPH), or master of public administration (MPA). However, the MHA degree, or its equivalent, has been the accepted training model for entry-level managers in the various sectors of the health- care industry. The MHA program, when compared to the MPH program, of- fers core courses that focus on building business management (theory and ap- plied management), quantitative, and analytical skills and that emphasize experiential training. In addition, some MHA programs require students to complete three-month internships or 12-month residencies as part of their two- or three-year curricula. Some graduates elect to complete postgraduate fellowships that are available in selected hospitals, health systems, managed care organizations, consulting firms, and other health-related organizations.

A growing number of healthcare administrators are physicians and other clinicians. As evidence, membership in the American College of Physi- cian Executives (ACPE 2007) has increased to more than 10,000 in 2007, up from 5,700 in 1990, although stable since 2000. Physicians, nurses, and other clinicians refocus their careers on the business side of the enterprise, getting involved in the strategy, decision making, resource allocation, and operations of healthcare organizations. A traditional management role for physician ex- ecutives is the chief medical officer (or a similar position) in a hospital, over- seeing the medical staff and serving as a liaison between clinical care and ad- ministration. Likewise, a typical management career path for nurses is to become the chief nursing officer, with responsibility for the clinical care pro- vided by employed professional staff.

Typically, chief medical officers begin their careers practicing medi- cine, then they slowly transition into the operations side of healthcare. How- ever, physician executives work at every level and in every setting in health- care. Many physician executives earn a graduate degree such as an MHA or an MBA if interested in pursuing a formal educational program in healthcare administration and management. As of 2007, 49 medical schools offer a combined MD/MBA program, and two medical schools offer the MD/MHA dual degrees (AAMC 2007). Whether physician executives start as administrators or later shift to become executives after clinical practice, they represent for other doctors an alternative way to make an impact on healthcare delivery.

Nursing home administrator programs require students to pass a na- tional examination administered by the National Association of Long Term Care Administrator Boards. Passing this examination is a standard require- ment in all states, but the educational preparation needed to qualify for this exam varies from state to state. Although more than one-third of states still require less than a bachelor’s degree as the minimum academic preparation, approximately 70 percent of the practicing nursing home administrators have,

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at a minimum, a bachelor’s degree. As the population continues to live longer, the demand and educational requirements for long-term-care administrators are estimated to increase, along with the growth of educational programs tar- geted to this sector.

Considerations for Human Resources Management

The role of human resources management (HRM) in healthcare organiza- tions is to develop and implement systems, in accordance with regulatory guidelines and licensure laws, that ensure selection, evaluation, and retention of healthcare professionals. In light of this role, human resources (HR) per- sonnel should be aware that each of the healthcare professions, and often the subspecialties within those professions, has specific requirements that allow an individual to qualify for an entry-level job in his or her chosen profession. The requirements of national accrediting organizations (e.g., the Joint Commis- sion), regulatory bodies (e.g., the Centers for Medicare & Medicaid Services), and licensure authorities (e.g., state licensure boards) should be considered in all aspects of HRM. In this section, we briefly discuss some of the issues that a healthcare organization’s HR department must consider when dealing with healthcare professionals.

Qualifications

In developing a comprehensive employee-compensation program, HR per- sonnel must include the specific skill and knowledge required for each job in the organization. Those qualifications must be determined and stated in writing for each job. The job description usually contains the level of educa- tion, experience, judgment ability, accountability, physical skills, responsibil- ities, communication skills, and any special certification or licensure require- ments. HR personnel need to be aware of all specifications for all job titles within the organization. This knowledge of healthcare professionals is neces- sary to ensure that essential qualifications of individuals coincide with job specifications, and it is also necessary for determining wage and salary ranges (see Chapter 7).

Licensure and Certification

An HR department must have policies and procedures in place that describe the way in which licensure is verified on initial employment. Also, HR must have a system in place for tracking the expiration dates of licenses and for en- suring licensure renewal. Therefore, HR must be conscientious about whether the information it receives is a primary verification (in which the in- formation directly comes from the licensing authority) or a secondary verifica- tion (in which a candidate submits a document copy that indicates licensure

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has been granted, including the expiration date). Certifications must be veri- fied during the selection process, although certifications and licenses are gen- erally not statutory requirements. Many healthcare organizations accept a copy of a certification document as verification. If the certification is a job re- quirement, systems must be in place to track expiration dates and to access new certification documents.

Career Ladders

In selecting healthcare professionals, HR personnel must consider past em- ployment history, including the explanation of gaps in employment. To assess the amount of individual experience, evaluating the candidate’s breadth and depth of responsibility in previous jobs is essential. Many healthcare organiza- tions have career ladders, which are mechanisms that advance a healthcare professional within the organization. Career ladders are based on the Dreyfus and Dreyfus model of novice to expert (explained earlier in the chapter), and experience may be used as a criterion for assignment of an individual to a par- ticular job category. In addition, healthcare organizations may conduct annual reviews of employees who have leadership and management potential. This re- view entails that HR works with senior management to assess the competency, ability, and career progression of employees on an ongoing basis.

Educational Services

Healthcare professionals require continuous, lifelong learning. Healthcare or- ganizations must have in-house training and development plans to ensure that their healthcare professionals achieve competency in new technologies, pro- grams, and equipment and are aware of policy and procedure changes. Cer- tain competencies must be renewed annually in areas such as cardiopulmonary resuscitation, safety and infection control, and disaster planning.

In addition to developing specific training programs, healthcare organ- izations should provide orientation for all new employees. Such organization- specific training enables the leadership to share the values, mission, goals, and policies of the institution. Such clear communication often serves as a reten- tion tool that enables employees to better understand how the organization works and how to be successful in that organization. Similarly, some profes- sions and licensing jurisdictions may require continuing education that is pro- fession specific.

A healthcare organization can provide training and development in a variety of ways. On one end of the spectrum, training and development can be outsourced to a firm that specializes in conducting educational programs. Conversely, another option is to consolidate all training and development in- house, which are managed typically by the HR department. Regardless of how each healthcare organization provides continuing education, training and de- velopment should be a priority. Strong programs can be viewed as recruitment

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and retention tools. As such, healthcare organizations must be cognizant of fiscal resources necessary to support these educational requirements.

Practitioner Impairment

Healthcare professionals are accountable to the public for maintaining high professional standards, and the governing body of a healthcare organization is, by statute, responsible for the quality of care rendered in the organization. This quality is easily jeopardized by an impaired practitioner. An impaired practitioner is a healthcare professional who is unable to carry out his or her professional duties with reasonable skill and safety because of a physical or mental illness, including deterioration through aging, loss of motor skill, or excessive use of drugs and alcohol.

The HR department must periodically evaluate the performance of all healthcare professionals in the organization to ensure their competence (i.e., the basic education and training necessary for the job) and proficiency (i.e., the demonstrated ability to perform job tasks). Mechanisms must be in place to identify the impaired practitioner, such as policies and procedures that de- scribe how the organization will handle investigations, subsequent recom- mendations for treatment, monitoring, and employment restrictions or sepa- ration. Hospitals, for instance, usually have a process in place for the board of directors (which has the ultimate responsibility for the quality of care deliv- ered in the organization) to review provider credentials and performance and to oversee any employment actions. Each national or state licensing authority maintains legal requirements for reporting impaired practitioners.

As a result of ever-increasing changes in the health professions, in the foreseeable future, new challenges and opportunities, such as the issues described in this section, will face the HR department of every healthcare organization.

Changing Nature of the Health Professions

In the 1990s, we entered a new era of uncertainty in healthcare, one faced with a quickening pace of change (Begun and White 2008). Within this framework, new ways of thinking are rewarded as the meaning of health is re- defined, the boundaries of healthcare professionals are reshaped, and the out- comes of healthcare professional interventions are measured in terms of qual- ity of life. Changes in the organization and financing of healthcare services have shifted delivery from the hospital to outpatient facilities, the home, long-term-care facilities, and the community. This is largely the result of three major forces: (1) a shift in managed care reimbursement to outpatient settings and a focus on cost containment; (2) technological advances, such as

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telemedicine and the electronic medical record; and (3) medical innovation— the science of medicine has progressed to the point that complicated procedures that once required several nights of stay can now be treated with a simple pro- cedure or even solely with medication. These changes are intended to improve the delivery of healthcare while reducing cost and increasing access for patients.

As the setting for the delivery of care continued to change, so did arrangements between physicians and healthcare organizations. For instance, physicians can function as individual providers (either in solo or group prac- tice) and refer patients to the hospital. Typically, these private-practice doctors have admitting privileges to the hospital but are not governed by the hospi- tal, do not serve as attending physicians, and infrequently participate on hos- pital committees. Physicians considered “on staff” at any hospital are those who refer and treat patients at that hospital. They are credentialed by the hos- pital credentialing committee (usually managed by the chief of staff office) and are governed by the medical staff bylaws. This is a common type of hos- pital-provider arrangement.

However, a trend toward hospitals employing physicians has been growing. In this arrangement, physicians are on staff, referring to and treat- ing at only the hospital that employs them. Because they are considered em- ployees, physicians are not only held to the HR policies of the healthcare or- ganization but are also governed by the medical staff bylaws. Physicians who are employed by a hospital can also maintain a private practice.

Finally, the field of hospitalists is also growing. Typically, these physi- cians do not run their own practice aside from their hospital employment. Hospitalists work full time for the hospital and are trained in delivering spe- cialized inpatient care. Regardless of the type of arrangement, most hospitals have a chief medical officer, or a similar position, who oversees the roles and responsibilities of the hospitalist as a member of the medical staff; the hospi- talist’s employee issues and responsibilities are typically managed by the HR department. These hospital–physician arrangements get more complex in ac- ademic medical centers, which must integrate the roles and responsibilities of the physicians, the hospital, and the medical school.

As a result of the changing environment and decreased reimburse- ment, more primary care physicians are joining or forming group practices. Large physician-owned group practices offer several advantages to physi- cians, including competitive advantage with vendors and manufacturers, im- proved negotiating power with managed care organizations, shared risk and decision making, and improved flexibility and choice for patients. Physicians usually own or share ownership in the group practice and, therefore, are re- sponsible for the business operations. Typically, group practices employ an office manager who works closely with the physicians to manage the day-to- day operations. Often, a full-time administrator is on staff not only to man- age everyday issues but also to formulate strategies and oversee personnel,

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billing and collection, purchasing, patient flow, and other functions. Many group practices opt to outsource their business functions, including human resources, to specialized firms. For complete details on medical practice man- agement, go to www.mgma.com.

These shifts in various healthcare settings and arrangements have changed the roles, functions, and expectations of the healthcare workforce and gave way to the emergence of the following issues.

Supply and Demand

Throughout the twentieth century, the nursing labor market cycled through periods of shortages and surpluses (Lynn and Redman 2005; Aiken et al. 2002; Kovner 2002; Coile 2001; Jones 2001; Buerhaus, Staiger, and Auer- bach 2000). The beginning of the twenty-first century brought the nursing and allied health professions the challenge of keeping pace with the demand for their services. Indicators of demand include numbers of vacancies, turnover rates, and an increase in salaries. To fill positions, hospitals—the largest employers of nurses and allied health professionals—have raised salaries, provided scholarships, and given other incentives such as sign-on bonuses and tuition reimbursement.

The supply of nurses and allied health professionals is reflected in the number of students in educational programs and those available for the healthcare workforce. Future supply of such professionals continues to be threatened by the following factors:

• The aging of the nursing workforce. According to the results of the 2004 National Sample Survey of Registered Nurses (HRSA 2006a), the average age for all nursing faculty was 51.6, and for nursing faculty who have doctoral degrees, it was 55.4 (up from 53.5 in 2003).

• The decline in available educational resources. Almost two-thirds (68.5 percent) of the nursing schools that responded to the 2006 American Association of Colleges of Nursing (AACN 2007a) survey identified faculty shortages as a reason for not accepting all qualified applicants into entry-level baccalaureate programs. The survey also noted lack of classroom space and clinical facilities and budgetary restraints.

• The decline in nursing school enrollees. From 1995 through 2000, enrollment decreased by 21 percent. From 2001 through 2007, increases of 3.7 to 16.6 percent were observed, but more than 30,000 qualified applicants were turned away from baccalaureate nursing programs in 2007 (AACN 2007a).

As a result, recruitment of nursing and allied health professions stu- dents has become a major focus of practitioners, professional associations, and academic institutions. In response, healthcare organizations (in addition to in- creasing salaries) are developing innovative ways to recruit and retain nurses

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and allied health professionals. Such developments include opening or spon- soring new schools, offering shorter and more flexible shifts, and providing child care.

Alternative Therapies

Alternative therapies have gained more popularity, judging by the growing number of publications on this topic in the lay press and in academic literature. A turning point in this acceptance and increased respectability was the sentinel study of the prevalence of the use of alternative or unconventional therapies (Eisenberg et al. 1993). In the study, Eisenberg and colleagues concluded that one in three adults relied on treatments and interventions that are not widely taught at medical schools in the United States; examples of these alternative in- terventions included acupuncture and chiropractic and massage therapies. In a follow-up study, Eisenberg and colleagues (1998) determined that, from 1990 to 1997, visits to alternative medicine practitioners increased by 47.3 percent. Another study reported that 75 (60 percent) out of the 125 medical schools that participated in the survey offered a course in complementary or alterna- tive medicine (Wetzel, Eisenberg, and Kaptchuk 1998). Additionally, con- sumers are demanding the use of alternative therapies, and hospitals have be- gun offering more of these services (Clement et al. 2006). As the use of alternative therapies continues to gain acceptance and to be integrated in med- ical school curriculum, this specialty area may be more and more considered as an emerging healthcare profession.

Nonphysician Practitioners

With the advent of managed care, greater reliance has been placed on non- physician practitioners. Collaborative practice models with nurse practition- ers, physician assistants, pharmacists, and other therapists are appropriate to both acute and long-term healthcare delivery. Strides have been made in the direct reimbursement for some nonphysician healthcare provider services, which is an impetus for further collaboration in practice. The consolidation and integration of the healthcare delivery system have not, however, elimi- nated slack and duplication of services. Although the changes attributed to managed care have led to the promotion and use of less-costly sites for care delivery, a larger impact on the division of labor among all healthcare profes- sionals, and thus on health professions, may yet occur.

Licensure and Certification

The use of nonphysician practitioners at various sites may be viewed as an op- portunity for the growth of nursing, pharmacy, allied health professions, and health administration. Alternatively, Hurley (1997) contends that it may lead to concerted efforts to repeal professional licensure and certification in health- care. If policymakers jump on the bandwagon, this deregulation may lead to

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not only the demise of some healthcare professions but also the proliferation of functionally trained, unlicensed personnel. The use of personnel who have less education will have greater implications for the existence and growth of educa- tional programs in academic medical centers. The use of unlicensed support per- sonnel poses concerns about the intensity and quality of healthcare delivered. When fewer highly trained professionals are employed to oversee operations and care delivery, the potential for adverse outcomes increases. Aiken, Sochalski, and Anderson (1996) found that, although the percentage of RNs increased over- all, fewer nurses per patient were available in the mid-1990s than in the 1980s to provide care for more acutely ill patients. The net effect was a relative increase in nonclinical personnel, which added stress for those who were expected to su- pervise unlicensed staff and to care for sicker patients. This is a trend that con- tinues to affect the provision of healthcare (Aiken et al. 2002).

Recruitment and Retention

Recruitment and retention of healthcare professionals are important in the face of continuing shortages in key healthcare professions, including nursing and allied health professions. The American Hospital Association (2007) re- ported an average hospital nurse vacancy rate of 8.1 percent. The RN vacancy rate is projected to be 20 percent by 2020 (Buerhaus, Staiger, and Auerbach 2000; Heinrich 2001). This vacancy rate is related to an RN shortage, which is estimated to be in the range of 340,000 to 1 million nurses by 2020 (Auer- bach, Buerhaus, and Staiger 2007; HRSA 2006b). Nearly 17 percent of RNs were not employed in nursing in 2004, which was a 26.2 percent increase over the 1992 rate (HRSA 2006a). Letvak (2002) predicted that one in five nurses planned to leave the profession and turnover costs could be up to two times a nurse’s salary. Fifty-five percent of nurses reported their intention to retire between 2011 and 2020 in a survey released in 2006 (AACN 2007b), which would further contribute to the RN shortage. Similarly, the American Hospi- tal Association (2007) reported vacancy rates among allied health profession- als (e.g., occupational and physical therapists, laboratory technologists, imag- ing technicians) that range from 6 percent to 11 percent of needed positions. These shortages require current professionals to treat more patients and to work longer hours. Such conditions can contribute to emergency department diversions, increased patient wait times, and decreased patient safety.

In response, healthcare organizations need to develop and execute re- cruitment and retention programs. These programs require senior manage- ment support and dedicated financial and human resources. Such programs should focus on building a culture of retention. While salary is an important aspect of employee recruitment and retention, other aspects of work are also influential, such as leadership support, ability to contribute to the organ- ization and provide quality care to patients, degree of autonomy, engaging in positive relationships with direct supervisors and peers, good working

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conditions, and ability to maintain a work–life balance. Additional tools for retaining employees include conducting employee-engagement surveys, pro- viding mentoring, and making training programs available.

One innovative way to differentiate a hospital from its competitors, which helps in recruitment and retention, is to achieve Magnet status. In 1993, the American Nurses Credentialing Center’s Magnet Recognition Pro- gram was developed as a way to specifically recognize excellence in nursing services at the institutional level and to benchmark best practices to be dissem- inated throughout the industry. Hospitals that apply for and achieve Magnet status have created and demonstrated a professional practice environment that ensures quality outcomes. These hospitals are recognized for their best prac- tices in nursing care, improved patient outcomes, and increased workplace sat- isfaction. The actual evaluation process is based on nine Magnet standards, the completion of an intensive written application, and a two-day site visit by a team of nurse scholars. Hospitals that do not wish to engage in the applica- tion process can benefit greatly from using Magnet strategies to create a cul- ture based on excellence in nursing and patient care (Pieper 2003). For more information on Magnet status, see www.nursecredentialing.org/magnet.

Entrepreneurship

Given the bureaucratic nature of organizations, the regulation of the health- care industry, and additional constraints by payers and managed care, many healthcare professionals are choosing to pursue opportunities on their own. The service economy coupled with knowledge-based professions may encour- age pursuit of new and different ventures for individuals who have the person- ality, skills, and tenacity to go into business for themselves. An entrepreneur must have a mix of management skills and the means to depart from a tradi- tional career path to practice on one’s own.

White and Begun (1998) characterize the entrepreneurial personality traits of a profession in terms of its willingness to take the risks associated with undertaking new ventures. Each profession may be categorized either as de- fending the status quo, which therefore entails little risk (defender professions), or as looking for new and different opportunities with greater risk (prospector professions). White and Begun view the more entrepreneurial professions as more diversified in terms of processes and services delivered. The accrediting bodies of such entrepreneurial professions encourage educational innovation that may extend to nontraditional careers. Each of the healthcare professions has, to greater or lesser extents, defender and prospector aspects.

Workforce Diversity

Each of the healthcare professions must continue to monitor and encourage diversity in its membership because the demographic shifts that the United States is going through will have an impact on the workforce composition in

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the coming decades. Although workforce diversity is a broad concept, it fo- cuses on our differences in gender, age, and race; these aspects not only re- flect the population that healthcare serves but also the people who provide the services. Some professions are dominated by one gender or the other, which is illustrated by the predominantly female field of nursing or the historically predominantly male field of health administration. The health administration profession, however, has made strides in recent years as more female adminis- trators have entered the field. Labor shortages and employee turnover are common in the healthcare professions. Consequently, healthcare executives must balance the needs of new entrants into the profession and those already in the profession.

Changes in the ethnic and racial composition of the workforce are pro- portional to the changes in the size and age of the population (D’Aunno, Alexander, and Laughlin 1996). Because many healthcare professionals are racial/ethnic minorities, a concerted effort needs to be made to recruit and retain them because the diversity of the members of a profession should re- flect the diversity of the members of the population.

Summary

Healthcare professionals are a large segment of the U.S. labor force. Histori- cally, the development of healthcare professionals is related to the following trends:

• Supply and demand • Increased use of technology • Changes in disease and illness • The impact of healthcare financing and delivery

The healthcare workforce is very diverse. The different levels of education, scopes of practice, and practice settings contribute to the complexity of manag- ing this workforce. The coming decades will be characterized by some reforms within the healthcare professions because of increasing pressures to finance and deliver healthcare with higher-quality, lower-cost, and measurable outcomes.

94 H u m a n R e s o u r c e s i n H e a l t h c a r e

1. Describe the process of profes- sionalization. What is the difference between a profession and an occupation?

2. Describe the major types of healthcare professionals (excluding physicians and dentists) and their roles, training, licensure requirements, and practice settings.

Discussion Questions

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References

Aiken, L. H., S. P. Clarke, D. M. Sloane, J. Sochalski, and J. H. Silber. 2002. “Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction.” JAMA 288 (16): 1987–93.

Aiken, L. H., J. Sochalski, and G. F. Anderson. 1996. “Downsizing the Hospital Nursing Workforce.’’ Health Affairs 15 (4): 88–92.

American Association of Colleges of Nursing (AACN). 2007a. “Enrollment Growth Slows at U.S. Nursing Colleges and Universities in 2007 Despite Calls for More Regis- tered Nurses.” [Online news release; retrieved 1/31/08.] www.aacn.nche.edu/ Media/NewsReleases/2007/enrl.htm.

———. 2007b. “Nursing Shortage.” [Online news release; retrieved 1/29/08.] www.aacn .nche.edu/Media/FactSheets/NursingShortage.htm.

American College of Physician Executives (ACPE). 2007. [Online information; retrieved 2/4/08.] www.acpe.org/Footer/AboutACPE.aspx.

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3. Describe and apply the issues of human resources management and systems development to healthcare professionals.

4. How has managed care affected the healthcare professions?

5. Who are nonphysician practitioners who provide primary care? What is their role in the delivery of health services?

Experiential Exercise

The purpose of this exercise is to give you an opportunity to explore one healthcare pro- fession in detail.

From all of the healthcare professions, select one for analysis. Table 4.1 provides a starting point for selection. Describe the fol- lowing characteristics of the profession you selected:

• Knowledge base • Collective goals • Training • Licensure (this varies by state) • Number of professionals in practice by

1. Vertical differentiation (position, experience, education level)

2. Horizontal differentiation (geography, practice setting, specialty)

• History and evolution of the profession • Professional associations and their roles • Competitor professions • Current strategic issues that face the

profession and the profession’s position on these issues

To get started on this exercise, you may wish to go to the websites of profes- sional organizations and various state licens- ing boards. You may also interview members of the profession as well as leaders in the field.

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American Hospital Association. 2007. “The 2007 State of America’s Hospitals—Taking the Pulse: Findings from the 2007 AHA Survey of Hospital Leaders July 2007.” [Online information; retrieved 1/31/08.] www.aha.org/aha/content/2007/ PowerPoint/StateofHospitalsChartPack2007.ppt.

American Nurses Association (ANA). 2008. “The Nursing Process: A Common Thread Amongst All Nurses.” [Online article; retrieved 2/6/08.] www. nursingworld.org/EspeciallyForYou/StudentNurses/Thenursingprocess.aspx.

Association of American Medical Colleges (AAMC). 2007. “Combined Degree Pro- grams.” [Online article; retrieved 7/16/07.] http:/services.aamc.org/currdir/ section3/degree2.cfm.

Association of Schools of Allied Health Professions (ASAHP). 2007. [Online information; retrieved 2/4/08.] www.asahp.org/history.htm.

Auerbach, D. I., P. I. Buerhaus, and D. O. Staiger, 2007. “Better Late than Never: Work- force Supply Implications of Later Entry into Nursing.” Health Affairs 26 (1): 178–85.

Begun, J. W., and K. R. White. 2008. “Positioning Nursing for Leadership in a Complex Healthcare System.’’ In On the Edge: Nursing in the Age of Complexity, edited by C. Lindberg, S. Nash, and C. Lindberg. Allentown, NJ: Plexus Institute.

Buerhaus, P. I., D. O. Staiger, and D. I. Auerbach. 2000. “Implications of a Rapidly Ag- ing Registered Nurse Workforce.” JAMA 283 (22): 2948–54.

Bureau of Labor Statistics (BLS). 2006. “Licensed Practical and Licensed Vocational Nurses, 2006.” [Online information; retrieved 2/5/08.] www.bls.gov/oco/ ocos102.htm.

———. 2007. “Health Care.” [Online information; retrieved 2/6/08.] www.bls.gov/ oco/cg/cgs035.htm.

Clement, J. P., H. Chen, D. Burke, D. G. Clement, and J. L. Zazzali. 2006. “Are Con- sumers Reshaping Hospitals? Complementary and Alternative Medicine in US Hospitals 1999–2003.” Health Care Management Review 31 (2): 109–18.

Coile, R. C. 2001. “Magnet Hospitals Use Culture, Not Wages, to Solve Nursing Short- age.” Journal of Healthcare Management 46 (3): 224–28.

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