The Health Care Employer's Perspective (2023)

MANY OF THE THEMES THAT RUN SEPARATELY through this report come together when we begin to view allied health workers from the perspective of health care employers. When the supply of practitioners in an allied health field declines because fewer students choose that career or because schools close, health care administrators who employ allied health personnel are among the first to experience the change. If licensure laws change or a new technology, is introduced, employers are among the first to respond to the change. When a glut of workers in an allied health field exists in a locality, employers notice it in the number of responses they get to vacancies they advertise.

Employers are not merely users of a given supply of allied health personnel, however—they are also active participants in the forces that determine the supply of workers. In other words, the quantity of workers demanded and the quantity supplied are not independent. Wage and salary rates and working conditions affect the supply of workers. The supply of workers in turn affects the wages, salaries, and working conditions that they are offered. Yet employers setting wage and salary levels have to balance many considerations other than the amount of money needed to attract the required number of workers. They must consider the payment they can get for services and the bottom-line impact of personnel expenses, the regulatory requirements that constrain work force deployment, and the skills and knowledge demanded by the technologies in use.

In the past, cost-based reimbursement, the absence of competition, and a generally adequate supply of allied health personnel allowed administrators to make the salary adjustments that were needed to maintain their desired staffing levels. They were able to accomplish this without appreciably changing staffing or service levels or the deployment of staff. Yet changes in the health care system and in allied health labor markets may force administrators to rethink their staffing practices. There will be increasing competition for technically oriented workers, who have more employment options than nontechnical workers. In addition, administrators will have strong economic incentives to control personnel costs to compete in terms of price, yet remain financially viable.

These changes have created a new environment with which administrators have little experience. Although some administrators have had to face periodic shortages of nurses, only recently have they faced personnel shortages and price competition simultaneously. There is no historical pattern to indicate how employers will adapt to difficulties in hiring and staffing.

The committee identified some allied health professions in which shortages are likely to occur if changes in the labor market fail to take place. This chapter focuses on forestalling shortages; it emphasizes the importance of planning for the future. Market mechanisms will force adjustments that will eventually decrease stresses in the allied health labor market. Yet markets adjust slowly. For example, there is a considerable lag between educational institutions recognizing and responding to increased student interest in an allied health field and an increased number of graduates in that field. Employers have many reasons to act early to forestall possible personnel shortages. For instance, acute shortages of workers in an allied health field may cause salaries to rise sharply, some services to close, or the initiation of new needed services to be postponed. More subtly, the quality of health care may be eroded if, over extended periods of time, too few existing employees must struggle to maintain services. These and other serious service dislocations could be reduced if administrators were to respond appropriately to early market signals.

In this chapter the committee focuses mainly on what personnel administrators, corporate human resource administrators, and department heads in all types of health care facilities—hospitals, nursing homes, freestanding facilities—might consider doing to help relieve or prevent personnel shortages. It discusses two types of activities that can produce gains in personnel supply: (1) making employment more attractive, and (2) using the available work force more effectively. None of the activities discussed is new; they have been tried in fields other than allied health. There is a need for further investigation, however, to ascertain which activities are best suited to resolve problems with the allied health labor force, taking into account the different characteristics of the work force in each field.

There are other ways in which health care providers can lessen their personnel problems. For instance, hospitals in Texas have responded to shortages by using the state hospital association to mount an elaborate campaign to recruit high school graduates into health careers (Texas Health Careers, 1987). Other mechanisms, such as offering vacationing high school students jobs in health care facilities, are also used to inform and encourage students to select health care careers.

Throughout this chapter, terms such as "human resource administrators" and "facility administrators" are used. These terms are purposefully vague. Health care organizations often have a personnel function to facilitate the details of personnel management, departmental administrators who make decisions about the deployment of staff, and upper level human resource administrators who deal with facility-wide labor force issues. This fragmentation makes it difficult to develop and implement creative staffing arrangements that would likely be part of the solution to allied health staffing problems.

Strategies for Employers to Enhance The Supply of Allied Health Practitioners

Several factors play roles in creating imbalances between the supply of and demand for allied health workers: the diminishing size of the college-age population; students' propensities to choose careers outside of health care; and the decreasing availability of allied health programs on the one hand and the aging of the population, disease patterns, and technological advances in health care on the other. These imbalances will likely remain unless something changes on one or both sides of the equation. However, generalizations of this sort do not apply to all allied health fields or to all parts of the country. Demand and supply vary from place to place, and with varying characteristic circumstances. Individual facilities and areas will in some cases experience an adequate or even excess supply of personnel in fields in which a national shortage is predicted, and the balance between supply and demand will differ among the fields. This is readily apparent today as facility administrators in some parts of the country struggle to hire physical therapists when, for example, respiratory therapists are plentiful.

The expectation is that in many parts of the nation and for many employers of allied health practitioners the labor market will be tight.

To increase the supply of workers, employers can intervene to make education more accessible and employment more attractive. Students may then be more likely to select allied health careers. People who have left the work force to pursue other interests—raising families, new careers, or leisure—may return. In addition, workers may choose to remain in the work force longer or to remain in a particular career longer. Increasing the supply of workers by encouraging greater numbers of students to enter the allied health fields is a strategy that depends both on employers making employment in allied health careers more attractive and on educational institutions expanding programs in response to increased student demand.

The second strategy for coping with shortages, using workers more productively or effectively, in essence reduces the demand for allied health personnel at a given level of output. Yet there are limits to the productivity improvements that can be achieved. These limits can result from regulatory restrictions, the skills of individuals, technological constraints, or the nature of the work. The challenge for administrators in today's competitive health care environment is to try to ensure that productivity improvements are pushed to their limits.

Undertaking one or both of these strategies would require a serious reconsideration of the role of human resource management. For many facility administrators, it would mean giving human resource management a higher priority than in the past. Yet such investments or efforts would be repaid if the service dislocations that could result from tight labor markets were avoided. Moreover, private sector employers must take the initiative in enhancing the supply of allied health personnel. The public policy options, such as programs of grants or scholarships, cannot on their own solve manpower problems. Making education inexpensive and readily available might attract some people into allied health fields, but unless good jobs offering competitive wages are available, too few people will be attracted, and those who choose an allied health occupation will not stay in it long.

Salaries

In a perfectly competitive market, an imbalance between demand and supply would cause prices to change until demand and supply were once again in equilibrium. Thus, if a shortfall of allied health personnel were to occur, wage rates would be expected to rise, demand would fall, and the supply of personnel would increase to match demand. This series of reactions is likely to occur in the allied health personnel market. Yet market forces do not always work freely, and there can be delays before equilibrium is reestablished. If demand increases at a greater rate than supply, wages may rise, but there will be a lag before supply catches up with demand. In addition, wage rates may be slow to respond to supply shortages if employers are unwilling or unable to raise wages. An explanation offered for the slow adjustment of nurses' compensation is that large health care providers, such as hospitals, have often been one of just a few employers of allied health practitioners in a locality. Realizing that these practitioners have few alternative places at which to work, employers have been able to keep wages down (Aiken, 1982). In many local markets, however, the competition for allied health practitioners has been increasing with a proliferation of work sites—freestanding units of numerous types, sometimes independent practice options, and so on. Slow wage adjustments can be expected if employers do not recognize that wage competition is taking place. There are also many reasons why employers may be reluctant to adjust wages.

Sometimes employers recognize that competition for workers is occurring but are unable to compete with the salaries being offered by other organizations. Some types of employers for whom this is likely to be true are discussed at the end of this chapter. During the course of the study the committee often heard of allied health practitioners who left traditional employment settings to establish independent practices or to work for employers paying substantially higher salaries—for example, health spas, food manufacturers, and biotechnology firms. The committee also heard that the traditional service ethic that in the past attracted individuals to relatively low-paying health care jobs is being eroded. Opportunities in alternative places of work or higher paying careers are felt to overwhelm the traditional service satisfaction.

Employers' reluctance to respond to indications of a personnel shortage by raising salaries is due not only to the expense of paying higher wages but also to the fact that the compensation levels of the many types of workers in a hospital are interrelated. An increase in one group's pay is likely to be quickly followed by increases for other workers. Such failures of the market are not unique to health care providers. The Wall Street Journal (Mitchell, 1987), noting a serious shortage of skilled blue-collar craftsmen, remarked:

Surprisingly, the labor market has sparked only modest wage gains so far. Although desperate for certain key skills, some employers would rather limp along without a full workforce than raise wages high enough to attract needed workers ... many companies have chosen to ignore issues of supply and demand for fear that higher labor costs will make it more difficult to compete.

A similar attitude prevails in health care. The New York Times (Uchitelle, 1987) cited Jerome Grossman, chairman of the New England Medical Center, where 200 of 2,800 jobs were vacant, as saying ''The amounts we can charge patients are capped and so ... we are forced to make tradeoffs.'' Moreover, there are sometimes alternatives to pay increases. For example, when laboratory technicians are in short supply, chemists and individuals trained in other relevant disciplines can be substituted. When there are alternative sources of workers, such as lower level practitioners or individuals with other training, substitution may be a preferable alternative to raising pay. For example, in one locality in which there is an oversupply of dentists and a shortage of hygienists, an HMO uses dentists to perform the hygienists' tasks. In some allied health fields, however, the freedom to substitute personnel is constrained by regulation.

Alternatively, other ways of dealing with personnel shortages include marginally curtailing services, asking allied health employees to work overtime, or taking measures to increase output.

Other ways of attracting personnel through economic incentives without increasing wages or salaries include paying bonuses for joining and staying on staff, and offering continuing education and day-care subsidies. These methods avoid an upward shift in pay scales; consequently, if utilization or occupancy rates decline the employers are not left with an excessively highly paid staff when the supply of workers is plentiful. Evidently, health care administrators, who are necessarily concerned with their organization's bottom line, have an array of strategies available that can be implemented before wage rates are increased. Thus, a lag in the response of wages to a perceived shortage of personnel is not unexpected.

Although raising salaries has been shown to increase the size of the nursing work force, other economic factors also influence the decision to work. Family income is important. As spouses' incomes rise, nurses tend to reduce their working hours or to stop working altogether. In addition, when nurses' salaries become high enough, some nurses reduce the number of hours they work. Conversely, in times of high unemployment, inactive nurses often return to the work force (Aiken, 1982). These phenomena are likely to occur in some of the allied health fields—in particular, those that are mainly composed of women and that are similar to nursing in education and pay levels.

An analysis of nurses' compensation in relation to changes in the balance of demand and supply notes that sometimes wage increases have lagged behind shortages. The same analysis also notes that wage increases have repeatedly succeeded in reducing shortages (Aiken and Mullinex, 1987).

Pay differentials between various educational levels in the same occupation also have the potential of increasing or decreasing the supply of' personnel of a given level. For example, when there was no difference between the earnings of baccalaureate nurses and associate degree nurses, students realized that the economic return to the 2-year education was higher than the return to the 4-year program, and the number of associate degree graduates eventually exceeded the number of baccalaureate graduates (Buerhaus, 1987).

Pay levels affect the supply of allied health practitioners at each point at which an individual makes a career decision. Although economic considerations often are not the sole or primary considerations, earnings potential is one of many factors considered by students who are selecting an educational program. Once started on a career, satisfaction with current earning levels and expected increases in earnings will figure in decisions to continue working; to leave the work force; to pursue child care, leisure, or other unpaid activities; or to change to another occupation with better compensation. Similarly, the return to an occupation will be in part dependent on pay levels—especially when the cost of work includes major expenditures such as child care.

How does allied health compensation compare with that in other occupations? First, compensation for allied health practitioners should be understood in the context of women's earnings, because women dominate many allied health fields. In 1986 women earned on average 69.2 cents for every dollar earned by men (Mellor, 1987). Moreover, occupations in which women represent the majority of workers tend to rank lower in terms of earnings than male-dominated occupations (Rytina, 1982). The American Physical Therapy Association is one group that is trying to address these problems. It recently examined factors contributing to the disparity in professional and economic status between men and women members as indicated by self-employment, administrative responsibility, graduate degrees, and earnings. Full-time salaried female physical therapists had annual salaries that were only 85 percent of those of full-time salaried men. Self-employed physical therapists are more likely to be men (62 percent) and they earn more than self-employed women physical therapists. The annual gross earnings of these women were 71 percent of those of self-employed men. The study concluded that the association should explore approaches for creating career ladders, encourage women to commit themselves to their careers and to the maintenance of their skills, and consider societal barriers that limit women's aspirations and opportunities (Reagan, 1986).

Table 6-1 arrays compensation data for several allied health fields and other selected occupations. These data for allied health occupations were obtained through a national survey of 33 hospitals, 16 medical schools, and 28 medical centers. These institutions were chosen for their similarity in size to the University of Texas Medical Branch at Galveston, which has 1,100 beds and 7,500 employees. Thirteen of the institutions are in Texas, Arkansas, and Louisiana, which represents an oversampling of that region. Thus, these data pertain to large institutions and have a regional bias. The occupational categories are carefully defined and clear, and although the Texas-Arkansas-Louisiana region is oversampled there are no other reasons to believe that the manpower markets of the institutions have any special characteristics. In Table 6-1 the starting rate refers to the rate normally paid to fill a vacancy in the occupation. The maximum rate is the highest rate actually paid to employees in the occupation (University of Texas Medical Branch, 1986).

TABLE 6-1

Monthly Salary Ranges of Selected Allied Health Occupations and Other Occupations, 1986.

Data for the other occupations are from a nationwide salary survey of firms with at least 50 employees. Each occupation was divided into levels with detailed job content descriptions for each level. For the non-allied health fields the starting salary in Table 6-1 is for the lowest level, and the maximum is for the highest level (Bureau of Labor Statistics, 1986). Some of the occupations selected for inclusion in Table 6-1 were chosen because they require investments in education comparable to those required in the allied health fields. Others were chosen to show how compensation for a lesser educational investment compares with compensation in allied health occupations. The table indicates that starting salaries for allied health fields in some cases do not compare unfavorably with other occupations requiring similar educational investments or that students might consider as alternative careers. For example, auditors and accountants must have bachelor's degrees and receive mean monthly starting salaries of $1,797 and $1,752, respectively; these are similar to or a little below the mean starting salaries for physical and occupational therapists and medical record administrators, occupations that also require bachelor's degrees. In computer fields the starting salaries of systems analysts exceed the starting salaries for speech-language pathologists and audiologists for whom a master's degree is the entry level requirement. Engineering technicians, who are described as "semiprofessional," and computer operators are included in technical support operations and can be considered equivalent to medical laboratory and medical record technicians with associate degrees. Engineering technicians start at salaries roughly $1:50 per month higher than the equivalent allied health fields; computer operators start at roughly $100 per month lower. It will come as no surprise that attorneys and engineers start at salaries closer to the mean maximum rate than to the starting salary for speech-language pathologists and audiologists.

Increases in earnings over the length of a career are substantially lower in allied health fields than in the other listed occupations. The salary spread for each of the non-allied health fields listed, except typists, is larger than that in any allied health field.

In sum, these data indicate that although allied health practitioners' starting pay is not always competitive with the earnings of workers in alternative fields, the differences are not large. However, the relative lack of a pay ladder puts individuals who stay in allied health fields at a significant economic disadvantage. Although there is no empirical evidence that prospective students turn away from allied health careers because of wage compression, it seems likely that students know of it and react by seeking careers with. brighter economic futures.

An important factor for employers who are considering raising pay to alleviate personnel shortages is the value of the job to the institution. This factor is brought out starkly when administrators consider the costs and benefits of expanding the pay ladder—in other words, paying more for experience. In some facilities, and for some allied health fields, experience may be of little value from the employer's perspective. Indeed, recent graduates may be preferable if they bring more up-to-date skills or the enthusiasm of a novice to the job. Why then should an organization reward experience? One answer is the high cost of recruiting and orienting new personnel. In addition, some would say that treating employees like disposable objects by not recognizing loyalty or tenure is simply inhumane management. Furthermore, by combining further education with pay and career progression, the quality of services may be upgraded and advances in knowledge can be incorporated into the facility's practice. This latter point becomes more important when the stream of newly trained practitioners slows. Employers who must substantially increase pay to attract needed personnel may consider examining job content and restricting tasks to ensure that the now more expensive personnel are used effectively. If higher compensation succeeds in increasing by even a small amount the time that individuals remain in the allied health work force (either by continuing to work or by returning to work), the impact on supply can be significant.

Although supply problems may be alleviated by increasing compensation, employers may be reluctant to act. The most fundamental and obvious reason for this reluctance has to do with the facility's bottom line. Higher salaries may not appear justified by the revenue generated for a service. Another possible deterrent for some managers is that pay raises in one occupation may produce similar salary expectations in other hospital occupations.

In the face of price competition and prospective payment, hospital financial administrators feel they have reason to be reluctant to increase salary expenses. At a recent Senate Finance Subcommittee hearing, a spokesman for the American Hospital Association said that the level of Medicare payments constrained hospitals' revenues so that nurses' salaries could not be increased (Health Professions Report, 1987). Yet data indicate that the early 1980s were relatively profitable for hospitals. Hospital operating margins—key indicators of their fiscal health—peaked in 1984 (Table 6-2). By September 1987 total operating margins and patient revenue operating margins in community hospitals were close to the levels of the early 1980s, and there were no signs that the deterioration in financial status had ceased. However, operating margins in the 1960s and 1970s were consistently lower than in the 1980s. Thus, although some hospitals are running in the red and the situation for the average hospital has deteriorated in the past few years, hospital administrators with longer memories may not be feeling so pressured that they will not consider salary increases.

TABLE 6-2

Operating Margins (percentage) for U.S. Community Hospitals, 1963-1987.

Furthermore, a hospital's financial viability rests to a great extent on its ability to admit and care for patients. If a lack of staff in any allied health field interferes with this ability or slows down discharge rates, then a wage increase is likely to be more than offset by revenue increases or decreases in other costs that result from the return to normal services.

Indeed, employers who need scarce allied health employees may have no choice but to raise wages. As one observer put it,

Gone are the days when doctors and hospitals could look upon America's bright and motivated women as a source of cheap labor denied economic opportunities elsewhere. To attract this pool of talented workers into health care, we must get used to the notion of paying competitive wages. (Reinhardt, 1987)

Other Strategies to Increase Job and Occupational Tenure

A review of the recent periodical literature of hospital administration reveals scant coverage of human resource management. Most of that attention is focused on short-term issues in spite of radical and long-term changes in the hospital's environment as the nation redefines how health care is perceived, delivered and paid for. (Mansfield, 1987)

So opens the report of a literature review of the nine major hospital administration and personnel journals for the years 1983 through 1985, forcing the conclusion that human resource management is not a high priority for health services researchers or for their audience of health care corporate executives and hospital administrators. This is a surprising finding when we consider that payroll represents about half of hospital expenses. The review also noted that, of 157 articles related to human resources, 71 percent were published in Nursing Management. The committee's own search of the Cumulative Index of Nursing and Allied Health Literature (which covers nursing and allied health personnel) and of selected psychological, management, and popular publications was similarly revealing. Searching literature published since 1983 on such descriptors as the occupational tides of each of the 10 allied health fields covered in this report, as well as "manpower," "turnover," ''retention," and "personnel," 36 articles were found. Thirty related to nursing.

Human resource administrators are often in a perplexing situation. They manage a resource that is fundamental to ensuring the quantity and quality of care desired by management and whose cost accounts for a major portion of the facility's expenditures. Yet, as the committee heard at one of its workshops, during site visits, and through discussions with knowledgeable observers, human resource managers are not often given the visibility or status they need to do their complex job. Moreover, even large health care corporations have not generally changed the way they manage human resources as they adapt to the changing health care environment.

Human resource administrators are most often expected to respond to and implement the decisions of strategic planners. Yet strategic planners do not always recognize the constraints and changes in labor markets that confront human resource administrators. If, however, strategic management and human resource management were brought together, several benefits could ensue. The importance of human resource management as a vital part of facility management would be confirmed. Plans would be made with cognizance of labor market conditions, and human resource administrators would be in a position to act early to implement plans in whose development they had participated.

However, more often, personnel administrators must assemble a labor force to provide services decided on by other administrators. Experience shows that it is not until labor markets become tight that upper management supports serious efforts to retain and attract allied health practitioners.

The previous section suggested that pay increases would enhance the supply of allied health personnel. But money, although important, is only one of the many factors that make employment in a field an attractive alternative to leisure, home activities, or other types of employment. What makes employment attractive? What nonmonetary aspects of a job produce satisfaction or dissatisfaction? The knowledge base for answering these questions about the allied health fields is sparse. A review of the general job satisfaction literature notes that explanations of differences in satisfaction are usually related either to individual characteristics of workers, including their needs and values, or to the nature of the jobs and the characteristics of employing organizations (Hanson et al., 1987).

Employers should not assume that factors they cannot control, such as family responsibilities, dominate employee decisions. A review of studies of self-reported reasons for resignation of nurses notes that at least one-third of the resignations resulted from job dissatisfaction, and a recent study attributed three-quarters of "contemplated turnover" to job problems (Weisman et al., 1981).

Workers' job requirements are known to vary according to sex, race, age, and so on. The Hudson Institute in its project "Workforce 2000" drew some conclusions about work force problems that employers will have to address if they want to hire the workers of the future. With the increasing age of the work force, they must be concerned about the adaptability of these workers and their willingness to learn. With regard to working women, reform is needed in day care, time off (time off for child care, sick leave, flexible hours, etc.), and policies to assist welfare mothers in entering the labor force. The full utilization of the work force will require integrating blacks and Hispanics into the labor market, but that means overcoming the fact that they are also the least advantaged groups in our society with respect to skill levels and educational backgrounds (Hudson Institute, 1987). Employers using an allied health work force that is largely composed of women will want to pay attention to findings about what makes a job appealing to women. Some results suggest that women's unique work needs stem from their dual responsibilities at home and at work. Studies indicate that factors such as travel time to and from work are more important to women than to men. For those women who are not career motivated and who are more interested in supplementing the household income or getting out of the house, jobs that substitute other rewards for advancement, stability, and high pay may have attractions (Hanson et al., 1987). Some differences in work force behavior between men and women include women being less likely to remain in one occupation and one particular job than men, and women having more frequent career interruptions—although this latter difference may be diminishing. Women who pursue longer term careers are less likely to differ from men in the factors that contribute to job satisfaction.

For many workers, satisfaction, dissatisfaction, and decisions to leave or stay in a job or field are based on factors related to their job tasks, how they fit into the organizational structure, and expectations about their working conditions. The nursing literature is replete with analyses of reasons for dissatisfaction—boredom, limited possibilities for advancement, lack of status, lack of opportunities for full use of their skills, lack of further educational opportunities, lack of autonomy, problems in relationships with physicians, and staffing patterns that do not allow for the provision of high quality, care. (See, for example, Price and Mueller, 1981; Weisman et al., 1981 and a literature review that notes that every major study since the 1960s has pointed to the factors of autonomy, interpersonal relations, and job status as critical components of job satisfaction, Institute of Medicine, 1983). Satisfaction often stems from recognition by peers and supervisors, professional growth, perceptions of being important to patient care and to the institution, and involvement in decisions concerning both patient care and institutional policy. An analysis of the importance of these factors in determining turnover found that autonomy is the strongest predictor of job satisfaction, and the supervisor's responsiveness to the nurse's work and communication needs is the best predictor of a sense of autonomy (Weisman et al., 1981).

Findings of this sort have generated numerous strategies (not always adopted) to enrich nurses' working environments in order to extend both job and occupational tenure. Strategies include creating decision-making links among the chief executive officer, nursing service administrator, and staff nurses; introducing primary nursing; and developing patterns of upward mobility. One important difference between nursing and allied health in this regard is that although allied health practitioners hold administrative jobs—managing laboratories, dietary services, radiology departments, and so on—there is usually no umbrella allied health administrator position to promote the interests and raise the level of visibility of the allied health work force. By way of contrast, hospitals commonly have a director or vice-president for nursing, who increasingly is assuming even broader responsibilities such as vice-president for patient services, which sometimes subsumes allied health services. The fragmented, diverse nature of allied health makes the development of a unified power block within institutions difficult. Consequently, these fields have found it difficult to establish the linkages to central administration that have been helpful in addressing work environment issues for nurses.

The nurse-physician relationship is an important factor in the way nurses perceive their roles and in their job satisfaction. For many allied health occupations, physicians also play a major role in shaping an environment that will induce practitioners to extend their tenure. Reporting on a successful effort to lengthen nurses' tenure, one nursing administrator noted:

The physician's role in nurse retention cannot be overstated. When there is close communication between physicians and nurses, an increased level of satisfaction for both parties is evident. Nothing enhances the role of the nurse as much as awareness that a physician is hearing her perspective of a patient care issue. Orthopedic physicians and orthopedic nurses simultaneously requested that nursing practice be expanded to include more activities. Nursing activities then were planned and implemented as a joint venture. (Araujo, 1980)

Reports like these underline the importance of action by facility administrators to encourage physicians to be involved in efforts to extend tenure.

Also of importance is the role of research. Knowledge of the factors that persuade practitioners to leave or remain in their allied health field could be usefully expanded—and what seems obvious is not always the right answer. For example, a small study of burnout among respiratory care personnel (Shelledy and Mikles, 1987) found, to the authors' surprise, that hours worked per shift or per week, shift assignment, frequency of rotation of daily work assignments, variety of procedures performed, and number of treatments per shift did not relate to burnout. Lower burnout rates were found in practitioners with higher educational levels, a greater sense of autonomy, and perceptions that high-quality work was being done in their departments.

Just as with salary decisions, however, it is unreasonable to expect facility administrators to make changes that are not in their institutions' best interests. Although opportunities for upward mobility are generally seen as an important element of job satisfaction, there are clearly limits to the number of higher level practitioners that are needed. In some cases, any sort of upward mobility may be impracticable. As an alternative, employers may find that encouraging an expansion of skills to another area can sustain employee interest and extend tenure in work that could become tedious. Methodist Hospital in Indianapolis, Indiana, sponsors a program called ''Add-A-Comp" that enables individuals with health care experience to acquire additional competencies. The program also fulfills employers' needs for cross-trained personnel. Moreover, employees who are more challenged and stimulated are less likely to leave an employer or the work force.

A secondary benefit of improving job satisfaction will accrue to employers interested in avoiding unionization among their employees. Health care union membership, which has been growing despite a national decline in other union membership, stands at about 20 percent. Recent organizing issues have included quality of care, quality of work, stress, job restructuring, and benefits. Because of similar concerns with issues of compensation, job security, and meaningful work involvement, professionals and white-collar workers are identifying with blue-collar workers and with unionized groups (American Hospital Association, Department of Human Resources, 1986). Thus, health care employers cannot rely on their employees' sense of professional status to avoid unionization. By making adaptations to increase job satisfaction, however, employers can attend to issues that might otherwise result in union activity.

Lower level health care practitioners such as orderlies and technicians have negotiated contracts that include retraining programs in case of layoff. As a result, one hospital has started training programs for sterilization technicians and licensed practical nurses (Lunzer, 1987). Organizations with contracts like these have a ready pool of workers whose training can be channeled toward skills needed by the facility. Thus, although unionization can reduce an employer's ability to redesign jobs and may reduce work force flexibility, it can also occasionally increase the options available in uses of manpower.

Job satisfaction also relates to the socialization process that occurs during professional education and through contact with role models. This socialization emphasizes the importance of upward mobility. Studies of nursing indicate that higher levels of education correlate with a greater likelihood of job dissatisfaction (Weisman et al., 1981). Although this correlation could be related to frustrations that occur if practitioners do not fully use their skills, the job dissatisfaction research findings relating to upward mobility, role, use of skills, and autonomy all point to the conclusion that some discrepancy exists between what employers need and the aspirations and needs of graduates from educational programs. More extensive communication among educators, employers, and professional associations might help to improve the fit between the needs of employers and those of their employees, and thus might also help extend job and occupational tenure.

The problem of matching education with workplace needs is also addressed in Chapter 5, in which educational issues are discussed. That chapter contains a recommendation that the groups most influential in developing work site tasks, curricula, and aspirations—educators, employers, and professional associations—should interact more. One special problem they might address is to attempt to ensure that the diversity of employers' needs is matched by a similar diversity in the education of practitioners. Allied health jobs exist in numerous settings—hospitals, nursing homes, primary care practices, and so on. Different settings vary in their need for various ranges of skills and levels of expertise, even in a single field. Reflecting this diversity in the content and level of educational programs would help increase job and occupational tenure by matching practitioners' abilities and aspirations with patient and institutional needs.

Another issue that could usefully be addressed by employers, professional associations, and educators also relates to professional aspirations. Allied health practitioners working in health care facilities of all types become part of a larger group of workers with an organizational structure. The "medical model" of autonomous work, which is pursued by the many physical therapists, speech-language pathologists, and laboratory technologists who become independent consultants, is not always either realistic or attainable in complex medical settings or for most practitioners. These practitioners need goals that provide satisfactory alternatives to independent practice.

A further element, already noted in Chapter 5, is the provision of clinical sites for education. The number of health care facilities providing sites for the clinical component of educational programs is decreasing. Employers should consider that the cost of providing clinical education is often offset in the long run by an increased supply of practitioners and the avoidance of personnel shortages.

Enhancing The Use of The Existing Work Force

Easing scarcities in the supply of allied health practitioners by expanding educational capacity is a strategy that only begins to be effective several years after initiation. Of more immediate effect would be extending the tenure of existing workers and bringing back into the work force individuals who have chosen to leave it. A still different approach is to examine ways of using the existing work force more productively and effectively.

In the early part of this chapter, it was noted that when demand for allied health practitioners exceeds supply, market forces will drive up the wages and salaries employers must pay to hire the needed personnel. This increased compensation will, in the long run, enlarge the supply of workers. It will also diminish the upward thrust of demand as employers, with a more expensive work force, seek ways to contain this expense. An approach that has the potential to provide a dual benefit—increasing job satisfaction as well as using staff more efficiently—is the restructuring of tasks and staff deployment. This approach requires that administrators shed traditional ways of thinking about individual and departmental responsibilities and allow themselves to consider new staff and task configurations. Sometimes expanded roles for lower level staff will permit more flexible staffing of units, to the extent that regulation allows. Occasionally it is possible to combine tasks to form a new, enlarged work module. Using multidisciplinary teams can break down departmental barriers to permit enlarged spheres of responsibility for individual staff. Many new configurations of tasks and staff are possible, but they must be preceded by an investment in human resource management to engage in the necessary fundamental analyses and rethinking of tasks.

A familiar industrial response to manpower shortages or to perceptions of overly high personnel expenses is attempts to improve labor productivity. However, there is a common perception that the service sector of the economy has very low rates of productivity growth (Kutcher and Mark, 1983) and that health care, because it requires a hands-on, one-on-one approach, is not amenable to measures to increase productivity. Certainly, if operating margins continue to deteriorate, it seems reasonable to expect administrators to seek ways of improving productivity. If health care is viewed not as a whole but rather as individual specific services, some areas appear to have some potential for productivity gain. One of the areas often cited is automation in medical laboratories.

Today's financial incentives to reduce costs are expected to encourage the development and adoption of technologies that improve productivity. Some structural changes in the way health care is delivered also have a potential for productivity improvement. For instance, large-scale specialized delivery sites (e.g., special surgery or imaging units) may be able to reap economies of scale in the use of personnel. However, it is unlikely that changes such as these will outweigh other changes—for example, the move to home services and new, complex technologies—that use manpower in a less productive manner.

The advantages and disadvantages of cross-trained or multicompetent allied health personnel have been discussed for many years. In the past the context was their use in solving rural health care staffing problems. Today, they are seen by some as innovative solutions to personnel shortages, especially in small hospitals, physicians' offices, and other small delivery units. Multicompetent personnel are also regarded by some larger hospitals as economical sources of staff who must be available 24 hours a day but whose work time is punctuated by low-use periods. More generally, as revenue restrictions force administrators to examine ways to control labor expenses, employers are becoming interested in increasing labor productivity by decreasing specialization, as evidenced by the American Hospital Association's sponsorship of a number of workshops on the multiskilled concept. A 1986 national survey of medical laboratory managers indicated that 46.3 percent said they could use cross-trained personnel (Watrous, 1987). A survey of hospital administrators, directors of nursing, directors of community health organizations, and physicians in Philadelphia showed that multicompetent practitioners were already employed in approximately a quarter of the hospitals. Sixty percent of the hospital administrators surveyed said they were willing to employ multicompetent practitioners now (Low and Weisbord, 1987), and educators report that their multicompetent graduates generally find jobs that use their training (Blayney, 1982). Using multicompetent practitioners is not an all-purpose solution, but it is the result of an effort to think through the tasks that must be performed and how the educational system can respond to help meet the need.

Productivity improvements, however they are achieved, are defined as decreasing the input per unit of output. Thus, we say that productivity is increased if a laboratory worker, for example, increases the number of tests he or she performs per hour. Another way of thinking about how best to use allied health manpower and thus improve productivity is to redefine output in terms of a contribution to patient care. To make this definition operational, we must evaluate effectiveness. Output can be increased, and pressures on manpower supply relieved, by reducing services that do not contribute to patient welfare.

Suggestions of unnecessary care (or at least a lack of agreement about what is appropriate care) are found in studies that show variations in the amounts of service performed in different countries, in different regions of the same country, and in different types of organizations. But information about the identification of effective and ineffective care by allied health practitioners is not plentiful. Shroeder (1987) reports on studies that have detected patterns of overuse. Overused procedures or technologies, according to these studies, include white blood cell differential counts, measurements of serum lactic dehydrogenase, blood cross matches, barium enema studies, upper gastrointestinal series, nursing service orders, tonsillectomies, chest x rays, prescription drugs, preoperative screening tests, and thyroid function tests. Shroeder adds:

A recent study from our institution estimated the proportion of redundancy among a wide variety of diagnostic and nursing services for patients on a general medical ward. Of the more than 8,000 services ordered for 173 patients during the observation period, 21% were judged to be unnecessary by faculty auditors who reviewed the medical records. The most overused services were partial thromboplastin time (deemed unnecessary in 63% of uses), stat/emergency orders (43%), nuclear medicine studies (26%) and platelet counts (25%).

Another way of assessing overutilization is by determining whether clinical services contribute to patient management. Reports from several teaching institutions and one community hospital show that as few as 3% to 5% of diagnostic tests are actually used in the management of the patients for whom they are ordered. (Shroeder, 1987)

Probably the allied health service most studied for overutilization is the clinical laboratory. Barr (1987) suggests that ensuring effectiveness is in part the responsibility of laboratory scientists, who should ask a number of questions such as "Are the ordered tests appropriate for the patient's clinical condition?" "What level of accuracy and precision is needed for clinical judgment?" Other investigators are working to develop methods for detecting overutilization (see, for example, Eisenberg, 1982; Garg et al., 1985).

Many questions about effectiveness remain unanswered. If cost-containment pressures continue to mount, some employing organizations may initiate their own research. HMOs may shift their focus from a concentration on reducing hospitalization to reducing ineffective care in other areas. Other prospectively paid providers also have reason to try to eliminate excess services.

Finally, some allied health practitioners may want to undertake effectiveness research to justify their place in patient care. Until such research is done, they may be vulnerable to cuts by institutions seeking to reduce personnel expenses.

Employers with Special Problems

Some health care providers are particularly disadvantaged in the competition for allied health practitioners. These employers will find that, for one reason or another, they cannot implement many of the strategies discussed previously in this chapter. In this section the committee discusses the predicaments of two of these employers—rural health care facilities and nursing homes and other long-term care sites. The committee also suggests some strategies they might find useful in trying to cope with their needs for allied health manpower.

Rural Health Care Facilities

According to the Census Bureau, more than a quarter of the population of the United States lives in rural areas. These areas differ from other parts of the nation in many aspects, and often these differences have implications for the delivery of health care.

Rural areas are more sparsely populated than urban localities, and therefore fewer people live in the catchment area of a rural health care provider. In addition, rural populations are more often poor (14 percent below the poverty level, compared with 11 percent in metropolitan areas in 1981) and elderly (13 percent over 65 compared with 10.7 percent in 1980); therefore, they have different health statuses and health care needs. Examples of rural health status differences include higher infant mortality rates; a higher incidence of hypertension, coronary heart disease, emphysema, and some other chronic conditions; but a lower incidence of acute conditions on the whole (Cordes and Wright, 1985).

Some of these differences may be related to differences in the health care services available to rural populations. The hospital-bed-to-population ratio is approximately the same for rural and nonrural areas, thanks to the hospital construction program mandated by the Hill Burton Act of 1946. Yet the number of health professionals in relation to total population is less in rural areas, and the range of services offered by hospitals is narrower (Cordes and Wright, 1985).

That rural hospitals have special problems is well documented. Of the 5,732 community hospitals in the United States in 1986, 47 percent were rural and 17 percent had fewer than 50 beds. Eighty percent of the small hospitals in the United States are rural. Small hospitals anywhere are more likely to close than larger hospitals: of the 214 community hospitals that closed between 1980 and 1985, 75 percent had fewer than 50 beds, 86 were rural, and 128 were urban (Health Resources and Services Administration, Office of the Administrator, 1987).

The reasons for the vulnerability of rural hospitals may relate not only to their rural characteristics but also to their small size. Analyses of American Hospital Association data (Table 6-3) show that, between 1980 and 1986, the smaller the hospital, the greater the deterioration in several key indicators of strength. Operating margins, admissions, and occupancy rates have fallen more and are lower in smaller hospitals. These data show why raising salaries to attract allied health practitioners is not feasible for many small rural hospitals.

TABLE 6-3

Selected Indicators of Hospital Strength.

It is more difficult to attract practitioners to rural employment than to other settings. Table 6-4 contrasts the ratio of practitioners to population in metropolitan and nonmetropolitan settings for some allied health professions. It is evident that metropolitan areas in 1980 had a more plentiful supply of practitioners in all the listed fields. The lower rural concentration may be due in part to the lower concentration in rural areas of some of the individuals and organizations that usually employ allied health practitioners—dentists, physicians, and so on. But with the hospital-bed-to-population ratio quite similar in rural and nonrural areas, the usual employers of the majority of allied health practitioners would seem to be present.

TABLE 6-4

Geographic Distribution of Selected Allied Health Professions, 1980.

For rural hospitals, allied health employment problems can be viewed in three ways: (1) the difficulty of attracting practitioners to rural employment, (2) being able to afford the practitioners, and (3) finding practitioners with the type of education and training that suits them for rural employment.

The geographic maldistribution of personnel in some health care fields has been well studied. Less work has focused on the maldistribution of allied health practitioners. Some lessons can be drawn from what is known about other types of health care practitioners. Allied health education, like most health care education, takes place primarily in metropolitan areas. Most often, clinical experience is provided in acute care settings with sufficient patient volumes to support state-of-the-art, high-technology services. Graduates are subsequently drawn to employment in similar settings for several reasons. They perceive these settings as offering high-quality care, personal challenges, full use of their education, and the stimulation of contact with peers and supervisors. By contrast, to city-reared workers, rural facilities are an unknown setting, often perceived as isolated, technologically backward, and with little room for advancement in their field. One lesson from studies of health personnel education and employment decisions is that graduates who grew up in rural areas or whose education included experience in these areas are more likely to choose rural employment.

Individuals whose roots are in rural areas can find the monetary and psychological costs of attending educational programs in metropolitan areas prohibitive. Taking education to rural areas would help bring these individuals into the allied health work force. Such techniques include the use of telecommunications technologies and ''circuit riding" faculty. Employers could assist such efforts by encouraging qualified allied health staff to participate in teaching. They could also provide classroom space and clinical experience in their facilities.

The employer's role in increasing the supply of graduates who are familiar with rural settings is thus twofold: first, to work with local high schools and career counsellors to encourage students to pursue allied health careers and second, to work with allied health educators to provide clinical experience in their facilities. In Alabama a group of junior colleges and the University of Alabama formed a consortium in 1969 to enhance the supply of allied health practitioners in underserved areas. As described by Keith Blayney (1981), dean of the School of Community and Allied Health at the University of Alabama:

In 1969, the state's junior college presidents and representatives of the University of Alabama in Birmingham (UAB) met and endorsed the concept of a consortium to link the two-year schools with UAB. The benefits were readily apparent—by sharing students with the Regional Technical Institute (RTI) at UAB, the duplication of specific allied health programs and their high costs could be avoided. Also, students could attend school near their homes for the first year of the program.

After the second year at RTI, graduates were likely to return to their homes, located in the medically underserved areas of the state, and provide ancillary support for medical services there. As the program developed, efforts were made to establish clinical training sites for the students in or near their homes, thus providing an additional impetus to return home.

Before their year of technical training at the RTI ends, the students spend six to eight weeks in on-site clinical training. Although the RTI is located in the heart of UAB's Medical Center, where there is a large volume and variety of clinical materials, it soon became clear that the Medical Center alone would not be sufficient to provide adequate experience for all the allied health students. As a result, linkage students can now complete the last weeks of their clinical training at smaller health care facilities throughout the state. These facilities range from doctors' offices to nursing homes, clinics, and hospitals. This arrangement has other advantages. The students can work close to their homes, in facilities similar in size and scope to those in which they will probably work. Also, upon graduation, the students are often offered positions at the facilities where they did their training.

Since the number of clinical facilities has been expanded, a higher percentage of RTI graduates have returned to rural areas to work. In 1977, 59% of graduates of programs that have clinical training sites outside of Birmingham took jobs outside of the city, while only 34% of the graduates who had no clinical affiliation outside Birmingham left the city.

An evaluation of the linkage program after 11 years found that 66 percent of the graduates who remained in allied health fields returned to their home counties to work (Cooper, 1982). Clearly, this model requires serious commitments by employers and leaders in educational institutions who are concerned with and willing to help resolve some of the problems of rural care.

Another type of linkage would be for rural employers to arrange regular, periodic secondment to an urban facility for their allied health employees. Arrangements with educational programs and leaders in allied health fields to provide lectures or seminars to practitioners in rural areas might also help dispel fears of isolation and ensure that practitioners are kept up to date in their field—generous allowances for continuing education would also help to achieve this goal.

Rural employers who operate low-volume facilities that cannot afford or fully use a full-time staff member can also try to develop linkages. In Wisconsin, 22 small rural hospitals have formed a cooperative that shares services, mobile technologies, and professional staff who travel among the hospitals (Health Resources and Services Administration, Office of the Administrator, 1987). Employer-initiated sharing (as opposed to employees who on their own find several part-time jobs) may also appeal to practitioners because they get full-time employment and benefits that are often not offered to part-time employees.

A further model of cooperation among employers is the regional organization of services with each hospital specializing in certain services. The Robert Wood Johnson Foundation is offering grants for this and other models to help rural health providers with financial problems.

The notion of multicompetent personnel is frequently suggested as a solution for low-volume rural providers. There are currently a small number of programs training multicompetent practitioners. A program providing dual certification at Southern Illinois University at Carbondale, which was started in the 1970s, is popular with rural communities. Recently, however, students have sought certification in only one field, a trend that is thought to be the result of better pay for single-field jobs (Cordes and Wright, 1985). As the committee has noted, the ability to pay competitive salaries is likely to be limited in rural locations and is dependent on reimbursement decisions. Still, without attractive compensation, efforts to ease rural manpower problems will fail in the long run.

Employers who want to hire multicompetent practitioners can help by ensuring that educators know that a demand for them exists and also by making known the mix of competencies they need. If an individual's education is tailored to an employer's requirements, the employer can use the practitioner efficiently, and thus maximize the results from his or her salary.

The third type of problem of rural health providers—finding allied health personnel with the special skills needed for employment in small rural settings—can also be alleviated by linkages with educational programs. Again, providing clinical sites for students ensures that they learn about rural practice. Models for these programs already exist. We have already mentioned the University of Alabama's Linkage Program. Another is the University of Wisconsin Medical Technology Program, which places students in a generalist capacity in small hospital laboratories. This program is said to have contributed significantly to students' interest in clinical laboratories in community and rural hospitals, as the majority of students have been employed in such laboratories after graduation (Bamberg, 1981). Still another model offers students experience on health care teams in rural Kentucky. Students at Kentucky Southern Community College are exposed to rural practice and learn how to function with other members of the health profession team (Bamberg, 1981).

One type of linkage already in place for some rural providers is membership in a multiprovider organization. Regardless of whether this organization is horizontally or vertically integrated, if it includes both rural and urban sites, then an opportunity for innovative solutions to staffing problems exists. Rural members of the organization might negotiate arrangements whereby service at or rotation through a rural location becomes a necessary step for upward mobility in the organization's career ladder.

Long-Term Care Facilities

Long-term care providers (e.g., nursing homes and chronic mental care facilities), like rural health care providers, have special needs and characteristics that make some of the strategies suggested in the earlier part of this chapter inapplicable. For example, it is difficult to increase salaries to attract allied health practitioners when reimbursement is extremely tight. It is also often impossible to provide advancement paths in small facilities, a category into which many nursing homes fall.

Chapter 8 explores some of the reasons long-term care facilities are not seen as attractive work sites. A number of these reasons are subjective and perceptual. Caring for elderly patients and patients with chronic or mental diseases is seen as unsatisfactory in contrast to working with patients in whom real and lasting improvements can be realized. Mental disturbances in patients make practitioners' tasks more difficult and are a condition for which their education often fails to prepare them. In the course of this study the committee uncovered a concern among the providers of long-term care that educators and practitioners in many allied health fields are both unwilling and unprepared for work with elderly patients and patients with chronic conditions. Remarks like the following were often heard: ''Physical therapists would rather work in sports medicine and with the acute phase of trauma rehabilitation than with frail, confused, nursing home patients." Long-term care facilities in some regions are not perceived as giving high-quality or sometimes even adequate care. Clearly, a long-term, major effort is needed to change perceptions of work in the chronic care sector. The figures in Table 6-5 suggest that, for dietitians working part-time and for full-and part-time occupational and physical therapists, compensation is not likely to be a decisive factor in choosing between employment in a nursing or personal care facility and employment in a hospital. Job satisfaction, however, may be greater in acute care settings.

TABLE 6-5

Average Hourly Earnings in Hospitals and Nursing and Personal Care Facilities, 1985.

Lower level personnel—nursing aides and orderlies—have fewer opportunities in the acute care sector. Yet for these individuals the average hourly salary of $5.15 for nursing aides in nursing and personal care facilities might not be competitive with alternative employment in such places as fast-food restaurants, which pay more, require no formal post-secondary education, and in which working conditions are less stressful (Kerschner, 1987).

Long-term care employers can try to use some of the options suggested in the earlier section for rural health employers. Establishing links with allied health education programs to increase curriculum content relating to long-term care could help to deflect some of students' anxieties about serving these special populations. Similarly, providing clinical sites for students can dispel misconceptions about the work, enhance the skills needed to serve in long-term care, and establish ties with an employer.

An Institute of Medicine committee in 1983 recommended that educational programs for nursing should provide more formal instruction and clinical experience in geriatrics. It was believed that this would augment the supply of new nurses interested in caring for the elderly (Institute of Medicine, 1983). This could also be an effective strategy for allied health practitioners, and it is discussed further in Chapter 8.

Conclusions and Recommendations

Human resources planning has not been a high priority or an integral part of strategic planning in the health care organization. As a result, there has been little emphasis on or investment in research and experimentation in structuring staffing policies and working environments. Moreover, when there is a plentiful manpower supply, there is little incentive to undertake such an onerous task. The committee foresees, however, that the availability of alternative employment and stable or falling enrollments in allied health education programs will find some employers—particularly hospitals—unprepared to solve staffing difficulties and fulfill service demands. Relying on the government to create incentives, such as educational subsidies for entry into professions that turn out to be poor careers, and complaining about licensing barriers are not likely to be as effective solutions as an investment in improved management capability. Except in the face of appreciably lower operating margins, it will be difficult for administrators to make a convincing case for increased reimbursement (e.g., through the prospective payment system) to help support salary increases without having demonstrated to payers that management solutions have been pursued to their practical limits. To date, employers have relied on new graduates and short-term incentives to offset turnover and prolong tenure in the work force.

The committee recommends that employers strive to increase the supply of allied health practitioners by attracting people into allied health occupations and prolonging their attachment to their fields. Some ways to do this include increasing compensation, developing mechanisms for retention, and establishing flexible schedules and educational opportunities. Employers should also look to new labor pools that include men, minorities, career changers, and individuals with handicapping conditions.

Yet attracting and keeping individuals in allied health fields is only one part of a strategy to relieve pressures. The committee also recommends that chief executive officers, human resource directors, and other health care administrators develop methods for the effective utilization of the existing supply of allied health personnel. Such methods must grow out of experimentation with new ways of organizing work efficiently and distributing labor among skill levels while ensuring that the quality of care is not compromised.

As the health industry looks more aggressively beyond cost savings through reduced hospital utilization and toward technology assessment, quality assurance, and nonhospital utilization controls, it is appropriate that allied health services should come under scrutiny. This scrutiny should be viewed by management as an opportunity to work with allied health professionals to use a scarce labor resource effectively. It is also an opportunity for the allied health field to help provide the research underpinning that will be the foundation for decision making.

The committee recommends that health care providers and administrators seek innovative ways to channel limited allied health resources toward activities of proven benefit to consumers. Agencies such as the National Center for Health Services Research and the Health Care Financing Administration should sponsor research and technology assessment to ensure that allied health services are effective and that they are organized efficiently. Associations of employers, unions, accrediting agencies, and professional associations should assist in disseminating research findings and providing technical assistance in their implementation.

If employers are to use limited human resources effectively, personnel must be appropriately educated. In addition, the goals and aspirations of new graduates should accord with the realities of life in the workplace; otherwise, their job satisfaction is likely to be undermined. The committee therefore strongly recommends that health care administrators and academic administrators engage in constructive exchanges to improve the congruence of employment and education. These exchanges, which should take place at the state and local levels, will be enhanced by the participation of educators who are also leaders of the professional associations.

Although the analyses in this study are most often based on national data, the committee emphasizes that conditions differ among states and even among localities. State legislators have a legitimate interest in ensuring an adequate supply of health care personnel, educational opportunities for the states' citizens, and employment opportunities for graduates of state-supported educational programs. The committee recommends that state legislatures establish special bodies whose primary purpose would be to address state and local issues in the education and employment of allied health personnel.

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