Chapter 2: The Healthcare Professional PDF

CHAPTER 2...

CHAPTER 2 THE HEALTHCARE All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. PROFESSIONAL Patrick D. Shay and Dolores G. Clement Learning Objectives After completing this chapter, you should be able to ➤ identify the roles of healthcare professionals in healthcare organizations; ➤ define the elements of a profession, with an understanding of the theoretical underpinnings of the healthcare professions in particular; ➤ describe the major healthcare professions and the required educational levels, scopes of practice, and licensure issues for each; Copyright 2023. Gateway to Healthcare Management. ➤ relate knowledge of the healthcare professions to selected human resources management issues and systems development; and ➤ comprehend the changing nature of existing and emerging healthcare professions in the healthcare workforce. 31 Copying and distribution of this PDF is prohibited without written permission. EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 1/6/2024 11:04 AM via UNIVERSITY OF CENTRAL FLORIDA ForBruce AN: 3588513 ; Carla Jackie Sampson, permission, please J. Fried.; contact Copyright Fundamentals of HumanClearance Resources Center at www.copyright.com. in Healthcare, Third Edition Account: current.main.ehost  32 Fundamentals of Human Resources in Healthcare Vignette Kara, a sophomore student at New State University, is weighing potential majors and is meeting with Dr. Fontelera, a faculty member in the Department of Health Professions, to learn more about its undergraduate major and potential career options. “Tell me,” Dr. Fontelera begins, “what makes you interested in healthcare man- agement?” Kara thinks for a moment and replies, “Well, I’ve always admired the work that doctors and nurses do in caring for patients. At the same time, I’ve never really wanted to be a doctor or a nurse, because being around blood creeps me out, and so I guess I kind of ruled out a career in healthcare for a long time. But when I came to college and saw that you offer a major in healthcare management, I got very curious. I really like the idea of being involved in a field that directly cares for people in need, and I’m good at problem solving and feel like I have natural administrative skills. So, I suppose I’m interested in healthcare management because even if I can’t be a doctor or nurse who treats patients, maybe I could help those doctors and nurses by being an administrator for them.” “I like your passion,” Dr. Fontelera replies, “and I’m excited about your interest in our field. I also think that as you learn more about healthcare management, you’ll real- ize that it’s perhaps a much broader field that you may currently imagine. Doctors and nurses each play critical roles in health services, and they have historically been the face of healthcare. But the work of healthcare managers extends well beyond serving doctors and nurses; we serve a vast array of healthcare professionals. I think you’re going to be amazed about the opportunity to make a meaningful difference across a broad industry of professionals dedicated to improving the health and well-being of others.” Kara feels intrigued and inspired. Drawn further to explore this potential major, Kara is eager to understand the varied healthcare professions and the issues and chal- lenges they face across healthcare organizations. Copying and distribution of this PDF is prohibited without written permission. For permission, please contact Copyright Clearance Center at www.copyright.com. EBSCOhost - printed on 1/6/2024 11:04 AM via UNIVERSITY OF CENTRAL FLORIDA. All use subject to https://www.ebsco.com/terms-of-use  Chapter 2: The Healthcare Professional 33 I n t r od uct i on Healthcare professionals are central to the delivery of high-quality healthcare services. Extensive training, education, and skills are essential to meet society’s needs for safe, com- petent healthcare. The specialized techniques and skills that healthcare professionals acquire through systematic programs of study are the basis for socialization into their profession. The healthcare industry is labor intensive and distinguished from other service industries by the number of licensed and registered personnel in various healthcare fields. These healthcare fields have emerged as a result of numerous trends, including the specialization of medi- cine, the increased scope of advanced practice nursing, the development of public health, an increased emphasis on health promotion and prevention, and technological advances. Because of the division of labor within medical and health services delivery, many tasks that were once the responsibility of physicians are now shared with or delegated to other healthcare professionals. Today, healthcare is commonly delivered by interprofessional teams with the physician at the helm, with a greater emphasis on patient- and family-centered care. Such collaboration raises important questions for the industry: What healthcare pro- fessions are involved in delivering healthcare? What is the extent of their scope of practice? In this chapter, we respond to these questions by defining key terms, describing the healthcare professions and labor force, explaining the role of human resources (HR) in healthcare, and discussing key HR issues that affect healthcare delivery. P r o f e s s ional i z at i on Although the terms occupation and profession often are used interchangeably, they can be differentiated from each other. An occupation is the principal activity that supports one’s livelihood. It is different occupation from a profession in several ways. An occupation typically does not require a high level of One’s principal activity and means of skill specialization. An individual in an occupation is usually closely supervised, adheres support. to a defined work schedule, and earns an hourly wage. A profession requires specialized knowledge and training. Compared with nonpro- profession fessionals, a professional has more authority and responsibility and must adhere to a code A calling that of ethics. A professional usually has considerable autonomy in determining the content requires specialized of the service provided and in monitoring the workload. A professional generally earns a knowledge and salary, obtains higher education, and works with more independence and mobility than training. Professionals nonprofessionals do. have more authority The distinction between an occupation and a profession is important because as and responsibility healthcare evolves, it requires more and more professionals who are empowered to make than people in an occupation and adhere decisions in the absence of direct supervision. The proliferation of knowledge and skills to a code of ethics. needed in the prevention, diagnosis, and treatment of disease has required increasing levels of education. Undergraduate or graduate-level degrees are now required to enter virtually Copying and distribution of this PDF is prohibited without written permission. For permission, please contact Copyright Clearance Center at www.copyright.com. EBSCOhost - printed on 1/6/2024 11:04 AM via UNIVERSITY OF CENTRAL FLORIDA. All use subject to https://www.ebsco.com/terms-of-use  34 Fundamentals of Human Resources in Healthcare every professional healthcare field. Some professions, such as pharmacy, physical therapy, and nursing, are moving toward professional doctorates (i.e., doctor of pharmacy [PharmD], doctor of physical therapy [DPT], and doctor of nursing practice [DNP], respectively) for practice. Countering this increase in professionalization, healthcare organizations are finding fewer financial resources available because of consolidation, demands for efficiency, and ongoing changes in the mechanisms for delivery and payment of services. As a result, health- care organizations face pressure to replace highly trained—and therefore more expensive— healthcare professionals with unlicensed support personnel. Those with advanced degrees are required to supervise more assistants who are functionally trained for specific roles. functional training Functional training produces personnel who can perform tasks but may not know Training that produces the theory behind the practice. However, understanding theory is essential to becoming fully personnel who can skilled and making complex management and patient care decisions. Conversely, knowing perform tasks but the theory without having the experience also makes competent practice difficult. When who may not know educating future healthcare professionals, on-the-job training or a period of apprenticeship the theory behind the practice. is needed in addition to basic coursework. (See also the accompanying Critical Concept sidebar “Five Stages of Ability.”) H e a lt h c a r e P r o f e s s i on a ls Healthcare is the largest and most powerful industry in the United States. It constitutes more than 10 percent of the country’s total labor force (US Bureau of Labor Statistics [BLS] 2022b) and 19.7 percent of gross domestic product (Centers for Medicare & Medicaid Services [CMS] 2022). Healthcare professionals include physicians, nurses, dentists, pharmacists, optometrists, psychologists, nonphysician practitioners (e.g., physician assistants and nurse practitioners), healthcare managers, and allied health professionals. Allied health encompasses a vast array of professionals, including therapists, medical and radiologic technologists, social workers, health educators, and other ancillary personnel. Exhibit 2.1 provides a sample of professional associations representing healthcare professionals, and other key organizations in the health sector, including accrediting associations and trade associations. Healthcare professionals work in a variety of settings, including hospitals, ambula- tory care centers, managed care organizations, and long-term care organizations; behavioral health organizations; pharmaceutical companies; community health centers; physician offices; laboratories; research institutions; and schools of medicine, nursing, and allied health professions. According to the BLS (2022a), healthcare professionals are employed by the following types of organizations: ◆ Hospitals (32 percent) ◆ Nursing and personal and residential care facilities (18 percent) Copying and distribution of this PDF is prohibited without written permission. For permission, please contact Copyright Clearance Center at www.copyright.com. EBSCOhost - printed on 1/6/2024 11:04 AM via UNIVERSITY OF CENTRAL FLORIDA. All use subject to https://www.ebsco.com/terms-of-use  Chapter 2: The Healthcare Professional 35 ◆ Physician offices and clinics (17 percent) ◆ Home health care services (10 percent) ◆ Dentist offices and clinics (6 percent) ◆ Other health service sites (17 percent) ! CRITICAL CONCEPT Five Stages of Ability Dreyfus and Dreyfus (2009) contend that both theoretical knowledge and practiced response are required to acquire skill in a profession. These authors describe five stages in becoming a professional: 1. Novice. The novice learns tasks and skills that enable them to determine actions based on recognized situations. Rules and guidelines direct the novice’s energy and action at this stage. 2. Advanced beginner. The advanced beginner has gained enough experience and knowledge that certain behaviors become automatic, and they can begin to learn when tasks should be addressed. 3. Competent. The competent individual has mastered definable tasks and processes and has acquired the ability to deal with unexpected events that may not conform to plans. 4. Proficient. The proficient individual has the ability to discern a situation, intuitively assess it, plan what needs to be done, decide on an action, and perform the action more effectively than in the earlier stages. 5. Expert. At this final stage, the expert can accomplish the goals without realizing that rules are being followed because the skills and knowledge required to reach the goal have become second nature. Theoretical understanding is melded with practice in each progressive stage. Func- tional training can help an individual progress through the first three stages and pro- vide the individual with the ability to apply and improve theories and rules. At the proficient and expert levels, one has the ability to challenge and improve theories and rules learned. Healthcare professionals need to become experts in fields where self-direction, autonomy, and decision making for patient care are required (Dreyfus and Dreyfus 2009). Copying and distribution of this PDF is prohibited without written permission. For permission, please contact Copyright Clearance Center at www.copyright.com. EBSCOhost - printed on 1/6/2024 11:04 AM via UNIVERSITY OF CENTRAL FLORIDA. All use subject to https://www.ebsco.com/terms-of-use  36 Fundamentals of Human Resources in Healthcare Exhibit 2.1 Resource Guide Organization Target Audience Website for Healthcare Accrediting Organizations Professionals Accreditation Association Ambulatory healthcare www.aaahc.org for Ambulatory Health Care facilities (AAAHC) Accreditation Commission Nursing education and www.acenursing.org for Education in Nursing transition-to-practice (ACEN) programs Accreditation Council for Graduate medical edu- www.acgme.org Graduate Medical Educa- cation programs tion (ACGME) American Association of Blood banks www.aabb.org Blood Banks American College of Radiol- Diagnostic imaging www.acr.org ogy (ACR) American College of Sur- Surgeons www.facs.org geons (ACS) American College of Sur- Cancer programs www.facs.org/cancer geons: Cancer Programs American Osteopathic Osteopathic hospitals www.osteopathic.org Association and health systems CARF International Rehabilitation facilities www.carf.org College of American Clinical laboratories www.cap.org Pathologists (CAP) Commission on Accredita- Graduate healthcare www.cahme.org tion of Healthcare Manage- management programs ment Education (CAHME) The Joint Commission Hospitals and health www.jointcommission.org systems National Committee for Health plans www.ncqa.org Quality Assurance (NCQA) Professional Associations American Association for Home health care www.aahomecare.org Homecare administrators American Association for Physician executives www.physicianleaders.org Physician Leadership Copying and distribution of this PDF is prohibited without written permission. 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All use subject to https://www.ebsco.com/terms-of-use  Chapter 2: The Healthcare Professional 37 Exhibit 2.1 Organization Target Audience Website Resource Guide for Healthcare American Association for Respiratory therapists www.aarc.org Respiratory Care (AARC) Professionals (continued) American Association of Nurse anesthetists www.aana.com Nurse Anesthetists (AANA) American College of Health Long-term care www.achca.org Care Administrators (ACHCA) administrators American College of Health- Healthcare executives www.ache.org care Executives (ACHE) American Health Informa- Medical records and www.ahima.org tion Management Associa- information manage- tion (AHIMA) ment professionals American Medical Tech- Medical technologists www.americanmedtech.org nologists (AMT) American Nurses Associa- Registered nurses www.ana.org tion (ANA) American Occupational Occupational therapists www.aota.org Therapy Association (AOTA) American Organization for Nurse executives www.aonl.org Nursing Leadership (AONL) American Physical Therapy Physical therapists www.apta.org Association (APTA) American Society for Clini- Pathologists and labora- www.ascp.org cal Pathology (ASCP) tory professionals American Society for Healthcare HR www.ashhra.org Healthcare Human professionals Resources Administration (ASHHRA) American Society of Health- Health system www.ashp.org System Pharmacists (ASHP) pharmacists American Society of Radio- Radiologic technologists www.asrt.org logic Technologists (ASRT) American Speech-­ Speech-language pathol- www.asha.org Language–Hearing Asso- ogists; audiologists; and ciation (ASHA) speech, language, and hearing scientists (continued) Copying and distribution of this PDF is prohibited without written permission. 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All use subject to https://www.ebsco.com/terms-of-use  38 Fundamentals of Human Resources in Healthcare Exhibit 2.1 Resource Guide Organization Target Audience Website for Healthcare Association for Healthcare Medical transcriptionists www.ahdionline.org Professionals Documentation Integrity (continued) (AHDI) Healthcare Financial Controllers, chief www.hfma.org Management Association financial officers, and (HFMA) accountants Healthcare Information Health information and www.himss.org and Management Systems technology Society (HIMSS) Medical Group Manage- Physician practice man- www.mgma.com ment Association (MGMA) agers and executives National Association of African American health- www.nahse.org Health Services Executives care executives (NAHSE) National Association of Latine healthcare www.nalhe.org Latino Healthcare Execu- executives tives (NALHE) National Cancer Registrars Cancer registry www.ncra-usa.org Association (NCRA) professionals National League for Nursing Nurse faculty and www.nln.org (NLN) educators Trade Associations American Hospital Associa- Hospitals, health www.aha.org tion (AHA) systems, and personal membership groups America’s Health Insurance Health insurers www.ahip.org Plans (AHIP) Association of American Teaching hospitals and www.aamc.org Medical Colleges (AAMC) health systems Catholic Health Association Roman Catholic hospi- www.chausa.org (CHA) of the United States tals and health systems Federation of American Investor-owned www.fah.org Hospitals (FAH) ­hospitals and health systems Copying and distribution of this PDF is prohibited without written permission. For permission, please contact Copyright Clearance Center at www.copyright.com. EBSCOhost - printed on 1/6/2024 11:04 AM via UNIVERSITY OF CENTRAL FLORIDA. All use subject to https://www.ebsco.com/terms-of-use  Chapter 2: The Healthcare Professional 39 The US Department of Labor recognizes about 400 specific job titles in the healthcare sector; however, many of these job titles are not included in the definition of healthcare professionals used in this chapter. For example, the BLS (2022b) categorizes many positions in the healthcare sector as “healthcare support occupations.” Curiously, however, it does not consider these healthcare support occupations part of the patient care team or directly delivering healthcare services. These occupations include nursing aides, home health aides, personal attendants, and other aides, assistants, and support workers who are indeed critical to the delivery of healthcare services. In its consideration of healthcare professions, this chapter further explores the roles and issues relating to nurses, pharmacists, selected allied health professionals, and healthcare administrators, with each category discussed in the following sections. Nurses The art of caring, combined with the science of healthcare delivery, is the essence of nursing. Although diverse types of nurses work across a variety of healthcare settings, the nursing process serves as a common thread that embodies nurses’ delivery of holistic, patient-focused care. As outlined by the American Nurses Association (ANA 2022), the nursing process has five components: 1. Assessment: Collecting and analyzing physical, psychological, sociocultural, spiritual, economic, and lifestyle factors about a patient 2. Diagnosis: The nurse’s clinical judgment about the client’s response to actual or potential health conditions or needs 3. Outcomes/planning: Based on the assessment and diagnosis, involves writing an individualized care plan in the patient’s record so that nurses as well as other members of the interprofessional team have access to it 4. Implementation: Includes supervising or carrying out the treatment plan and documenting it in the patient’s record 5. Evaluation: Continuous assessment of the plan and modifications as needed Nurses also serve as patient advocates, interprofessional team members, managers, executives, consultants, researchers, and entrepreneurs. Nurses comprise the largest group of licensed healthcare professionals in the United States. According to the 2020 National Nursing Workforce Survey conducted by the National Council of State Boards of Nursing (NCSBN), the United States has 4.2 million licensed registered nurses (RNs), of whom roughly 3.5 million (84 percent) are actively employed in healthcare organizations (Smiley et al. 2021). Approximately 60 percent of employed Copying and distribution of this PDF is prohibited without written permission. For permission, please contact Copyright Clearance Center at www.copyright.com. EBSCOhost - printed on 1/6/2024 11:04 AM via UNIVERSITY OF CENTRAL FLORIDA. All use subject to https://www.ebsco.com/terms-of-use  40 Fundamentals of Human Resources in Healthcare RNs, or 1.9 million, work in hospitals, while 18 percent work in ambulatory settings (BLS 2022f ). Complementing this workforce are nearly 950,000 licensed practical nurses (LPNs), or licensed vocational nurses (LVNs), as they are known in some states (Smiley et al. 2021). Employment for LPNs and LVNs has been projected to increase 6 percent between 2021 and 2031, comparable to the average growth rate for all occupations (BLS 2022c). For other demographic findings from the national survey, see the accompanying “Did You Know?” sidebar. All US states require nurses to be licensed to practice. Licensure requirements 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, a diploma program, or a bachelor of science degree in nursing (BSN) to qualify for the licensure examination, while LPN/LVNs must complete a state-approved program in practical nursing—often offered at community colleges, post- secondary learning institutions, or hospital systems’ own vocational nursing programs—and achieve a passing score on a national examination. Each state maintains regulations and scope of practice practice acts that delineate the scope of practice—that is, the services that their role permits The services them to perform given their professional license—for RNs and LPN/LVNs. For RNs, the a healthcare professional’s role permits them to perform given their DID YOU KNOW? professional license. Demographics of Nurses in the United States Demographic profiles from the 2020 National Nursing Workforce Survey (Smiley et al. 2021) revealed the following: Whereas most nurses are women, men are a growing demographic, accounting for 9.4 percent of the RN workforce and 8.1 percent of the LPN/LVN workforce, an increase of 0.3 and 0.4 percentage points, respectively, from 2017. In 2020, the median age of RNs was 52, while the median age for LPN/LVNs was 53, with both groups exhibiting an increasing median age over time. Although the proportion of minority groups among nurses continues to grow, white/Caucasian nurses represent the majority of the nursing workforce, with nurses from racial and ethnic minority backgrounds representing about 19 percent of RNs and more than 30 percent of LPN/LVNs. Despite some gains in recruiting underrepresented minorities into nursing, more work must be done to increase the numbers of men and persons from racial and eth- nic minority backgrounds. Copying and distribution of this PDF is prohibited without written permission. For permission, please contact Copyright Clearance Center at www.copyright.com. EBSCOhost - printed on 1/6/2024 11:04 AM via UNIVERSITY OF CENTRAL FLORIDA. All use subject to https://www.ebsco.com/terms-of-use  Chapter 2: The Healthcare Professional 41 time required to complete educational preparation to qualify for licensure examination can vary. Associate’s degree programs generally take two years to complete and are offered by community colleges. Hospital-based diploma programs can be completed in about three years. The fastest-growing avenue for nursing education is the BSN, which typically can be completed in four years and is offered by colleges and universities. For decades, prominent voices and academic studies have supported higher levels of education in the nursing profession to prepare nurses for the more complex care needs of sicker patients and the sophisticated technologies for providing care (e.g., Djukic, Stimpfel, and Kovner 2019; Gerardi, Farmer, and Hoffman 2018). A 2011 National Academy of Medicine report titled The Future of Nursing: Leading Change, Advancing Health recom- mended increasing the proportion of nurses holding a BSN to 80 percent by 2020. However, despite increased education at initial licensure across the nursing workforce since 2013, the 2020 National Nursing Workforce Survey reported that efforts to meet that goal have fallen short, with roughly 67 percent of RNs and 3 percent of LPN/LVNs holding a bachelor’s degree or higher (Smiley et al. 2021). In light of widespread calls for a more highly educated nursing workforce, academic progression has become a key focus of efforts to improve the deployment of the nursing workforce. Academic progression refers to efforts to promote the advanced education of academic progression the nursing workforce (e.g., LPN to RN, RN to BSN, BSN to MSN [master of science Efforts to promote the advanced education of in nursing] or other graduate nursing degree). It is valued largely because of evidence that the nursing workforce, higher proportions of nurses with BSNs and MSNs are associated with improved patient including LPN to RN, outcomes (Harrison et al. 2019; O’Brien, Knowlton, and Whichello 2018; Sloane et al. RN to BSN, and BSN to 2018). Academic progression efforts are supported by the American Association of Col- MSN or other graduate leges of Nursing, the National League for Nursing, the American Nurses Association, the nursing degree. American Organization of Nurse Leadership, and the Robert Wood Johnson Foundation’s Academic Progression in Nursing Program (Farmer et al. 2018). During the twenty-first century, educational transformation and academic pro- gression have been observed in the US nursing workforce. Still, challenges and barriers to academic progression persist, most notably including social and economic disruptions, increased stress and burnout, and organizational changes resulting from the COVID-19 pandemic (Fernandez et al. 2022). As a result, further commitment and investment across diverse healthcare stakeholders will be required to advance BSN degree attainment in the US nursing workforce (T. Jones, Yoder, and Baernholdt 2019; Ma, Garrard, and He 2018). In addition to licensure and educational achievements, some nurses obtain certifi- cation in nursing specialty areas such as acute and critical care, infection control, trauma/ emergency, acute care surgery, or obstetrics. Certification in these areas requires additional specialty education, practical experience, and successful completion of a national examina- tion. Some nurses obtain certification in these specialty areas because doing so helps them maintain their competence and membership in professional associations. Continued employ- ment, continuing education units, or reexamination may be required to remain certified. Copying and distribution of this PDF is prohibited without written permission. For permission, please contact Copyright Clearance Center at www.copyright.com. EBSCOhost - printed on 1/6/2024 11:04 AM via UNIVERSITY OF CENTRAL FLORIDA. All use subject to https://www.ebsco.com/terms-of-use  42 Fundamentals of Human Resources in Healthcare Beyond specialty certification, some nurses also receive education and preparation to work as advanced practice registered nurses. An advanced practice registered nurse (APRN) is a registered nurse who has completed an accredited graduate-level education program and obtained certification and licensure to practice in one of the four roles recognized by the NCSBN (2022): certified nurse practitioner (CNP), clinical nurse specialist (CNS), certified registered nurse anesthetist (CRNA), or certified nurse-midwife (CNM). Broadly, APRNs assume responsibility and accountability for health promotion or maintenance as well as the assessment, diagnosis, and management of patient problems, which includes the use and prescription of pharmacological and nonpharmacological interventions (NCSBN 2022). Each of the specific APRN roles builds on the competencies of RNs by demonstrating a greater depth and breadth of knowledge, a greater synthesis of data, increased complexity of skills and interventions, and greater role autonomy. CNPs are the largest subset of APRNs, who may further specialize in primary or acute care, adult care or gerontology, neonatology or pediatrics, women’s health, or psychiatric and mental health. CNPs have developed an autonomous role in which their collaboration is encouraged, and they generally have the legal authority to implement management actions. In contrast, the CNS scope of practice is not as broad: CNSs are often employed by hospitals as nursing experts in particular specialties, working with a specialty population under a circumscribed set of conditions, and the patient management authority still rests with physicians. CRNAs complete additional education to specialize in administering anesthesia and analgesia to patients, often working collaboratively with surgeons and anesthesiologists as part of the perioperative care team. CNMs specialize in low-risk obstetric care, including all aspects of the prenatal, labor and delivery, and postnatal processes. The workforce of CRNAs, CNMs, and CNPs comprised 300,000 jobs in 2021, with an expected growth of 40 percent—an increase of more than 118,000 APRNs—by 2031 (BLS 2022d). Pharmacists Up to the late twentieth century, pharmacists performed the traditional role of preparing drug products and filling prescriptions. Today, pharmacists are key members of healthcare teams and experts for clients and patients on the effects of drugs, drug interactions, generic drug substitutions for brand-name drugs, and other issues. Pharmacists also oversee the work of pharmacy technicians, who assist pharmacists in filling and dispensing prescrip- tion medications. To be eligible for licensure, pharmacists must graduate from an accredited bachelor’s degree program in pharmacy, successfully complete a state board examination, and obtain practical experience or complete a supervised internship. After passing a national examina- tion, a registered pharmacist (RPh) is permitted to carry out the scope of practice outlined by state regulations. Since 2000, most schools of pharmacy have begun offering only the Copying and distribution of this PDF is prohibited without written permission. For permission, please contact Copyright Clearance Center at www.copyright.com. EBSCOhost - printed on 1/6/2024 11:04 AM via UNIVERSITY OF CENTRAL FLORIDA. All use subject to https://www.ebsco.com/terms-of-use  Chapter 2: The Healthcare Professional 43 six-year PharmD degree. The extensive training of doctorally prepared pharmacists allows them to pursue careers in research, education, healthcare management and leadership, or clinical pharmacy as a member of interprofessional patient care teams. This educational preparation also requires successful completion of a state board examination and other practical clinical experience, as outlined by state laws. In 2021, pharmacists comprised more than 323,000 jobs within the healthcare workforce, and total employment of pharmacists in the United States was projected to increase 2 percent by 2031, with about 7,700 openings for pharmacists anticipated each year as a result of workers retiring or transferring to other occupations (BLS 2022e). O t h e r H e a lt h P r o f e s s i on a l s A wide range of health professionals work collaboratively with physicians, nurses, and pharmacists, and these professionals are commonly categorized as allied health professionals. The United States Code defines an allied health professional as follows (Title 42, Chapter 6A, Subchapter V, Part G § 295p): A health professional (other than a registered nurse or a physician assistant)— (A) who has received a certificate, an associate’s degree, a bachelor’s degree, a master’s degree, a doctoral degree, or postbaccalaureate training, in a science related to health care; (B) who shares in the responsibility for the delivery of health care services or related services, including— (i) services relating to the identification, evaluation, and prevention of dis- ease and disorders; (ii) dietary and nutrition services; (iii) health promotion services; (iv) rehabilitation services; or (v) health systems management services; and (C) who has not received a degree of doctor of medicine, a degree of doctor of osteopathy, a degree of doctor of dentistry or an equivalent degree, a degree of doc- tor of veterinary medicine or an equivalent degree, a degree of doctor of optometry or an equivalent degree, a degree of doctor of podiatric medicine or an equivalent degree, a degree of bachelor of science in pharmacy or an equivalent degree, a degree of doctor of pharmacy or an equivalent degree, a graduate degree in public health or an equivalent degree, a degree of doctor of chiropractic or an equivalent degree, a graduate degree in health administration or an equivalent degree, a doctoral degree in clinical psychology or an equivalent degree, or a degree in social work or an equivalent degree or a degree in counseling or an equivalent degree. Copying and distribution of this PDF is prohibited without written permission. For permission, please contact Copyright Clearance Center at www.copyright.com. EBSCOhost - printed on 1/6/2024 11:04 AM via UNIVERSITY OF CENTRAL FLORIDA. All use subject to https://www.ebsco.com/terms-of-use  44 Fundamentals of Human Resources in Healthcare The exclusiveness and inclusiveness of this definition continue to be debated. Some healthcare observers consider nursing, public health, and social work to fall under the umbrella of allied health, but these professions are often categorized as separate groups. Exhibit 2.2 lists the major categories that make up allied health professions, along with job titles and a sample of positions that generally fall under each category. According to the Association of Schools Advancing Health Professions (ASAHP 2022b), licensed and unlicensed personnel traditionally included in the allied health profes- sions constitute up to 60 percent of the healthcare workforce in the United States. Although this number excludes physicians, nurses, dentists, pharmacists, veterinarians, chiropractors, optometrists, and podiatrists, its members are integral to interprofessional teams. With a wide variety of nonnurse, nonphysician professions, this collection of health professions is the most heterogeneous of the personnel groupings in healthcare. Although no single, commonly defined list of allied health professions exists, they are generally divided into two categories: (1) therapists/technologists and (2) technicians/ assistants (Shi and Singh 2022). In general, the therapist/technologist category represents those with higher-level professional training and often responsible for supervising those in the technician/assistant category. Therapists/technologists usually hold a bachelor’s or higher-level degree, and are trained to evaluate patients, understand diagnoses, and develop treatment plans in their area of expertise. Technicians/assistants are most likely to have two years of postsecondary education or less, and they are functionally trained with procedural skills for specified tasks. Some job titles shown in exhibit 2.2 may not easily fit into the categories of therapists/ technologists or technicians/assistants, such as community health workers or dietitians. How- ever, these roles collectively work to optimize health outcomes across patients and communities through the evaluation, treatment, and management of disease, as well as the promotion of wellness, and the provision of dietary and rehabilitation services (ASAHP 2022b). Educational and training programs for these health professions are sponsored by a variety of organizations in an array of academic and clinical settings. They range from degree offerings at colleges and universities to clinical programs in hospitals and other health facilities. The ASAHP (2022a) membership includes 124 academic institutions as well as numerous accreditation bodies and professional organizations. Not only four-year undergraduate institutions but also community colleges, vocational or technical schools, and academic health centers can sponsor allied health programs. These programs can stand alone when they are aligned with an academic health center, or they may operate 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 be trained in their respec- tive schools or a school of allied health professions. The Commission on Accreditation of Allied Health Education Programs (CAAHEP) accredits a vast number of health professions programs. CAAHEP is intended to simplify Copying and distribution of this PDF is prohibited without written permission. For permission, please contact Copyright Clearance Center at www.copyright.com. EBSCOhost - printed on 1/6/2024 11:04 AM via UNIVERSITY OF CENTRAL FLORIDA. All use subject to https://www.ebsco.com/terms-of-use  Chapter 2: The Healthcare Professional 45 Exhibit 2.2 The following lists include examples of professional titles within the allied health professions; the lists are not all-inclusive. Major Categories of Allied Health Behavioral Health Services Ophthalmology Professions and Community health worker Ophthalmic technician Home health aide Optician Professional Titles Mental health aide Optometric aide Mental health assistant Orthotics/Prosthetics Substance abuse counselor Orthopedic assistant Clinical Laboratory Sciences Physical Therapy Associate laboratory microbiologist Physical therapist Biochemist Physical therapy assistant Laboratory associate Radiological Services Laboratory microbiologist Diagnostic medical sonographer Laboratory technician Medical radiation dosimetrist Microbiologist Nuclear medicine technician Dental Services Nuclear medicine technologist Dental assistant Radiation technician Dental hygienist Radiologic (medical) technologist Dental laboratory technologist Ultrasound technician Dietetic Services Rehabilitation Services Assistant director of food service Addiction counselor Associate supervising dietitian Addiction specialist Dietary assistant Art therapist Dietitian Dance therapist Emergency Medical Services Exercise physiologist Ambulance technician Music therapist Emergency medical technician Psychiatric social health technician Health Information Management Services Recreational therapist Assistant director of medical records Recreation therapy assistant Coder Rehabilitation counselor Data analyst Rehabilitation technician Director of medical records Sign language interpreter Health information manager Respiratory Therapy Services Medical record specialist Respiratory therapist Senior analyst of medical records Respiratory therapy assistant Medical and Surgical Services Respiratory therapy technician Ambulatory care technician Speech-Language Pathology/Audiology Services Biomedical engineer Audiology clinician Biomedical equipment technician Speech clinician Cardiovascular technologist Staff audiologist Dialysis technologist Staff speech pathologist Electrocardiograph technician Other Allied Health Services Electroencephalograph technician Central supply technician Electroencephalograph technologist Chiropractic assistant Medical equipment specialist Health unit coordinator Operating room technician Home health aide Surgical assistant Medical illustrator Occupational Therapy Podiatric assistant Occupational therapist Occupational therapy aide Occupational therapy assistant Copying and distribution of this PDF is prohibited without written permission. For permission, please contact Copyright Clearance Center at www.copyright.com. EBSCOhost - printed on 1/6/2024 11:04 AM via UNIVERSITY OF CENTRAL FLORIDA. All use subject to https://www.ebsco.com/terms-of-use  46 Fundamentals of Human Resources in Healthcare the accrediting process, be more inclusive of health professions programs that provide entry-level education, and serve as an initiator of change. Some health professions gradu- ate programs, such as physical therapy and occupational therapy, are accredited through professional and specialized professional accreditation agencies. H e a lt h c a r e M a n a g e r s Healthcare managers organize, coordinate, and oversee the delivery of health services; pro- vide leadership; and guide the strategic direction of healthcare organizations. The variety and numbers of healthcare professionals they employ, the complexity of healthcare delivery, and environmental pressures to provide access, high quality, and efficient services make healthcare institutions some of the most complex organizations to manage. Healthcare management is taught at the undergraduate and graduate levels in various settings, including schools of medicine, public health, business, and allied health professions. A bachelor’s degree in health administration allows individuals to pursue positions such as nursing home administrator, supervisor, or middle manager in healthcare organizations. Most students who aspire to a career in healthcare management go on to earn a master’s degree. Graduate education programs in healthcare management are accredited by the Commission on Accreditation of Healthcare Management Education. The most common degrees include the master of health administration (MHA), master of business adminis- tration (MBA) with a healthcare emphasis, master of public health (MPH), and master of public administration (MPA). However, the MHA degree, or its equivalent, has been the accepted training model for entry-level managers in the healthcare industry. The MHA program, in contrast to the MPH program, offers core courses that focus on building busi- ness management competency, quantitative and analytical skills, and experiential learning. 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 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 managers are physicians and other clinicians. Membership in the American Association for Physician Leadership (AAPL 2022) increased to more than 11,000 in 2022, more than double the number in 1990. Physicians, nurses, and other clinicians may 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 executives is the chief medical officer (CMO, or a similar position) in a hospital, overseeing the medical staff and serving as a liaison between clinical care and administration. Likewise, a typical management career path for nurses is to become the chief nursing officer (CNO), with responsibility for the clinical care provided by employed professional staff. Copying and distribution of this PDF is prohibited without written permission. For permission, please contact Copyright Clearance Center at www.copyright.com. EBSCOhost - printed on 1/6/2024 11:04 AM via UNIVERSITY OF CENTRAL FLORIDA. All use subject to https://www.ebsco.com/terms-of-use  Chapter 2: The Healthcare Professional 47 Typically, CMOs begin their careers practicing medicine and then transition into management roles. Physician executives work at every level and in every setting in healthcare. Many physician executives earn a graduate degree, such as an MHA or an MBA. As reported by the Association of American Medical Colleges (AAMC 2022), as of 2022, 85 medical schools offer a combined MD/MBA program. MD/MHA degrees have also proliferated. Nursing home administrator programs require students to pass a national examina- tion administered by the National Association of Long Term Care Administrator Boards (NAB). Passing this examination is a standard requirement in all states, but the educational preparation needed to qualify for this exam varies among states. One-third of states still allow less than a bachelor’s degree as the minimum academic preparation (NAB 2022). However, the demand and educational requirements for long-term care administrators are predicted to increase as the population continues to live longer, along with the growth of educational programs targeted to this sector. C on s i d erat i ons for H u m an R es our ces M a n ageme n t The role of HR management in healthcare organizations is to develop and implement systems according to regulatory guidelines and licensure laws for the selection, evaluation, and retention of healthcare professionals. In light of this role, HR personnel should be aware that each healthcare profession, and often the subspecialties within the profession, will have specific requirements that allow an individual to qualify for a job in their chosen profession. The requirements of national accrediting organizations (e.g., The Joint Commis- sion), regulatory bodies (e.g., CMS), and licensure authorities (e.g., state licensure boards) should be considered in all aspects of HR management. This section briefly discusses some of the issues that a healthcare organization’s HR department must consider when dealing with healthcare professionals. Q u a l i f i c at i on s In developing a comprehensive employee compensation program, HR personnel 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 education, experience, judgment ability, accountability, physi- cal skills, responsibilities, communication skills, and any special certification or licensure requirements. HR personnel need to be aware of all specifications for all job titles within the organization. This knowledge of healthcare professionals is necessary to ensure that essential qualifications of individuals coincide with job specifications, and it is also neces- sary for determining wage and salary ranges. Copying and distribution of this PDF is prohibited without written permission. For permission, please contact Copyright Clearance Center at www.copyright.com. EBSCOhost - printed on 1/6/2024 11:04 AM via UNIVERSITY OF CENTRAL FLORIDA. All use subject to https://www.ebsco.com/terms-of-use  48 Fundamentals of Human Resources in Healthcare Licensure and C e rt i f i c at i on An HR department must have policies and procedures that describe how licensure is verified upon initial employment. Also, HR must have a system in place for tracking the expira- tion dates of licenses and for ensuring licensure renewal. Therefore, HR team members primary verification must be conscious of whether the information received is a primary verification (i.e., the Information directly information comes directly from the licensing authority) or a secondary verification (i.e., received from the the candidate submits a copy of a document indicating that licensure has been granted, licensing authority including the expiration date). Certifications must be verified during the selection pro- that verifies a new hire’s license. cess, although certifications and licenses generally are not statutory requirements. Many healthcare organizations accept a copy of a certification document as verification. If the secondary verification certification is a job requirement, systems must be in place to track expiration dates and A copy of a document access new certification documents. that indicates licensure has been granted and shows the E d u c at i on a l S e r v i c e s license’s expiration Healthcare professionals require continuous, lifelong learning. Healthcare organizations must date. have training and development plans to ensure that professionals achieve competency in new technologies, programs, and equipment and are aware of policy and procedure changes. In addition to providing training programs, healthcare organizations should provide onboarding for all new employees, including interprofessional team training. Such training enables leadership to share the values, mission, goals, and policies of the institution and indicate how to be successful in that organization. Some professions and licensing jurisdic- tions may require profession-specific continuing education. (See also the “Did You Know?” sidebar on career pathways.) DID YOU KNOW? Career Pathways Many healthcare organizations have career pathways, which are mechanisms by which healthcare professionals advance within the organization or assume addi- tional responsibilities. Career pathways are based on the Dreyfus and Dreyfus (2009) model of novice to expert (explained earlier in this chapter), and experience may be used as a criterion for assigning an individual to a particular job category. In addi- tion, healthcare organizations may conduct annual reviews of employees who have leadership and management potential. Such reviews entail HR working with senior management to assess the competency, ability, and career progression of employees on an ongoing basis. Copying and distribution of this PDF is prohibited without written permission. For permission, please contact Copyright Clearance Center at www.copyright.com. EBSCOhost - printed on 1/6/2024 11:04 AM via UNIVERSITY OF CENTRAL FLORIDA. All use subject to https://www.ebsco.com/terms-of-use  Chapter 2: The Healthcare Professional 49 P r a c t i t i on e r I m pa i r m e n t Healthcare professionals are accountable to the public for maintaining high professional standards. By statute, the governing body of a healthcare organization is responsible for the quality of care rendered in the organization, but instances of practitioner impairment can easily jeopardize an organization’s quality of health services. An impaired practitioner is impaired practitioner a healthcare professional who is unable to carry out their professional duties with reason- A healthcare able skill and safety because of a physical or mental illness, including deterioration through professional who is unable to carry out aging, loss of motor skill, or excessive use of drugs and alcohol. their professional Mechanisms to identify and deal with the impaired practitioner—such as policies duties with and procedures that describe how the organization will handle investigations, subsequent reasonable skill and recommendations for treatment, monitoring, and employment restrictions or s­ eparation— safety because of a must be in place. Hospitals, for instance, usually have a process in place for the governing physical or mental board (which has the ultimate responsibility for the quality of care delivered in the orga- illness, including nization) to review provider credentials and performance and to oversee any employment deterioration through aging, loss of motor actions. Each national or state licensing authority maintains legal requirements for reporting skill, or excessive use impaired practitioners. of drugs and alcohol. T h e C h an g in g N at u r e of the H ea lth care P r ofessi on s Changes in the organization and financing of healthcare services have shifted delivery from hospitals to outpatient facilities, the home, long-term care facilities, and the com- munity. This trend is largely the result of three major forces: (1) a shift in reimbursement to outpatient settings and a focus on cost containment; (2) technological advances, such as telehealth and electronic health records; and (3) medical innovation—specifically, the fact that the science of medicine has progressed to the point that complicated procedures that once required several nights of stay in a hospital can now be treated with a simple procedure or even solely with medication. As the settings for care delivery have changed, so have arrangements between phy- sicians and healthcare organizations. For instance, physicians can function as individual providers (in either solo or group practice) and refer patients to the hospital. Typically, these private practice doctors have admitting privileges to the hospital but are not governed by the hospital, do not serve as attending physicians, and infrequently participate on hospital committees. Physicians considered “on staff” at any hospital refer and treat patients at that hospital. They are credentialed by the hospital credentialing committee and are governed by the medical staff bylaws. This scenario is a common type of hospital–physician arrangement. However, a trend toward employment of physicians by hospitals has been steadily growing, with more than half of US physicians now employed by hospitals or hospital- based systems (Physicians Advocacy Institute 2022). In this arrangement, physicians are on staff, referring to and treating at only the hospital that employs them. Because they are considered employees, physicians are not only held to the organization’s HR policies but Copying and distribution of this PDF is prohibited without written permission. For permission, please contact Copyright Clearance Center at www.copyright.com. EBSCOhost - printed on 1/6/2024 11:04 AM via UNIVERSITY OF CENTRAL FLORIDA. All use subject to https://www.ebsco.com/terms-of-use  50 Fundamentals of Human Resources in Healthcare also governed by the medical staff bylaws. Physicians who are employed by a hospital can also maintain a private practice. Finally, the field of hospital medicine, often called hospitalists, has also seen rapid growth, with hospitalists practicing at the vast majority of US hospitals (Ryskina et al. 2021; Wachter and Goldman 2016). Typically, these physicians do not run their own practice aside from their hospital employment. Hospitalists work full-time for the hospital and are trained in delivering specialized inpatient care. Regardless of the type of arrangement, most hospitals have a CMO, or a similar position, who oversees the roles and responsibilities of the hospitalist as a member of the medical staff. The HR department typically manages the hospitalist’s employee issues and responsibilities. These hospital–physician arrange- ments get more complex in academic medical centers, which must integrate the roles and responsibilities of the physicians, the hospital, and the medical school. As a result of the changing healthcare environment and declining reimbursements, the majority of physicians now work outside private practice (i.e., a practice wholly owned by physicians), and only 5.8 percent of physicians work as independent contractors (Kane 2021). Among physician practices, recent trends show that more than 25 percent of US physician practices are owned by hospitals or hospital-based systems, and another 27.2 percent are owned by corporate entities such as insurance companies and private equity firms (Physicians Advocacy Institute 2022). Many of the remaining practices are large DEBATE POINT Employment of physicians and acquisition of physician practices are key elements in the consolidation of the US healthcare industry. However, debates have grown regarding the potential benefits and consequences of such activity. Some opponents raise concerns that physician consolidation and employment by hospital systems may limit patient choice, inhibit transparency, stifle collaboration, and minimize physician autonomy, while proponents suggest that this activity can ensure financial viability, clinical network stability, physician work–life balance, and improved coordination of care (O’Hanlon 2020; O’Hanlon, Whaley, and Freund 2019; Richards, Seward, and Whaley 2022). What might be the impact of hospitals’ increased employment of phy- sicians and acquisition of physician practices on access to care, the cost of care, and the quality of care provided to communities? Who benefits from such consolida- tion, and what are some intended and unintended consequences? For health services administrators, what challenges and considerations might they have to navigate as a result of increased consolidation and employment of physicians? Copying and distribution of this PDF is prohibited without written permission. For permission, please contact Copyright Clearance Center at www.copyright.com. EBSCOhost - printed on 1/6/2024 11:04 AM via UNIVERSITY OF CENTRAL FLORIDA. All use subject to https://www.ebsco.com/terms-of-use  Chapter 2: The Healthcare Professional 51 physician-owned medical groups (Kane 2021), which offer several advantages to physicians, including competitive advantage with vendors and manufacturers, improved negotiating power with managed care organizations, shared risk and decision making, and enhanced flexibility and choice for patients. Physicians who own or share ownership in the group practice are also responsible for its business operations. Typically, group practices employ an office manager who works closely with physicians to manage day-to-day operations. A full-time administrator may also formulate strategies and oversee personnel, billing and collection, purchasing, patient flow, and other functions. Many group practices opt to outsource their business functions, including HR, to specialized firms. These shifts in healthcare settings and arrangements have changed the roles, functions, and expectations of the healthcare workforce and have led to the emergence of the issues of supply and demand; complementary, alternative, and integrative therapies; nonphysi- cian licensed independent practitioners; emerging and evolving roles; and innovation and entrepreneurship. These issues are discussed in the sections that follow. S u p p ly and Demand Labor markets for various health professions have cycled through periods of shortages and surpluses. Indicators of demand include numbers of vacancies, turnover rates, and increases in salaries. To fill positions, hospitals—the largest employers of nurses and health professionals—have raised salaries, provided scholarships, and given other incentives such as sign-on bonuses and tuition reimbursement. In addition to the challenges facing the nursing workforce (as described in the accompanying Current Issue sidebar “Supply Challenges Facing Nurses”), shortages of other health professionals persist, including behavioral health professionals, information technology professionals and analysts, laboratory technicians, and certified nursing assistants, among others (American Hospital Association [AHA] 2020). As a result, the recruitment of nursing and other health profession students has become a major focus of practitioners, professional associations, and academic institutions. Furthermore, healthcare organizations (in addition to increasing salaries) are developing innovative ways to recruit and retain health professionals. Such developments include opening or sponsoring new schools, offering shorter and more flexible shifts, issuing tuition reimbursement or loan repayment, providing child care, and aligning recruitment and retention processes to emphasize the organization’s mission of serving others (AHA 2020). C o m p l e m e n ta ry , A lt e r n at i v e , and I n t e g r at i v e M e d i c i n e T h e r a p i e s Complementary and alternative medicine (CAM) therapies continue to gain acceptance and popularity. A turning point was a seminal study of the prevalence of the use of alternative Copying and distribution of this PDF is prohibited without written permission. For permission, please contact Copyright Clearance Center at www.copyright.com. EBSCOhost - printed on 1/6/2024 11:04 AM via UNIVERSITY OF CENTRAL FLORIDA. All use subject to https://www.ebsco.com/terms-of-use  52 Fundamentals of Human Resources in Healthcare CURRENT ISSUE Supply Challenges Facing Nurses The supply of nurses and other health professionals is reflected in the number of stu- dents in educational programs and those available for the healthcare workforce. The future supply of nurses is a challenge, as reflected by the following factors: The aging of the nursing workforce. More than 50 percent of all RNs and LVN/ LPNs in the healthcare workforce are aged 50 or older, with nurses aged 65 or older representing nearly 20 percent of their peers (NCSBN 2022). As the current nursing workforce continues to age, a new generation of nurses will need to be educated and introduced to the field. The aging of nursing faculty. The American Association of Colleges of Nursing (AACN 2021) reports that nursing schools have restricted enrollment, in large part because of an insufficient number of nursing faculty. Related to this issue, the average ages of doctoral-prepared professors, associate professors, and assistant professors who serve as nurse faculty are 62.6, 56.9, and 50.9, respectively, while the average ages for master’s-prepared nurse faculty are 57.1, 56.0, and 49.6, respectively (AACN 2020). The lack of younger nurses in faculty positions may contribute further to both the shortage of nursing school faculty and barriers to educating the next generations of nurses. The barriers to available educational resources. According to the National League for Nursing’s biennial survey of schools of nursing, nursing programs turn away significant percentages of qualified applicants—including 29 percent of BSN program applicants as well as 35 percent of associate’s degree program applicants and 17 percent of diploma degree program applicants (Mazinga 2021). The survey found that a lack of clinical placement settings and a shortage of faculty are obstacles to program capacity expansion and increased nursing education opportunities (Mazinga 2021). In an American Association of Colleges of Nursing faculty vacancy survey, the 884 schools of nursing that responded had an average of 1.69 full-time faculty vacancies per school and a range of 1 to 31 vacancies (AACN 2022). A key challenge to recruiting potential nurse educators—and retaining current nurse educators—to address such faculty vacancies is the higher compensation that nurses can earn in clinical and private-sector settings in comparison to teaching positions (AACN 2020). Copying and distribution of this PDF is prohibited without written permission. For permission, please contact Copyright Clearance Center at www.copyright.com. EBSCOhost - printed on 1/6/2024 11:04 AM via UNIVERSITY OF CENTRAL FLORIDA. All use subject to https://www.ebsco.com/terms-of-use  Chapter 2: The Healthcare Professional 53 or unconventional therapies (Eisenberg et al. 1993). In that 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, such as acupuncture, chiropractic, and massage therapies. Consumers are increasingly using and paying for CAM approaches (Scott et al. 2022; Stussman et al. 2020), and more than half of office-based physicians recommend CAM approaches to their patients (Stussman et al. 2020). In recognizing the growing demand for CAM therapies, health systems are increas- ingly pursuing the integration of conventional medical care with CAM therapies, often referred to as “integrative health” (Ng et al. 2022). Some common challenges that systems may face in the further embrace of complementary, alternative, and integrative medicine therapies include initial costs associated with developing CAM or integrative medicine programs, teams’ disagreement on conflicting treatment approaches, and a lack of knowl- edge or education about integrative medicine among clinicians to support its expansion (Gannotta et al. 2018). N on p h y s i c i a n L i c e n s e d I n d e p e n d e n t P r a c t i t i on e r s As a result of the Affordable Care Act, healthcare organizations are relying more on non- physician licensed independent practitioners (LIPs). Collaborative practice models that include nurse practitioners, physician assistants, pharmacists, and other therapists are appropriate in both acute and long-term healthcare delivery. Advances have been made in the direct reimbursement for some LIP services, which is