RCPs are being given a cadre of opportunities from the hospital setting to home care due to a high demand for their services.

As the business of medicine continues to redefine itself, RCPs can expect to find a continued demand for their services into the next century, according to experts surveyed around the country. The need for additional skills will grow, and some RCPs will find jobs in new specialties or in areas they never knew existed.

Perhaps the most noticeable shift in the job market has been the decrease in hospital jobs for RCPs. Though RCPs continue to work in hospitals, there are not as many jobs in this area as in the past, and in some cases the duties of hospital-based RCPs have expanded or changed. “Managed care is cutting down on acute hospital care,” says Paul Mathews, PhD, RRT, associate professor of respiratory care education at the University of Kansas Medical Center in Kansas City. “Over the past 7 years or so, hospitals have cut back on the number of respiratory care providers.”

Now, however, the pendulum has begun to swing the other way, with hospitals finding a greater need than ever for qualified respiratory therapists. “There were a lot of efforts to do without the therapists,” says Sam Giordano, executive director of the American Association for Respiratory Care. “Some hospitals were misled into thinking that others could perform [therapists’] duties. They found, to their dismay, that that isn’t the case. They’ve missed us.”

Mathews sees this pattern of staff cuts mixed with periods of renewed recruitment efforts as part of a regular cycle. “There is a periodicity to this,” he says. “I’ve been looking at this over the past couple of decades and about every 5 years we go through this feast or famine cycle.”

RCPs In The Hospital
For many new respiratory care graduates, hospitals remain a good place to find entry-level positions. “Hospitals seem to be more apt to employ new graduates and I think that that’s probably not a bad idea,” Giordano says. “I think the new graduates would prefer to work in institutions, simply because it better positions them from an experiential standpoint to pass their examinations for licensure or for certification for registry.”

Many of these first jobs will be part-time or per diem positions. “A lot of our graduates find their initial work is per diem, but there is so much of that work available, it’s equivalent to a full-time job,” says Daniel Farrell, MA, RRT, clinical director for respiratory care at Orange Coast College in Costa Mesa, Calif.

The trend toward more part-time work and contracting out for jobs that is prevalent in many industries has reached the respiratory care field as well. “I think there may be more independent contractors [in respiratory care in the future],” Mathews says, “or more personnel who travel between several locations, several hospitals or clinics, providing care and training others to provide care.”

RCPs working in hospitals are likely to find themselves working with less supervision. Much of the streamlining that has taken place at hospitals around the country has eliminated middle management and supervisory positions. For this reason, some hospitals are looking to hire more experienced personnel. “It goes back to the economic crunch the industry is facing,” Giordano says. “Experienced people tend not to require as close supervision and there are not as many supervisors as there once were.”

Whether part-time or full-time, newly graduated or experienced, those RCPs who remain in the hospital setting will probably be expected to work harder than ever. “It seems like everybody has to do more,” Farrell says. “They have to be more productive.”

RCPs are working harder because patients in hospitals today are sicker. “Hospitals are recognizing that their patient populations enjoy a much higher degree of acuity,” Giordano says. “Because of the higher acuity level, the intensity of services increases.”

In some hospitals, basic respiratory care services such as breathing treatments are being administered by nonclinical personnel, while respiratory therapists focus their attention on more complex services, such as nitric oxide, or weaning patients from ventilators. “Respiratory care will always have opportunities for employment because the technological developments that come down the road are just overwhelming in their variety and their volume,” says Michael Mahlmeister, MS, RCP, RRT, of Mahlmeister & Associates, a private health care consulting company in San Francisco. “We’ve become so specialized, there is no reason to believe we will not continue to be needed in the acute care hospital to work with the technological developments.”

This practice of training other personnel to assume duties formerly handled by RCPs is not seen by everyone as a positive development, however. “The tendency a few years ago was to take out more highly compensated professionals and plug in some lower-compensated, on-the-job-trained persons,” Giordano says. “That was being very nearsighted, focusing only on the motor-skills aspects of the procedure. You might arrive at the conclusion that you could provide the procedure at less cost by using that less qualified person, but what you forgo in that person is the ability to recognize when that procedure isn’t needed in the first place.”

The Shift Away From Acute Care
While the hospital setting has seen its share of changes, the biggest growth area for RCPs is in subacute and long-term care facilities. Managed care restrictions on payment for acute care have pushed more and more patients into these settings. “The job market in subacute and long-term care is pretty impressive in our area,” Farrell says. “That’s where the patients are. It’s cheaper to care for them there than in the hospital.”

Just as the growth of managed care has driven more patients, and thus more jobs, into subacute settings, changes in Medicare payment structures for subacute care could shake up the job market there as well. The Health Care Financing Administration’s proposal to restrict payment for respiratory care services in skilled nursing facilities, for example, has led some facilities to lay off RCPs, and future job prospects in skilled nursing facilities remain uncertain. Mahlmeister sees payment issues such as these as a primary force that will drive the job market for RCPs in the next decade.

Another factor sure to affect the job market for RCPs is the aging population of the United States. US Census figures show that people over the age of 65 make up one of the fastest-growing segments of the population, and their numbers are expected to continue to grow over the next 50 years. “As we age, we tend to acquire more chronic diseases,” Giordano explains. “There are a significant number of chronic pulmonary diseases.”

With the rise in chronic pulmonary diseases, there should be a corresponding increase in the demand for RCPs, particularly in long-term care facilities where many of these patients are likely to be treated. “I think that you need to have a cadre of trained people, especially with the aging population and more chronic illnesses that go along with that,” Mathews says. “You need to have trained people in the places where those patients are.”

Another place these aging and/or chronically ill patients are likely to be is at home. The growing use of ventilators in the home setting and increased attempts to manage chronic pulmonary disease without hospitalization will create new opportunities for RCPs. “Certainly respiratory therapists will follow the patients,” Giordano says. “The more we can manage patients without incurring hospitalization, the lower costs will be and the higher quality of life will be for the patient.”

RCPs are also following patients into specialized medical areas, some of which did not exist 10 years ago. For instance, more and more respiratory therapy programs now include training in sleep studies. As more hospitals add hyperbaric chambers and find more uses for these chambers, RCPs are becoming involved in hyperbaric work. RCPs are expanding into pulmonary diagnostics and rehabilitation as well.

“What we’re seeing, and I think this is nationwide, is multitasking,” Farrell says. “Respiratory care people are doing not only respiratory care: you have to be able to do a whole lot of other things to be more marketable.” In some hospitals, RCPs are running ECGs, doing venous blood draws, and performing EEGs.

As a response to changes in the marketplace, the University of Kansas Medical Center has incorporated eight specialty practicums into its respiratory care program. Senior students complete internships in at least one of these programs: adult critical care, neonatal critical care, pulmonary rehabilitation, long-term care, pulmonary diagnostics, sleep diagnostics, hyperbaric medicine, and education and management.

“To make sure our students are as marketable as possible, we encourage them to cross-train as much as possible,” Farrell says. “When I was a student, everybody was really specialized. You had people who did only neonatal, or people who did only adult critical care. Now we’re going back to the generalist, someone who can do everything.”

Because of this need for additional skills, he foresees extending the RT training program to 3 and eventually 4 years. “We’re going to have to be able to do so much, maybe we’re looking at a 4-year program in order to cover all the clinical skills necessary,” he says.

New Possibilities
As RCPs expand their skills, Mahlmeister foresees them expanding their horizons as well, and looking to the corporate arena for new opportunities. “I think there are tremendous entrepreneurial opportunities for RCPs that haven’t been tapped,” he says. “One force that will drive the job market is our own profession and how we define ourselves. There are opportunities out there for respiratory therapists to be involved in preventative care and disease prevention if their role can be clearly defined, whether it’s in a hospital setting or in the community or in a corporate setting.” For example, he thinks RCPs could put together corporate wellness programs for asthma management and market these to industry as a way to reduce asthma-related absenteeism, much as some companies have marketed diabetes-education or injury-prevention programs to corporations.

Similar opportunities await RCPs in the area of community education. Community organizations, schools, and others may be in the market for asthma or COPD education programs designed and managed by RCPs.

Another possible area of job growth is in the research field. “There is a shortage of RCPs in private industrial and hospital research,” Mahlmeister says. He points to a recent issue of the Sunday San Francisco Chronicle, which included three pages of job ads in the bio-technology fields. “I think there is a potential opportunity for RCPs to help manage clinical trials, and to work as research assistants or researchers,” he says. “There is also opportunity for research within the hospital itself, through either NIH [National Institutes of Health] grants or hospital-driven research projects.”

For instance, a number of companies are developing inhalation delivery of medications for chronic illnesses. “RCPs are the experts on inhalation therapy,” Mahlmeister says. “It stands to reason there would be opportunities for them here.”

What The Future Holds
While the job market for RCPs looks strong, changes continue to rock health care and the situation is unlikely to stabilize any time soon. “I see the marketplace continuing to take two steps forward and one step back,” Giordano says, “simply because decision-makers are making staffing decisions based on reimbursement rather than the need for expertise. Until the health care system recognizes the fact that they should employ people to provide care based on the need for that caregiver’s expertise, rather than the current reimbursement scheme, they will find that they don’t have the right people intervening at the right time, and that the cost of care will actually go up. Health care costs are again rising.”

Flexibility, job skills, and an eye for new opportunities seem to be the key factors for future job security in the respiratory care field. “No matter what our job, we tend to wonder ‘are we going to be here next year,’ ” Mathews says. “But it’s not just respiratory care. There are a lot of other people under the ax. The key is to be able to change with the times. Those who can change will survive.”

Cynthia Myers is a contributing writer for RT.