Coalition Chronicle. Coalition for Baccalaureate and Graduate Respiratory Therapy Education. April 30, 2013 Volume 2 (4)

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1 Coalition Chronicle Coalition for Baccalaureate and Graduate Respiratory Therapy Education April 30, 2013 Volume 2 (4) North Carolina Responds to AARC 2015 Conferences By Tom Barnes, EdD, RRT, FAARC Academic Specialist MSRC Program College of Professional Studies Professor Emeritus of Cardiopulmonary Sciences Northeastern University The North Carolina Respiratory Care Board has recently submitted an amendment to their North Carolina licensure legislation The Respiratory Care Practice Act: Version This action was taken after RT educators reviewed the findings of the three American Association for Respiratory Care 2015 and Beyond conferences. 1-3 The leadership demonstrated in North Carolina by RT educators follows closely the recent rules change by the Ohio Respiratory Care Board requiring the RRT credential for new licensure applicants effective on January 1, The amended practice act will require the RRT credential and completion of a BSRT degree program to qualify for a license as a Respiratory Care Practitioner (RCP) effective January 1, The amended licensure act will allow ASRT graduates with either a CRT or RRT credential to be licensed as a respiratory therapist (RT) while they complete a BSRT degree. The North Carolina Association of Respiratory Care Educators (NCARE) has been working to increase educational opportunities for over three years. The completely online BSRT completion program at the University of North Carolina Charlotte was started as a result of the NCARE initiative. The curriculum was agreed upon by all the educators from all of the RT programs in North Carolina. The very successful UNC BSRT program accepted 30 students per year in 2008 when first started and plans to enroll 78 next September. NCARE is now talking to other UNC campuses to duplicate what is being accomplished at UNC-Charlotte. There is a clear pathway in North Carolina for new RRT associate degree graduate therapists to continue on to earn a BSRT degree and assume more responsibility as a respiratory care practitioner. Below Dr. Bill Croft a long- 1

2 time educator and state society leader shares a letter regarding the amended practice act that was recently sent to all members of the North Carolina Society for Respiratory Care. References 1. Kacmarek RM, Durbin CG, Barnes TA, Kageler WV, Walton JR, O'Neil EH. Creating a vision for respiratory care in 2015 and beyond. Respir Care 2009;54(3): Barnes TA, Gale DD, Kacmarek RM, Kageler WV. Competencies needed by graduate respiratory therapists in 2015 and beyond. Respir Care 2010;55(5): Barnes TA, Kacmarek RM, Durbin CG. Transitioning the Respiratory Therapy Workforce for 2015 and Beyond. Respir Care 2011;56((5): ) The Respiratory Care Practice Act: Version By Bill Croft, PhD, RRT, RCP Health Science Department Chair Program Director for Respiratory Care Sandhills Community College In 2000, the Respiratory Practice Act was finally passed in North Carolina to much celebration. In the years leading up to this historic event, we hoped this would help raise the status of respiratory therapist within the healthcare arena. After implementation in 2002, the North Carolina Respiratory Care Board (NCRCB) worked to set and enforce standards for competency to protect the public against unsafe patient care. Protecting the public is the primary charge of the board. In many cases, the power of the declaratory rulings was required when additional skills exceeded the normal duties outlined in the practice act. These rulings clarified the requirements to perform advanced skills as well as help evolve respiratory care practices in North Carolina. The board was forward thinking with these rulings by requiring additional education and credentialing from the beginning. The RRT credential was mandatory for each advanced skill, but it also included a BS degree when performing advanced skills such as ECMO and transport. In fact, the BSRT program at University of North Carolina - Charlotte was created to fill this need. Over the last 11 years, a number of these rulings have advanced the practice of respiratory care in NC and raised the status of respiratory therapist as part of the healthcare team. With the proposed amendment, respiratory care in NC is on the verge of another evolutionary change with the BSRT degree as an entry level requirement to become a licensed Respiratory Care Practitioner. 1 2

3 Background Before prejudging this legislation, please consider that this legislation was not promoted in a vacuum. It was based on the outcomes of the AARC 2015 and Beyond conferences after consulting with the leaders of the NC Society for Respiratory Care (NCSRC) and the North Carolina Association of Respiratory Care Educators (NCARE) members. The 2015 conferences were established to seek input from all states regarding the future direction of the profession. It had many different groups from all 50 states contribute to the conference outcomes during three different conferences from Community colleges, universities, managers, licensing boards, the American Association for Respiratory Care (AARC) and state affiliates, the National Board for Respiratory Care (NBRC), and the Commission on Accreditation for Respiratory Care (CoARC) were all represented. 2 After participating in the second 2015 AARC conference as the representative for the NCRCB, it was clear to me that it was time for the BSRT. As an educator and program director for 20 years, it would not be intellectually honest or educationally sound to suggest that the long list of objectives were possible to accomplish in a two-year associate degree program. While I cannot speak for my fellow educators in North Carolina, the North Carolina Association of Respiratory Care Educators (2013) has sent a letter of support for this legislation citing: The continued growth and development of the profession requires that every respiratory therapist demonstrate an advanced level of critical thinking, assessment and problem solving skills. These skills are essential in today s health care environment not only to improve the quality of care, but also to reduce inappropriate care and thereby reduce costs. Respiratory therapists are expected to participate in the development, modification and evaluation of care plans, protocol administration, disease management and patient education and it will be necessary to educate our future workforce in skills beyond those currently being included in an associate degree format. Evidence based practice, higher acuity patients, and increased technological advances in procedures and equipment have all continued to explode. We support the recommended changes to the practice act. We want to have quality respiratory care practice for the citizens of North Carolina; therefore, we also want to see our associate degree graduates continue their education to become more effective contributors to that end. 3 Despite the enormous work completed by numerous individuals and groups, questions and concerns may arise as part of this legislation. In fact, the following questions were recently forwarded to me by students and colleagues. 3

4 Questions and Concerns Potential Impact Has the board not considered the negative consequences of this legislation? Consider the evidence before assuming the board did not consider the negative consequences of these changes. For example, the original licensing act took over 20 years to pass. During the many discussions with legislatures, many thought licensing would result in many people losing their jobs. In reality, approximately fifty individuals lost their jobs. Some were by choice. They were all OJT s, who never passed the CRT exam. In some cases, respiratory therapists thought it was not necessary or beneficial. Over the last 11 years, the NCRCB has a 95% adjudication rate, which is the highest in the country. This means cases brought before the board result in some form of action. Therefore, the board has ensured a standard of competency in the state as required by law. In fact, NCRCB has become a positive example for the rest of the country in regards to licensing. From ECMO to transport, we have gained ground in securing the RCP s role in the health care arena. In summary, the evidence is clear that the public and profession has benefited from the law. What is the impact on a licensed RCP before the implementation of the changes? If licensed before the effective date of the bill, current licensees would be grandfathered. The licensees that have completed the CRT exam would be licensed as Respiratory Therapist (RT) and licensees that have completed the RRT exam would be licensed as Respiratory Care Practitioners (RCP). If licensed after January 1, 2015, a BSRT degree plus the RRT credential will be required to be eligible for the RCP license. After January 1, 2015, associate degree graduates with a CRT or RRT credential will be eligible for a license as a respiratory therapist until they complete a BS degree approved by the board. 1 What is the potential impact on community college programs? The legislation protects community college training for respiratory therapists. During the NCRCB education meetings, language was adopted that allows the AAS trained respiratory therapist to continue providing competent patient care. This decision resulted in the tiered system of care. Will any bachelor s degree be acceptable? The short answer is no. Currently, NC has only one BSRT program, so it may seem implausible to achieve this level of education for all therapists in the state. The board is working with the university system and the community college system partners to offer more BS level programs. The board will accept any CoARC accredited BSRT. Completion 4

5 programs without CoARC accreditation must be from a government recognized regionally or nationally accredited university or college if it is a BSRT program. BSRT completion programs are not required to have CoARC accreditation. If the BS program does not specifically have respiratory therapy as a major, the board will consider the program on a case-by-case basis. The degrees need to reflect advanced skills in clinical skills, supervision, management, education, diagnostics, and research. Of course, the specifics remain to be seen. What happens if the licensing credentials lapse? Anyone applying for active license after having a lapsed license will need to meet the current criteria for licensing when applying or reapplying. This is a current board practice. In addition, credentials must be active with NBRC, as well. Maintaining the required education is also mandatory to maintain your current license. Provided an individual maintains all of the required credentialing, he or she will fall under the grandfather clause in the legislation. 1 Is the AARC requiring this action? Rationale for Change First, it is only a recommendation from the AARC 2015 conferences. The AARC has no legal authority, so it is entirely a state s issue at this point since the NBRC has not changed their credentialing requirements. In addition, the NBRC does not have any legal authority. However, the NBRC could change their eligibility requirements for the credentialing exams, but it does not appear that the NBRC is planning any such action. Why is this happening in NC when other states are not requiring this level education? Individual state boards establish criteria for practice for the respective state, and they are independent of the AARC, NBRC, and CoARC. Regardless of other states actions, NCARE, NCSRC, and NCRCB collectively decided to move forward last year after the final AARC 2015 conference recommendations were published. Of course, the NCRCB had to submit the changes, but the AARC, NCARE and NCSRC have all supported the action. According to the article by Barnes et.al, a date of 2020 for achieving these changes was proposed, debated, and accepted by 63% of participants at the third 2015 conference. Recommendations were approved requesting resources be provided to help RT education programs, existing RT workforce, and state societies work through the issues raised by these changes. 4 It is quite straightforward. NC decided to move forward based on existing evidence from the 2015 conferences. 5

6 Why is this change important for the profession? According to Douce (2005), recognizing the need to increase the number of respiratory therapists with advanced levels of training and education to meet the demands of providing services requiring complex cognitive abilities and patient management skills. a bachelor's degree in respiratory therapy will inevitably become the standard for clinicians in the decades to come. 5 Competency is the number one reason. There is simply not enough time within the AAS programs to ensure competency of all new objectives to be implemented in In addition, other therapy groups have moved to the doctorate levels as entry to the practitioner level. They have secured reimbursement for their services by requiring higher levels of education with higher salaries. Of course, we cannot say that salaries will rise, but the evidence from the other therapy groups suggests it will for the advanced training since they are reimbursed for their services. Consider the median salary of a physical therapist is $76,310 whereas respiratory therapy is $54, This is not bad considering respiratory therapists have AAS degrees while physical therapists are required to have a clinical doctoral degree. It is necessary to understand that current RCP salaries are equivalent to Physical Therapist Assistants (PTA). The median salary of PTA s is $52,000 per year. 7 Consider, there is an even greater salary differential in Occupational Therapy with a 25-27K difference between therapists and therapy assistants. 8 Clearly, the evidence suggests a differential in salaries for those with advanced degrees. Furthermore, it underscores the fact that respiratory therapists are paid at the associate degree level when compared to other therapy groups. However, we are the only therapy group providing critical care life support, yet the federal government does recognize respiratory therapy at the professional level for reimbursement purposes. 9 Is this just about money? Money is a key driver in health care. As self-righteous as we may be that it should not matter, we cannot ignore this fact. If reimbursement is tied to respiratory care services, this will open many doors to achieving the same status as nursing and other therapy groups. While this will not directly improve care at the bedside, reimbursement for respiratory care services will make it feasible for hiring more respiratory therapists to provide care in outpatient facilities. Military officer commissions will be an option thus expanding on the existing commissions from the US Public Health Services. Employment in physicians offices will likely expand, as they will be able bill for respiratory care services. If we do not secure reimbursement for services, we will never be considered as equals among the other therapy groups. All of these advancements require a BS degree. 9 6

7 Will this be increasing the educational cost to obtain employment? Cost for education increases every year. The amendment has no direct cost increase. There will be a cost increase for those moving to the next level of licensing, but this would be the case for any additional education. Remember, completing a CoARC accredited AAS program will prepare graduates to take the CRT and RRT exams. This will meet the eligibility for the first level of licensing. Once employed, there are funding opportunities for those wishing to advance their education. In addition, the federal tax code also has deductions for individuals advancing in their profession. Of course, please contact a tax expert on the eligibility requirements. There are also forgiveness loans from the NC College Foundation up to $5,000 per year for three years for a maximum loan amount of $15, The loan obligation may be forgiven through approved employment within the state of North Carolina provided the recipient works in the field for which he/she was funded. 10(p1) A New Paradigm What will be the role of the licensed respiratory therapist? The licensed respiratory therapist and the licensed respiratory care practitioner will continue to provide patient care in a variety of settings. The difference is that the licensed RT must be under the direct supervision of a licensed respiratory care practitioner (RCP). Direct supervision standards have long been established by the board if there are concerns regarding the impact. This new-tiered system is similar to our fellow therapy groups in physical, occupational, speech language pathology. However, current RCP s with the RRT credential will maintain their present status after passage of the Bill provided they keep their credentials current. How will community college programs remain the main source of training? The amendment does not affect the traditional AAS programs. A collaborative working environment between the community college and the university system is essential to secure the sanctity of the community college programs in the future. One idea is to flip the curriculum. Here is how it might work. A student would spend, two years at the university followed by two years at a community college for the RT training. They will earn their AAS then complete the BS courses during their 5 th year at the university. This is similar to the plan advocated in the early college programs for high school students. Keep in mind, this is theoretical, so the reality remains to be seen. Final Thoughts Over the next few years, we will see the profession transition to the 2015 objectives whether the amendment succeeds or fails. NC can be the first state in the country to advance respiratory therapy practice to the next level rather than being one of the last ones as we did with licensing. I think is reasonable to see the majority of practitioners 7

8 holding BS degrees within the next 10 years. If the amendment passes, it will certainly exceed the 25%, who currently hold advanced degrees. In fact, it would be possible to see 50% of the workforce earning a BS degree within the next 10 years. With the development of new BSRT programs in cooperation with the community colleges, the opportunities will be available to all therapists in the state. Online, face-toface, and hybrid classes will make this conversion possible. In addition, as retiring therapist leave the profession, we will have new therapists in NC over the same 10-year period if the current graduation rate remains constant. If the current number of RCP s remains constant at 4500 active licenses, half of these individuals would have BS degrees by Since 25% currently hold advanced degrees, the number holding advanced degrees will likely be higher. Therefore, it is feasible to see the day when most therapists will have BS degrees rather than AAS. If not, we will maintain the two levels of care, which would still be a positive outcome. Despite which outcome is realized, the NCRCB wants to ensure patient care will not be harmed while securing the future of respiratory care in NC. This slower transition is a reasonable compromise towards raising the bar for future respiratory therapists. The NCRCB is acting on the evidence that is facing us. I would ask that you consider the evidence that our profession is changing. The future of respiratory care is dependent on advancing education. 4 References 1. Tolson J, Hollo M. Amend Respiratory Care Practice Act: House Bill 285 Information/History ( Session). North Carolina General Assembly Available at: 5. Accessed April 2, Barnes TA, Gale DD, Kacmarek RM, Kageler WV. Competencies needed by graduate respiratory therapists in 2015 and beyond. Respir Care. 2010;55(5): North Carolina Association for Respiratory. North Carolina Association for Respiratory Educators: Letter to support the amendment to the respiratory care act Barnes TA, Kacmarek RM, Kageler WV, Morris MJ, Durbin CG Jr. Transitioning the respiratory therapy workforce for 2015 and beyond. Respir Care. 2011;56(5): doi: /respcare

9 5. Douce FH. Bachelor of science degree education programs: organization, structure, and curriculum. Respir Care Clin N Am. 2005;11(3): doi: /j.rcc Respiratory Therapists: Occupational Outlook Handbook: U.S. Bureau of Labor Statistics Available at: Accessed April 2, US Department of Labor: Physical Therapist Assistants. US Department of Labor Available at: Accessed April 2, Occupational Therapists: Occupational Outlook Handbook: U.S. Bureau of Labor Statistics. US Department of Labor Available at: Accessed April 2, AARC. In the News - Medicare Respiratory Therapy Initiative Frequently Asked Questions. American Association of Respiratory Care. Available at: https://www.aarc.org/headlines/09/02/faq.cfm. Accessed April 2, CFNC - Paying For College: NC Student Loan Program for Health, Science and Mathematics. College Foundation of North Carolina Available at: Accessed April 2, Impact of Paid Clinical Instructors on RRT Success Rates Margaret-Ann Vaughan, RRT-NPS, Director of Clinical Education at Newman University and a graduate student at Northeastern University in the Master of Science in Respiratory Care Leadership Program, is conducting a research study regarding clinical instruction in BSRT programs. The goal of the study is to determine if there is a significant difference in the RRT pass rates of BSRT graduates who had paid clinical instructors, unpaid clinical instructors, or a combination of paid and unpaid clinical instructors. The study examines the three-year CoARC cohort of January 1, 2009, to December 31, Program directors have been provided with a survey link via ; the participation of all BSRT program directors is requested. The survey consists of 12 brief questions and furthers CoBGRTE s objectives regarding research and program development of baccalaureate and graduate respiratory therapy programs. 9

10 Rush University Class of 2013 The Rush University graduating class totals 24. Sixteen are entry level MS students and 5 are entry level BS students. The remaining 3 students have completed the Advanced Standing MS Program since they already had a BS degree and the RRT credential. CoBGRTE Membership Round Table Discussion Dinner Save the Date: At the AARC Summer Forum in Orlando, CoBGRTE will host a special Membership Round Table Discussion Dinner from 7:00p to 10:00p Sunday July 14, 2013, details to follow. Discussion groups are now forming and if you would like to attend RSVP by using the Contact Us form at Also use this form to register the topics you would like to see discussed, such as Advanced Practice Masters Degrees, CoARC Policy 13 Certificate of Completion, North Carolina Licensure Initiative, and Achieving High RRT Pass Rates. 10

11 Straight Talk The following opinion was posted on AARC LinkedIn on May 2, 2013 by Larry Conway, BS, LRCP, RRT, FAARC and is reprinted here (unedited) with permission. Larry Conway is Chief, Respiratory Care Service, Veterans Affairs Medical Center, Washington, D.C. We must bite the bullet and move to BS entry. The evidence is all around us. First of all, too many of us have it backwards: No State is interested in protecting our job rights. Licensure and credentialing are NOT about our job rights. They are about protecting patients. That is the only reason a State would have any business passing a licensure law. They are not in business to keep us employed. Here is the cruel reality: We have been trying the "let's secure our positions FIRST and THEN go for higher education" for forty years! To paraphrase a very visible politician, "How's THAT been working out for ya'?" It HASN'T!! By Einstein's definition, the field of respiratory care is crazy - because we insist on doing the same thing decade after decade - with the same excuses - and expecting a different outcome. I know experience is important. I know RRTs who are scary and CRTs who are excellent. I know that BSRT or even an MSRT might not make you a better caregiver, might not get you that job right now. But I also know this: All of those arguments have not had ONE POSITIVE IMPACT on promoting the field, its level of respect, its prospects for a future, or our pay levels. Meanwhile, all of the fields that HAVE embraced higher education HAVE increased their influence, their demand, their salaries, and their level of viability. HOW MUCH MORE EVIDENCE DO WE NEED?? How long until we see the reality that screaming "It's not FAIR!" "I don't wanna!" "It's the AARC/NBRC/Leadership conspiracy's fault!" will not improve our situation, but simply make us look like selfabsorbed, ENTITLEMENT-MINDED wannabees instead of the professionals we so desperately want to be considered. The AARC exists to promote and protect the field, but it must ALWAYS do so from the standpoint of protecting patients and society from unscrupulous or incompetent practitioners, or helping society through cost-beneficial services (e.g., having RTs do 11

12 home respiratory assessments will save more than it costs by reducing needless or harmful care). If the government perceives the AARC's motives as self-protection, jobcreation, or role protection, the government will reject it out of hand. Those are the rules of the game, and all the crying we can muster will not change that. We have to be able to prove that having someone else do respiratory's role is harmful to the public, not to the profession. A sad reality is that in politics and business (and this IS politics and business), what is right has less influence than what is politically/financially expedient. That is why nurses are allowed to do our roles. We didn't want it that way; the AARC didn't want it that way. But we were told early on (based upon politics and the hospitals' economics) that no respiratory license bill would pass if it "rolled back" nurses' ability to do things they were already doing. Nursing had the UNITY and NUMERIC CLOUT to make sure that was the rule. Some physician groups opposed our efforts for licensure; some supported us as long as it did not impact their offices, so there was generally a carve-out that RT licensure would not control what is done by whom in a physician's office. Unfortunately, we were late to seek licensure. For years the profession actually opposed licensure because we/they thought it would weaken our voluntary credentials. In the time it took for us to see the value of licensure, nurses and PTs and lab techs all gained political advantage and were able to largely control what could pass legislatures. We also had to prove that good therapists equaled good business so hospitals would get out of the way. EVERY profession has hoops you must jump through. Longshoremen have them, Nurses have them, Professional speakers have them. Don't want to jump the hoops? Sorry, you can't be a Longshoreman, Nurse or Professional speaker. We must GET OVER OURSELVES and step up! We whine and can't figure out why others don't see us as professionals. Ten Reasons Why You Should Become a CoBGRTE Member If you haven t already decided to become a CoBGRTE member after visiting the following are 10 reasons why you should join the coalition. 1. Collectively work towards the day when all respiratory therapists enter the profession with a baccalaureate or graduate degree in respiratory care. 2. Support a national association, representing the 55 colleges/universities awarding baccalaureate and graduate degrees in respiratory care, to move forward the recommendations of the third 2015 conference. 12

13 3. Help start new baccalaureate and graduate RT programs thus leading to a higher quality of respiratory therapist entering the workforce. 4. Work to change the image of the RT profession from technical-vocationalassociate degree education to professional education at the baccalaureate and graduate degree level. 5. Join colleagues to collectively develop standards for baccalaureate and graduate respiratory therapist education. 6. Develop public relations programs to make potential students aware of baccalaureate and graduate respiratory therapist programs. 7. Develop and promote wage standards for respiratory therapy faculty members. 8. Find answers to the flooding of the market place with under-educated respiratory therapists. 9. Help to publicize, among department directors/managers, the differences between respiratory therapists with associate, baccalaureate and graduate degrees. 10. Help to support maintaining a roster and web site for all baccalaureate and graduate respiratory therapist programs. To become a CoBGRTE member or Renew Membership complete the application on the Membership Page on the web site CoBGRTE Institutional Members Indiana Respiratory Therapy Consortium Georgia State University Weber State University Boise State University Bellarmine University Rush University Salisbury University University of Toledo 13

14 The Ohio State University State University of New York Upstate Medical University Northeastern University University of Texas Medical Branch - Galveston Wheeling Jesuit University Texas State University - San Marcos University of South Alabama Long Island University University of North Carolina Charlotte Louisiana State University New Orleans Midwestern State University University of Missouri Jefferson College of Health Sciences Youngstown State University University of Medicine and Dentistry of New Jersey Nova Southeastern University Loma Linda University University of Arkansas for Medical Sciences State University of New York at Stony Brook University of Texas Health Science Center San Antonio University of Hartford University of Cincinnati University of Kansas Medical Center College of Southern Nevada Highline Community College University of Akron Oregon Institute of Technology Georgia Regents University St. Alexius Medical Center-University of Mary Valencia College Kettering College of Medical Arts Shenandoah University Middle Georgia State College 14

15 Coalition for Baccalaureate and Graduate Respiratory Therapy Education Dedicated to Improving Respiratory Therapy Education 15

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