vulnerable to chronic and debilitating conditions that require therapeutic services. Also, the baby-boom generation is entering the prime age for heart attacks and strokes, increasing the demand for cardiac and physical rehabilitation. More young people will need physical therapy as technological advances save the lives of a larger proportion of newborns with severe birth defects. Future medical developments will also permit a higher percentage of trauma victims to survive, creating additional demand for rehabilitative care. Growth may also result from advances in medical technology which permit treatment of more disabling conditions.

Widespread interest in health promotion should also increase demand for physical therapy services. A growing number of employers are using physical therapists to evaluate worksites, develop exercise programs, and teach safe work habits to employees in the hope of reducing injuries.

Employment of physical therapits would grow even faster were it not for continued emphasis on controlling health care costs by limiting the use of therapeutic services in some instances.

Earnings

In 1996, median weekly earnings of salaried physical therapists who usually work full time were $757. The middle 50 percent earned between $577 and $1,055. The top 10 percent earned at least $1,294 and the bottom 10 percent earned less than $400.

According to the American Physical Therapy Association's survey of physical therapists practicing in hospital settings, the median annual base salary of full-time physical therapists was $48,000 in 1996. The middle 50 percent earned $42,000 and $57,000.

Related Occupations

Physical therapists rehabilitate persons with physical disabilities. Others who work in the rehabilitation field include occupational therapists, speech pathologists, audiologists, orthotists, prosthetists, and respiratory therapists.

Sources of Additional Information

Additional information on a career as a physical therapist and a list of accredited educational programs in physical therapy are available from:

American Physical Therapy Association, 1111 North Fairfax St., Alexandria, VA 22314-1488. Homepage: http://www.apta.org/

tants may prescribe medications. PA's may also have managerial duties. Some order medical and laboratory supplies and equipment, while others supervise technicians and assistants.

Physician assistants always work under the supervision of a physician. The extent of supervision, however, depends upon State law. For example, a PA may provide care in rural or inner city clinics where a physician is present for only 1 or 2 days each week, conferring with the supervising physician and other medical professionals as needed or required by law. PA's may also make house calls or go to hospitals and nursing homes to check on patients and report back to the physician.

In some States, the duties of a physician assistant are determined by the supervising physician; in others, they are determined by the State's regulatory agency. Aspiring PA's should investigate the laws and regulations in the States where they wish to practice.

Many PA's work in primary care areas such as general internal medicine, pediatrics, and family practice. Others work in specialty areas, such as general and thoracic surgery, emergency medicine, orthopedics, and geriatrics. PA's specializing in surgery provide preand post-operative care and may work as first or second assistants during major surgery.

Working Conditions

Although PA's generally work in a comfortable, well-lighted environment, those in surgery often stand for long periods, and others do considerable walking. Schedules vary according to practice setting and often depend on the hours of the supervising physician. The workweek of PA's in physicians' offices may include weekends, night hours, or early morning hospital rounds to visit patients. They may also be on-call. PA's in clinics usually work a 5-day, 40-hour week.

Employment

Physician assistants held about 64,000 jobs in 1996. Sixty-six percent were in the offices and clinics of physicians, dentists, or other health practitioners. Almost 20 percent were in hospitals. The rest were mostly in public health clinics, nursing homes, prisons, home health care agencies, and the Department of Veterans Affairs.

According to the American Academy of Physician Assistants, about one-third of all PA's provide health care to communities having fewer than 50,000 residents where physicians may be in limited supply.

Training, Other Qualifications, and Advancement Almost all States require that new PA's complete an accredited, formal education program. In 1997, there were 96 such educational programs for physician assistants; 53 of these programs offered a baccalaureate degree or a degree option. The rest offered either a

Physician Assistants

(D.O.T. 079.364-018)

Significant points

The typical physician assistant program lasts about 2 years and generally requires at least 2 years of college and some health care experience for admission.

Earnings are high and job opportunities are expected to be excellent.

Nature of the Work

Physician assistants (PA's) provide health care services with supervision by physicians. They should not be confused with medical assistants, who perform routine clinical and clerical tasks (see separate statement elsewhere in the Handbook). PA's are formally trained to provide diagnostic, therapeutic, and preventive health care services under the direction of a physician. Working as members of the health care team, they take medical histories, examine patients, order and interpret laboratory tests and x rays, and make diagnoses. They also treat minor injuries by suturing, splinting, and casting. PA's record progress notes, instruct and counsel patients, and order or carry out therapy. In 39 States and the District of Columbia, physician assis

A physician assistant conducts a neurological examination on a pa

tient.

certificate, an associate degree, or a master's degree. Most PA graduates have at least a bachelor's degree.

Admission requirements vary, but many programs require 2 years of college and some work experience in the health care field. Students should take courses in biology, English, chemistry, math, psychology, and social sciences. More than half of all applicants hold a bachelor's or master's degree. Many applicants are former emergency medical technicians, other allied health professionals, or

nurses.

PA programs generally last 2 years. Most programs are in schools of allied health, academic health centers, medical schools, or 4-year colleges; a few are in community colleges, the military, or hospitals. Many accredited PA programs have clinical teaching affiliations with medical schools.

PA education includes classroom instruction in biochemistry, nutrition, human anatomy, physiology, microbiology, clinical pharmacology, clinical medicine, geriatric and home health care, disease prevention, and medical ethics. Students obtain supervised clinical training in several areas, including primary care medicine, inpatient medicine, surgery, obstetrics and gynecology, geriatrics, emergency medicine, psychiatry, and pediatrics. Sometimes, PA students serve one or more of these "rotations" under the supervision of a physician who is seeking to hire a PA. These rotations often lead to permanent employment.

As of 1997, 49 States and the District of Columbia had legislation governing the qualifications or practice of physician assistants. Mississippi did not. Forty-nine States required physician assistants to pass the Physician Assistants National Certifying Examination that is only open to graduates of an accredited educational program. Only those successfully completing the examination may use the credential "Physician Assistant-Certified (PA-C)." In order to remain certified, PA's must complete 100 hours of continuing medical education every 2 years. Every 6 years, they must pass a recertification examination or complete an alternate program combining learning experiences and a take-home examination.

Although they are not accredited, PA postgraduate residency training programs are available in gynecology, geriatrics, surgery, pediatrics, neonatology, and occupational medicine. Candidates must be graduates of an accredited program and be certified by the National Commission on Certification of Physician Assistants.

Physician assistants need leadership skills, self-confidence, and emotional stability. They must be willing to continue studying throughout their career to keep up with medical advances.

Some PA's pursue additional education in order to practice in a specialty area such as surgery, neonatology, or emergency medicine. Others, as they attain greater clinical knowledge and experience, advance to added responsibilities and higher earnings. However, by the very nature of the profession, individual PA's are usually supervised by physicians.

Job Outlook

Employment opportunities are expected to be excellent for physician assistants, particularly in areas or settings that have difficulty attracting physicians, such as rural and inner city clinics. Employment of PA's is expected to grow much faster than the average for all occupations through the year 2006 due to anticipated expansion of the health services industry and an emphasis on cost containment. Physicians and institutions are expected to employ more PA's to provide primary care and assist with medical and surgical procedures, because PA's are cost-effective and productive members of the health care team. Physician assistants can relieve physicians of routine duties and procedures. Telemedicine using technology to facilitate interactive consultations between physicians and physician assistants-will also expand the use of physician assistants. Besides the traditional officebased setting, PA's should find a growing number of jobs in institutional settings such as hospitals, academic medical centers, public clinics, and prisons. Additional PA's may be needed to augment medical staffing in inpatient teaching hospital settings if the number

of physician residents is reduced. In addition, State-imposed legal limitations on the numbers of hours worked by physician residents are increasingly common and encourage hospitals to use PA's to supply some physician resident services. Opportunities will be best in States that allow PA's a wider scope of practice, such as the ability to prescribe medication.

Earnings

According to the American Academy of Physician Assistants, the median income for physician assistants in full time clinical practice in 1996 was $60,687; median income for first year graduates was $52,116. Income varies by specialty, practice setting, geographical location, and years of experience.

According to a Hay Group survey of HMO's, group practices, and hospital-based clinics, the median annual base salary of full-time physician assistants was $54,100 in May 1996. The middle 50 percent earned between $49,100 and $60,000.

The average annual salary for physician assistants employed by the Federal Government was $48,670 in early 1997.

Related Occupations

Other health workers who provide direct patient care that requires a similar level of skill and training include nurse practitioners, physical therapists, occupational therapists, clinical psychologists, speechlanguage pathologists, and audiologists.

Sources of Additional Information

For information on a career as a physician assistant, contact:

American Academy of Physician Assistants Information Center, 950 North Washington St., Alexandria, VA 22314-1552. Homepage: http://www.aapa.org For a list of accredited programs and a catalog of individual PA training programs, contact:

Association of Physician Assistant Programs, 950 North Washington St., Alexandria, VA 22314-1552.

For eligibility requirements and a description of the Physician Assistant National Certifying Examination, write to:

National Commission on Certification of Physician Assistants, Inc., 6849B2 Peachtree Dunwoody Rd., Atlanta, GA 30328.

Recreational Therapists

(D.O.T. 076.124-014)

Significant Points

Employment of recreational therapists is expected to increase rapidly as demand grows for physical and psychiatric rehabilitative services and for services for people with disabilities.

Opportunities should generally be good for persons with a bachelor's degree in therapeutic recreation or in recreation with an option in therapeutic recreation.

Nature of the Work

Recreational therapists provide treatment services and recreation activities to individuals with illnesses or disabling conditions. They use a variety of techniques to treat or maintain the physical, mental, and emotional well-being of clients. Treatments may include the use of arts and crafts, animals, sports, games, dance and movement, drama, music, and community outings. Therapists help individuals reduce depression, stress, and anxiety. They help individuals recover their basic motor functioning and reasoning abilities, build confidence, and socialize more effectively to allow them to be more independent, as well as reduce or eliminate the effects of illness or disability. Their focus is to help integrate people with disabilities into the community by helping them use community resources and

recreational activities. Recreational therapists should not be confused with recreation workers, who organize recreational activities primarily for enjoyment. (Recreation workers are discussed elsewhere in the Handbook.)

In acute health care settings, such as hospitals and rehabilitation centers, recreational therapists treat and rehabilitate individuals with specific health conditions, usually in conjunction or collaboration with physicians, nurses, psychologists, social workers, and physical and occupational therapists. In long-term care facilities and residential facilities, they use leisure activities-especially structured group programs to maintain general health and well-being. They may also treat clients and provide interventions to prevent further medical problems and secondary complications related to illness and disabilities. In these settings they may be called activity directors or therapeutic recreation specialists.

Recreational therapists assess clients based on information from standardized assessments, observations, medical records, medical staff, family, and clients themselves. They then develop and carry out therapeutic interventions consistent with patient needs and interests. For instance, clients isolated from others may be encouraged to play games with others, a right-handed person with a right-side paralysis may be instructed in adaptation and compensatory strategies to use his or her non-affected left side to throw a ball or swing a racket. Recreational therapists may instruct patients in relaxation techniques to reduce stress and tension, in correct stretching and limbering exercises, in proper body mechanics for participation in recreation activities, in pacing and energy conservation techniques, and in individual as well as team activities.

Community based recreational therapists work in park and recreation departments, special education programs for school districts, or programs for older adults and people with disabilities. In these programs, therapists help clients develop leisure activities and provide them with opportunities for exercise, mental stimulation, creativity, and fun.

In schools, recreational therapists help counselors, parents, and special education teachers address the special needs of students. They are especially important in helping to ease the transition phase

Recreational therapists help individuals reduce depression, stress, and anxiety, and increase self-esteem and self-confidence.

into adult life for the disabled. The transition phase extends from age 14 until high school graduation. Recreational therapists provide assistance in teaching the student about recreational activities and how to use community resources. The primary responsibility for these therapists is to integrate students into the community.

Recreational therapists observe and record patients' participation, reactions, and progress. These records are used by the medical staff and others, to monitor progress, to justify changes or end treatment, and for billing.

Working Conditions

Recreational therapists provide services in special activity rooms, but also must plan events and keep records in offices. When working with clients during community integration programs, they may travel locally to instruct clients on the accessibility of public transportation and other public areas, such as parks, playgrounds, swimming pools, restaurants, and theaters.

Therapists often lift and carry equipment as well as lead recreational activities. Recreational therapists generally work a 40-hour week, which may include some evenings, weekends, and holidays.

Employment

Recreational therapists held about 38,000 jobs in 1996. About 42 percent of salaried jobs for therapists were in hospitals and 38 percent were in nursing homes. Others worked in residential facilities, community mental health centers, adult day care programs, correctional facilities, community programs for people with disabilities, and substance abuse centers. About 1 out of 4 therapists was self-employed, generally contracting with long-term care facilities or community agencies to develop and oversee programs.

Training, Other Qualifications, and Advancement

A bachelor's degree in therapeutic recreation (or in recreation with an option in therapeutic recreation) is the usual requirement for entrylevel positions. Persons may qualify for paraprofessional positions with an associate degree in recreational therapy or a health care related field. An associates degree in recreational therapy; training in art, drama, or music therapy; or qualifying work experience may also be sufficient for activity director positions in nursing homes.

Most employers prefer to hire candidates who are certified therapeutic recreation specialists (CTRS). The National Council for Therapeutic Recreation Certification (NCTRC) certifies therapeutic recreation specialists. To become certified, specialists must have a bachelor's degree, pass a written certification examination, and complete an internship of at least 360 hours under the supervision of a certified therapeutic recreation specialist. A few colleges or agencies may require 600 hours of internship.

There are about 130 programs that prepare recreational therapists. Most offer bachelors degrees, although some offer associates, masters, or doctoral degrees. As of 1996, there were fewer than 50 recreation programs with options in therapeutic recreation that were accredited by the National Council on Accreditation.

In addition to therapeutic recreation course work in assessment, treatment and program planning, and intervention design and evaluation, students study human anatomy, physiology, abnormal psychology, medical and psychiatric terminology, characteristics of illnesses and disabilities, and the concepts of inclusion and normalization. Courses cover professional ethics, assessment and referral procedures, interdisciplinary teamwork, management, and the use of assistive devices and technology.

Recreational therapists should be comfortable working with persons who are ill or have disabilities. Therapists must be patient, tactful, and persuasive when working with people who have a variety of special needs. Ingenuity, a good sense of humor, and a strong imagination are needed to adapt activities to individual needs, and good physical coordination is necessary to demonstrate or participate in recreational events.

Therapists can advance to supervisory or administrative positions. Some teach, conduct research, or perform contract consulting work.

Job Outlook

Employment of recreational therapists is expected to grow faster than the average for all occupations through the year 2006, because of anticipated expansion in long-term care, physical and psychiatric rehabilitation, and services for people with disabilities. Job prospects are expected to be favorable for those with a strong health care background.

Health care facilities will provide a large number of recreational therapy jobs through the year 2006. A growing number of these will be in hospital-based adult day care and outpatient programs, or in units offering short-term mental health and alcohol or drug abuse services. Long-term rehabilitation, home-health care, transitional programs, and psychiatric facilities will provide additional jobs.

The rapidly growing number of older adults is expected to spur job growth for activity directors and recreational therapy paraprofessionals in nursing homes, assisted living facilities, adult day care programs, and social service agencies. Continued growth is expected in community residential facilities as well as day care programs for individuals with disabilities.

Earnings

According to a survey by the American Therapeutic Recreation Association, the average salary for recreational therapists was about $33,000 in 1996. The average annual salary for consultants, supervisors, administrators, and educators was about $42,000 in 1996. The average for all recreational therapists in the Federal Government in nonsupervisory, supervisory, and managerial positions was about $39,400 in 1997.

Related Occupations

Recreational therapists design activities to help people with disabilities lead more fulfilling and independent lives. Other workers who have similar jobs are recreational therapy paraprofessionals, orientation therapists for persons who are blind or have visual impairments, art therapists, drama therapists, dance therapists, music therapists, occupational therapists, physical therapists, and rehabilitation counselors.

Sources of Additional Information

For information on how to order materials describing careers and academic programs in recreational therapy, write to:

☛ American Therapeutic Recreation Association, P.O. Box 15215, Hattiesburg, MS 39402-5215. Homepage: http://www.atra-tr.org.

National Therapeutic Recreation Society, 22377 Belmont Ridge Rd., Ashburn, VA 20148 or by e-mail: NTRSNRPA@aol.com. Certification information may be obtained from:

National Council for Therapeutic Recreation Certification, P.O. Box 479, Thiells, NY 10984-0479.

Registered Nurses

(D.O.T. 075.124-010 and -014, .127-014, -026, -030 and -034, .137-010 and -014, .264-010 and -014, .364-010, .371-010, .374-014, -018, and -022)

Significant points

The largest health care occupation, with over 1.9 million jobs.

One of the five occupations projected to have the largest numbers of new jobs.

Earnings are above average, particularly for advanced practice nurses who have additional education or training.

Nature of the Work

Registered nurses (R.N.'s) work to promote health, prevent disease, and help patients cope with illness. They are advocates and health

educators for patients, families, and communities. When providing direct patient care, they observe, assess, and record symptoms, reactions, and progress; assist physicians during treatments and examinations; administer medications; and assist in convalescence and rehabilitation. R.N.'s also develop and manage nursing care plans; instruct patients and their families in proper care; and help individuals and groups take steps to improve or maintain their health. While State laws govern the tasks R.N.'s may perform, it is usually the work setting which determines their day-to-day job duties.

Hospital nurses form the largest group of nurses. Most are staff nurses, who provide bedside nursing care and carry out medical regimens. They may also supervise licensed practical nurses and aides. Hospital nurses usually are assigned to one area such as surgery, maternity, pediatrics, emergency room, intensive care, or treatment of cancer patients or may rotate among departments.

Office nurses assist physicians in private practice, clinics, surgicenters, emergency medical centers, and health maintenance organizations (HMO's). They prepare patients for and assist with examinations, administer injections and medications, dress wounds and incisions, assist with minor surgery, and maintain records. Some also perform routine laboratory and office work.

Home health nurses provide periodic services, prescribed by a physician, to patients at home. After assessing patients' home environments, they care for and instruct patients and their families. Home health nurses care for a broad range of patients, such as those recovering from illnesses and accidents, cancer, and child birth. They must be able to work independently and may supervise home health aides.

Nursing home nurses manage nursing care for residents with conditions ranging from a fracture to Alzheimer's disease. Although they generally spend most of their time on administrative and supervisory tasks, R.N.'s also assess residents' medical condition, develop treatment plans, supervise licensed practical nurses and nursing aides, and perform difficult procedures such as starting intravenous fluids. They also work in specialty-care departments, such as long-term rehabilitation units for strokes and head-injuries.

Public health nurses work in government and private agencies and clinics, schools, retirement communities and other community settings. They focus on populations, working with individuals, groups, and families to improve the overall health of communities. They also work as partners with communities to plan and implement programs. Public health nurses instruct individuals, families, and other groups in health education, disease prevention, nutrition, and child care. They arrange for immunizations, blood pressure testing, and other health screening. These nurses also work with community leaders, teachers, parents, and physicians in community health education.

Occupational health or industrial nurses provide nursing care at worksites to employees, customers, and others with minor injuries and illnesses. They provide emergency care, prepare accident reports, and arrange for further care if necessary. They also offer health counseling, assist with health examinations and inoculations, and assess work environments to identify potential health or safety problems.

Head nurses or nurse supervisors direct nursing activities. They plan work schedules and assign duties to nurses and aides, provide or arrange for training, and visit patients to observe nurses and to insure that care is proper. They may also insure that records are maintained and that equipment and supplies are ordered.

At the advanced level, nurse practitioners provide basic primary health care. They diagnose and treat common acute illnesses and injuries. Nurse practitioners can prescribe medications in most States. Other advanced practice nurses include clinical nurse specialists, certified registered nurse anesthetists, and certified nursemidwives. Advanced practice nurses have met higher educational and clinical practice requirements beyond the basic nursing education and licensing required of all R.N.'s.

A registered nurse monitors a patient's treatment.

Working Conditions

Most nurses work in well-lighted, comfortable health care facilities. Home health and public health nurses travel to patients' homes and to schools, community centers, and other sites. Nurses may spend considerable time walking and standing. They need emotional stability to cope with human suffering, emergencies, and other stresses. Because patients in hospitals and nursing homes require 24-hour care, nurses in these institutions may work nights, weekends, and holidays. They may also be on-call. Office, occupational health, and public health nurses are more likely to work regular business hours. Almost 1 in 10 RN's held more than one job in 1996.

Nursing has its hazards, especially in hospitals, nursing homes, and clinics where nurses may care for individuals with infectious diseases such as hepatitis and AIDS. Nurses must observe rigid guidelines to guard against these and other dangers such as radiation, chemicals used for sterilization of instruments, and anesthetics. In addition, they face back injury when moving patients, shocks from electrical equipment, and hazards posed by compressed gases.

Employment

As the largest health care occupation, registered nurses held about 1,971,000 jobs in 1996. About 2 out of 3 jobs were in hospitals, in both inpatient and outpatient departments. Others were in offices and clinics of physicians, home health care agencies, nursing homes, temporary help agencies, schools, and government agencies. About 3 out of 10 R.N.'s worked part time.

Training, Other Qualifications, and Advancement

In all States, students must graduate from a nursing program and pass a national licensing examination to obtain a nursing license. Nurses may be licensed in more than one State, either by examination or endorsement of a license issued by another State. Licenses must be periodically renewed. Some States require continuing education for licensure renewal.

In 1996, there were over 1,500 entry level R.N. programs. There are three major educational paths to nursing: Associate degree (A.D.N.), diploma, and bachelor of science degree in nursing (B.S.N.). A.D.N. programs, offered by community and junior colleges, take about 2 years. About two-thirds of all R.N. graduates in 1995 were from A.D.N. programs. B.S.N. programs, offered by colleges and universities, take 4 or 5 years. Nearly one-third of all graduates in 1995 were from these programs. Diploma programs, given in hospitals, last 2 to 3 years. Only a small number of graduates come from these programs. Generally, licensed graduates of any of the three program types qualify for entry level positions as staff

nurses.

There have been attempts to raise the educational requirements for an R.N. license to a bachelor's degree and, possibly, create new job titles. These changes, should they occur, will probably be made State by State, through legislation or regulation. Changes in licensure requirements would not affect currently licensed R.N.'s, who would be "grandfathered" in, no matter what their educational preparation. However, individuals considering nursing should carefully weigh the pros and cons of enrolling in a B.S.N. program, since their advancement opportunities are broader. In fact, some career paths are open only to nurses with bachelor's or advanced degrees. A bachelor's degree is generally necessary for administrative positions and is a prerequisite for admission to graduate nursing programs in research, consulting, teaching, or a clinical specialization.

Many A.D.N. and diploma-trained nurses enter bachelor's programs to prepare for a broader scope of nursing practice. They can often find a hospital position and then take advantage of tuition reimbursement programs to work toward a B.S.N. in their spare time.

Nursing education includes classroom instruction and supervised clinical experience in hospitals and other health facilities. Students take courses in anatomy, physiology, microbiology, chemistry, nutrition, psychology and other behavioral sciences, and nursing. Coursework also includes liberal arts classes.

Supervised clinical experience is provided in hospital departments such as pediatrics, psychiatry, maternity, and surgery. A growing number of programs include clinical experience in nursing homes, public health departments, home health agencies, and ambulatory clinics.

Nurses should be caring and sympathetic. They must be able to accept responsibility, direct or supervise others, follow orders precisely, and determine when consultation is required.

Experience and good performance can lead to promotion to more responsible positions. Nurses can advance, in management, to assistant head nurse or head nurse. From there, they can advance to assistant director, director, and vice president. Increasingly, management level nursing positions require a graduate degree in nursing or health services administration. They also require leadership, negotiation skills, and good judgment. Graduate programs preparing executive level nurses usually last 1 to 2 years.

Within patient care, nurses can advance to clinical nurse specialist, nurse practitioner, certified nurse-midwife, or certified registered nurse anesthetist. These positions require 1 or 2 years of graduate education, leading in most instances to a master's degree, or to a certificate.

Some nurses move into the business side of health care. Their nursing expertise and experience on a health care team equip them to manage ambulatory, acute, home health, and chronic care services. Some are employed by health care corporations in health planning and development, marketing, and quality assurance.