Meeting the Moment: Dallas College’s Health Care Apprenticeships

In 2019, Dallas College pledged to serve over 7,000 apprentices in health care occupations by 2023. When the COVID-19 pandemic hit, that work became harder to accomplish and even more urgent.

COVID-19 has left health workers traumatized and exhausted, with waves of these professionals leaving the field. A survey of health care workers in early 2021 found that approximately 30 percent were considering leaving health care. Over half, 55 percent, of surveyed workers felt burned out, with rates as high as 69 percent for workers under 30. Younger workers are those most likely to be new to the field and in need of mentorship, guidance, and additional training.

Even before the pandemic hit, nursing shortages were commonplace, and retention of nurses, nurse assistants, and other direct care workers was alarmingly low. On average, US nursing homes saw their entire staff turnover annually. And these long-term care facilities reported increased challenges with staffing and retention during COVID. Furthermore, in a population where older adults are projected to outnumber children by 2035 for the first time, introducing new ways to recruit and promote health care workers is ever more urgent, especially since waves of retirement in nurses, physicians, and other health professionals will arrive shortly. Pockets of health care workforce drought now threaten to become deserts without intervention.

At the same time, the sector has historically struggled to recruit and retain people of color at a level that reflects the population. Black, Latinx, and Indigenous people are underrepresented in diagnostic clinical roles—such as physicians or nurse practitioners—yet overrepresented among technical staff and other direct care roles with far lower pay, such as licensed practical nurses and medical assistants. Racial income and wealth gaps may also contribute to the financial inaccessibility of the higher education experience needed to enter or advance to higher paying roles, especially for career-changers or adults with caregiving responsibilities.

To meet acute need for a diverse cohort of workers across health care occupations, we need additional strategies to recruit and support workers. Apprenticeship is growing in health care but is still an underutilized strategy to hire, train, and retain professionals.

Dallas College is committed to changing that. When the college received a Department of Labor grant in 2019 to drastically expand health care apprenticeship opportunities, Chancellor Joe May said, “apprenticeships in healthcare are not as prevalent as in other industries, and this initiative is meant to change that.” The college has operated apprenticeships in other fields, such as manufacturing, for many years, and staff saw how it brought clarity to apprentices’ career paths, how employers could be engaged closely with their future workforce as they trained, and how the wages apprentices earn throughout their programs make careers accessible to people who may not be able to reduce work hours and enroll in a traditional college program.

It makes sense for employers and community colleges to leverage apprenticeship programs, which incorporate classroom-based learning and mentored on-the-job training, to prepare new professionals. Apprentices are always paid and earn progressively higher wages as they meet skill milestones. Apprenticeships that prepare people for certain occupations and that meet quality standards may be registered with the U.S. Department of Labor or, in some states, with a state department of workforce development or labor. Apprenticeships that are not registered likely share many characteristics with registered programs—for example, close integration of classroom and on-the-job learning—but there may be wider variation in how the programs operate or what credential apprentices earn.

While apprenticeships may be fairly new to health care in the U.S., integrated work-based and classroom learning is not, nor is constructing education and training around a set of clear competencies needed for professional success. Most health care occupations require workers to have degrees or certificates awarded through higher education, often in conjunction with professional licensure. The components of these academic programs share much with the apprenticeship model: opportunities for mentored, practical learning through required clinical rotations and extensive classroom learning.

As logical a fit as apprenticeship may seem for occupations in health care, challenges to using the model remain. Below, I outline three key challenges that Dallas College is addressing as it works to introduce and sustain accessible, labor market-relevant, and scalable health care apprenticeships. The college’s strategies for meeting each challenge follow, with recommendations for policy and practice designed to use Dallas’s work as a template for further apprenticeship expansion in health care.

Since apprenticeship makes good sense for health care training, it can be challenging to see why the model has not proliferated in the wake of shortages in the workforce. Three main challenges can help explain this. First, longstanding norms around how health care training looks can cause suspicion of new models, including, and especially, apprenticeship. Second, the tight link between higher education credentials and access to health care careers can complicate integrating apprenticeship into health care career pathways. Finally, apprenticeship is a locally focused training model, centering on close, individual mentorship. Therefore, finding a way to expand the number and size of apprenticeship opportunities is a challenge in health care, as well as in many other occupational sectors.

In health care, a key barrier to expanding apprenticeships is hesitation around the word apprenticeship itself. Though apprenticeships now exist in a wide range of fields, they are still perceived as limited to building trades and therefore unsuitable for care professions. They are also seen as less reliable and prestigious than traditional higher education. Even though the structure of apprenticeship is similar to programs delivered through higher education, hesitation around apprenticeship is still widespread.

This hesitation can make it challenging to recruit employers in the health care sector who are willing to commit to the model and want to use it to recruit and advance their workforces. Employers who do open the door to apprenticeship, however, have much to gain: more opportunities to recruit, potentially improved retention and employee engagement, and a deeper connection to the training of their employees.

Currently, higher education credentials are often the exclusive path to licensure and employment in health care, particularly in more advanced care roles. Of course, health care practitioners should be well trained and licensed in the field they choose. Yet the expense, unpaid clinical hours, and unrealistic class schedules—often requiring full-time enrollment—needed to prepare for licensure through higher education keeps people out of health care roles. However, changing licensing requirements so they do not include higher education credentials is not the right battle. But using apprenticeship in health care as a scalable, sustainable way to create better access to higher education promises to help employers and communities across the country welcome more new professionals into their ranks.

Challenges in socializing apprenticeship in health care and operating within a culture strongly reliant on specific credentials introduce a third barrier: expanding available health care apprenticeships. Currently, many apprenticeships in nontraditional fields like health care tend to be small and local, even if the eventual credential is portable. What needs to happen to expand many kinds of apprenticeships is socializing, smart network-building, and working with higher education. Without buy-in from influential partners, health care apprenticeship opportunities will operate in a patchwork system, not reaching all communities or professions that could benefit. As Dallas College shows, with the right strategic partners in place, expansion of apprenticeship in health care can move from potential to practice.

Funding

Dallas College received a $12 million federal grant in July 2019 to build an array of apprenticeships in health care—from health care culinary services to a transition-to-practice program for registered nurses—working with local employers and national partners.

The college is also participating in the American Association of Community Colleges’ Expanding Community College Apprenticeships Initiative, a $20 million collaborative effort with the Department of Labor launched in 2019. Resources from this three-year initiative, supporting eight college consortia and 58 individual colleges, are designed to launch 16,000 apprentices into college-connected apprenticeships, of which over 1,000 were projected to come through Dallas College.

In addition, the college contributed $4 million from its own coffers. With these funds, Dallas College is expanding its program offerings, means of delivery, and partnerships to offer local residents opportunities.

Dallas College Apprenticeships in Health Care

As Dallas operates several health care apprenticeships, still more programs are preparing to launch this year. Though the college’s current programs focus on clinical and direct care roles, its approach to the health care workforce with the most recent DOL funding has been focused on care-adjacent roles in health care facilities.

One program already in operation when COVID-19 emerged was Dallas College’s Patient Care Technician (PCT) apprenticeship. Designed for newcomers to health care, this program culminates in a Texas state patient care technician certification as well as national certification through the National Healthcare Association (NHA). The program structure may vary by employer partner, but the core components of coursework, on the job training, and mentorship remain central. At one employer partner, PCT apprentices work one 12-hour shift per week as a patient safety attendant, and they complete their on-the-job training hours at facilities around the Dallas area. Apprentices do not pay for their tuition at Dallas College, nor for any supplies they need to complete the course. The program is designed on a cohort model, so apprentices can build a supportive network with peers while they prepare for work as a PCT. Even during the pandemic, employer partners were continuing to hire and train patient care technician apprentices.

After completing the apprenticeship, PCTs can move directly into positions with local employers, often with the employer who supported their learning as an apprentice. Some employer partners also offer financial support for further education and college and career advising as a benefit to employees, allowing new PCTs to start using these benefits quickly to continue studies or start moving toward another occupation in health care. The continuing education credit that PCT apprentices earn through Dallas College can potentially give them a head start on further credentials through credit for prior learning opportunities.

With support from the Department of Labor in 2019, Dallas College began building a registered apprenticeship for registered nurses. Apprentices in this program have already earned the degrees and licensure necessary to practice. However, the sharp learning curve for new nurses—as well as experienced nurses moving to different care settings—often requires additional mentorship and training to facilitate retention. Research shows that residencies for nurses, often year-long positions with built-in professional development and mentorship, increase nurse retention. Through resources from DOL, Dallas worked on building a curriculum for nurse apprentices.

Many nurse residencies—whether classified as apprenticeships or not—use broad curricula, such as the Vizient/American Association of Colleges or Versant. Whereas the curriculum many health care employers use for nurse apprentices is designed to apply fairly generally, Dallas College worked with each employer to tailor and supplement available curricula to their specific needs, whether for a particular health care setting or nursing specialization. Through its collaboration with the Dallas-Fort Worth Hospital Council and nine employer partners in the Dallas-Fort Worth area, the resources that Dallas College is developing are poised to benefit nurses far beyond the region.

Not all of Dallas’s apprenticeships are registered. A few programs currently in development highlight how using the apprenticeship model outside the registered apprenticeship system can meet regional employer needs as well. The college is using DOL resources to develop a slate of industry recognized apprenticeship programs (IRAPs) in health care. [1] Two of these IRAPs, health care supply chain and health care facilities management, will be launching later in 2021. Rather than recruiting apprentices new to supply chain and facilities management, these apprenticeships will draw from entry-level professionals already working in health care and in other industries.

Individuals can use these IRAPs to hone their skills and prepare to move into more advanced positions. In the supply chain program, apprentices will sit for the American Hospital Association’s Certified Medical Resource Professional exam. Typically, individuals need a degree to take the certification exam. However, apprentices’ learning experiences are tailored to the occupation and they may sit for the exam, regardless of education level. Supply chain apprentices will also prepare for the Association for Supply Chain Management Certified Supply Chain Professional exam. The facilities manager apprentices will sit for the American Hospital Association’s Certified Health Care Facility Manager exam, as well as the International Facility Management Association’s Certified Facility Manager exam. All of these stackable, embedded credentials will help apprentices move forward in their careers and be more effective in their roles.

Dallas College does not have a corresponding academic program for health care facilities management, so these apprentices will not have an opportunity to earn a higher education credential through the program. However, health care supply chain apprentices may use their coursework to progress toward the college’s existing associate degree in logistics and manufacturing technology.

While the launch of these IRAPs has been delayed due to the pandemic, preparing professionals to staff these critical positions is essential to health care facilities in Dallas and beyond. As with other health care apprenticeships the system offers, these IRAPs can be shared through the college’s partnership with the American Hospital Association and wider employer networks.

Leaders at Dallas College thought early and creatively about how to meet each of the three key challenges to building and expanding health care apprenticeships. Their understanding of the barriers to scaling up opportunities led to innovative partnerships that will carry the work forward.

First, the college forged a critical partnership with the American Hospital Association (AHA) and its nonprofit human resources group, the American Society of Healthcare Human Resources Administration (ASHHRA), to support the socialization of apprenticeship in health care. In nursing and other health professions, there is often resistance to the word “apprenticeship,” due to an all-too-pervasive notion that apprenticeships are only for building trades and similar occupations, perhaps not trusted to be as high-quality as higher education alone. By inviting the AHA/ASHHRA to partner with it, Dallas College benefits from association guidance on emerging workforce needs and from its endorsement of apprenticeship. As Dallas convened local employers and national partners like the AHA/ASHHRA, it positioned the college to create well-tailored, up-to-date programs with the benefit of a well-established industry voice communicating the value of apprenticeships in hospitals across the country.

One of the key reasons for Dallas’s partnership with the AHA/ASHHRA, in addition to raising the profile of apprenticeship, was to expand new programs to member sites interested in bringing these opportunities to their current and future employees. With a reach into facilities in communities large and small, the AHA/ASHHRA makes an ideal partner in sharing these career development opportunities to a wide range of hospitals and employees who stand to benefit. Furthermore, Dallas’s nine employer partners in its You’re Hired! initiative have extensive reach and influence in the region. Some employer partners are part of statewide or national networks, providing opportunities to socialize the apprenticeship model well beyond the immediate Dallas area.

Second, Dallas College integrates academic credit into its apprenticeship programs in a variety of ways. Some allow apprentices to earn a full associate degree, such as the health care culinary services program. Others offer some academic credit for related technical instruction that applies toward certificate or degree programs that apprentices could pursue in the future, such as the patient care technician program.

Rather than apprenticeship serving as an entirely separate pathway into health care occupations, Dallas College is embracing apprenticeship while recognizing the clout of higher education credits and credentials in health care occupations. Credentialism can keep people out of good health care jobs. But rather than trying to remove credentials from their preeminence in the health care field, apprenticeship offers a new way to allow more people to access these jobs. They get paid training and still earn the academic credit or degree and preparation for the licensure they need.

Finally, Dallas College is thinking big in terms of sharing with others around the country. There are designated college staff working to identify opportunities to expand these programs to other communities. Partnerships with expansion potential, such as Dallas’s collaboration with the AHA, ASHHRA, and with the American Association of Community Colleges, can help share out related technical instruction curriculum and mentorship resources. The college will provide mentors—called “preceptors” in these programs, to use the language of health care—with communications, logistics, and assessment orientation and ongoing support as they work with their assigned apprentices. In creating the nurse residency apprenticeship, the college worked with local employers to tailor a curriculum for these new nurses’ related technical instruction.

The foundation of paid and mentored training in apprenticeship offers a more accessible pathway to a variety of health care occupations than more traditional pathways through higher education alone. As the field grapples with exacerbated workforce shortages emerging from the pandemic, apprenticeship offers a supportive pathway into health care careers, from caring for patients to ensuring staff have the resources and infrastructure they need to deliver care. Dallas College’s ambitious work to facilitate the growth of health care apprenticeships offers several lessons:

1. Consider messaging and communication potential when building partnerships.
For colleges seeking to build apprenticeships in nontraditional sectors such as health care, it is critical to find employers and other partners who share a commitment to the apprenticeship model and who will publicly validate these efforts. It is also important to use the language of the occupation to get people comfortable with this new kind of training. For instance, calling mentors preceptors makes them fit more clearly into the health care field.

2. Work with the academic credit and credential requirements in health care.
Though it is possible in some health care occupations to start a career with an apprenticeship completely outside of higher education, most health care occupations look favorably on or even require higher education credentials to practice or advance. Rather than fighting the value of higher education in health care workforce development, a more fruitful strategy is to lean into it. College-connected apprenticeships not only make occupational entry more accessible, but credits earned pave the way for future study and career progression.

3. Consider scale and replicability from the beginning.
If the goal is to create a multi-employer, multi-site apprenticeship, build it that way from the beginning even if the program launches with a small cohort. Dallas began early by planning for a portable curriculum, mentor orientation, and networks of employers who could support one another across sites.

4. Work with partners to ensure apprentices are paid throughout all portions of the apprenticeship.
A common complication when developing health care apprenticeships is the overlap between clinicals required for pre-licensure higher education programs and on-the-job training in an apprenticeship. Employers may not be able to pay wages for training in the work environment for apprentices who have not yet secured professional licensure and are required to do so for employment. Meanwhile, clinicals are unpaid in traditional higher education programs, which can present financial and time challenges for students. Future analysis should explore ways to ensure that apprentices receive a steady flow of financial support to allow them to persist and complete their programs, even before they are licensed.

Footnotes:

[1] Industry recognized apprenticeship programs (IRAPs) were first introduced following a 2017 Executive Order, which was rescinded in February 2021. Current IRAPs and already recognized regulatory bodies can continue operating.