What Are the Main Barriers to Health Care Degree Apprenticeship?

If degree apprenticeship addresses many of health care’s capacity, efficiency, and equity challenges, why has it not spread more quickly? While we identified more than 100 programs nationwide, they are concentrated in just a handful of occupations, leaving many high-demand health care careers with few or no degree apprenticeship options. 

Our research suggests the answer lies in the complexity of health care workforce development itself. The infrastructure of health care workforce development involves a number of actors, including employers, colleges and universities; institutional and program-level accreditors; and, for some occupations, state boards and national certification bodies. Degree apprenticeship introduces Registered Apprenticeship, a system with its own rules and actors, into this already complex landscape. 

Degree apprenticeship brings these systems together and forces them to question many long-standing structures and practices, sometimes exposing areas of misalignment. Where these can be addressed, degree apprenticeship has begun to flourish, yielding benefits for learners and employers alike. But when they cannot, implementation can stall, even in occupations deemed apprenticeable.

Our interviews revealed that many of the most significant barriers to degree apprenticeship are embedded in the governance structures, accreditation standards, and regulatory requirements that shape health care workforce development.²⁹ Designed over decades to promote quality and protect patients, these systems also shape if and how innovation occurs, and whether new approaches to preparing health care professionals can take root.

Accreditors, professional associations, and state regulatory bodies like state nursing boards are the gatekeepers who determine whether degree apprenticeship is viable. They play an important role in promoting quality in the American health care system, and their concern for assuring that apprenticeship preserves that quality and protects patient safety is well-placed. Apprenticeship also continues to be associated with the skilled trades for many, and that may make it difficult to imagine the model succeeding outside that context. Yet our sense is that a key barrier to wider adoption of degree apprenticeship in some health care occupations is not so much opposition from the gatekeepers than it is the absence of explicit endorsement. We found some higher education leaders almost reflexively certain that accreditation and occupational regulatory requirements make degree apprenticeship impossible. But, as we discuss later, those who sought permission or support and approached gatekeepers in a spirit of collaboration succeeded in creating degree apprenticeships.  

When gatekeepers support degree apprenticeship, it thrives. In 2023, for example, the accreditor for surgical technology associate degree programs, the Accreditation Review Council on Education for Surgical Technology and Surgical Assisting, publicly embraced degree apprenticeship as an important strategy to address the severe shortage of surgical technologists and explained to surgical technology educators how apprenticeship can be integrated with an associate degree program that meets its accreditation standards.³⁰ These programs have begun to flourish: Surgical technology programs were the second most common type of degree apprenticeship we identified in our search. Similarly, when the Alabama Board of Nursing enacted rules authorizing registered nursing apprenticeships in 2022, the model took off in that state.³¹

Disagreement over the purpose of clinical experience and whether it is compensated, as well as differences in its timing, is another barrier. Unpaid clinical experience is a norm in health care occupational preparation that makes it difficult for apprenticeship to get started. While accreditation requirements are commonly cited as the reason clinical experience is often unpaid, we did not find this to be the case. We found only one accreditor of apprenticeable health occupations, the Commission on Accreditation for Respiratory Care, that prohibited payment for clinical experience in its standards for respiratory therapy associate degree programs.³² As we discuss later, however, it removed this requirement earlier this year and clarified that students may receive payment as part of a Registered Apprenticeship.

The unpaid mandate, however, may be a state regulatory requirement or an interpretation of state requirements. (An exhaustive review of state rules for health care occupational preparation was beyond the scope of this paper, but it merits investigation.) In other cases, educators resist paying students out of concern that clinical experience could become “just a job” and lose its educational focus. As Jay Prosser, executive director of the Massachusetts Nursing Council on Workforce Sustainability, put it, educators do not want to “deprive the student of a structured and valuable learning experience.” 

The story is different for occupational therapy assistant (OTA) and physical therapy assistant (PTA), both of which were deemed apprenticeable in 2024 as part of the partnership between the U.S. Department of Labor and the Urban Institute to develop National Occupational Frameworks.³³ We were unable to locate any current or developing degree apprenticeships in either occupation. Here, the barrier is the expectation for when clinical experience occurs. 

The Accreditation Council for Occupational Therapy Education (ACOTE) requires students in OTA programs to complete 16 weeks of full-time “fieldwork,”³⁴ which colleges typically schedule only after students complete their academic coursework. The College of the Canyons’ OTA program, for example, schedules this fieldwork in the final semester.³⁵ This back-loaded clinical experience expectation mirrors ACOTE’s standards for master’s and doctoral degree programs for occupational therapists, which require 24 weeks of full-time “fieldwork,”³⁶ which programs like the University of South Alabama’s schedule after all academic requirements have been completed.³⁷ Similarly, the Commission for Accreditation in Physical Therapy Education’s accreditation standards for PTA associate degree programs require students to complete six weeks of clinical experience at the end of their academic program,³⁸ while requiring physical therapy doctoral programs to include 30 weeks of full-time clinical experience, some of which must occur at the conclusion of the program.³⁹ These expectations effectively prevent apprenticeships that are coterminous with a degree. 

This is an American choice. The World Federation of Occupational Therapists’ Minimum Standards for the Education of Occupational Therapists gives programs discretion to determine when fieldwork occurs, indicating “fieldwork placements can be distributed throughout every year of the curriculum as suitable for the culture and context.”⁴⁰ The United Kingdom’s system of educating occupational therapy professionals does not back-load clinical experience. Preparation for an OTA practitioner, which is the closest equivalent to an occupational therapy assistant in the United States,⁴¹ is often an apprenticeship. For example, the University Centre Weston at Weston College’s OTA practitioner foundation degree in science program is an apprenticeship in which students spend one day a week in the classroom and four days at the worksite.⁴² U.K. preparation for occupational therapy, which is a bachelor’s degree program⁴³ rather than a graduate program as in the United States,⁴⁴ also integrates clinical experience with academic instruction throughout the program. City St. George’s, University of London’s three-year bachelor’s in science degree program, for example, embeds four full-time supervised clinical experience placements that total 1,000 hours across the three years of the program.⁴⁵ The Royal College of Occupational Therapists, which accredits occupational therapy bachelor’s of science programs, promotes its delivery as degree apprenticeships.⁴⁶ In England, 20 universities now offer occupational therapy bachelor’s degree apprenticeships.⁴⁷ 

Degree apprenticeship does not simply introduce another training model into health care; it challenges long-standing practices that shape how health care professionals are educated and the roles different system actors play in educating them. In doing so, it functions as a stress test for the health care workforce development system, revealing where policies, regulations, and institutional practices support innovation and where they stand in its way. The most successful programs are not those that avoid these tensions, but those that bring employers, higher education institutions, accreditors, licensing bodies, and apprenticeship leaders together to work through them. The implementation strategies described below illustrate how programs across the United States are doing exactly that in their quest to make degree apprenticeship a more widely used model.