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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
The scope of occupational health nursing practice has expanded and taken on a variety of roles, giving rise to opportunities for nurses to care for workers in various workplace settings. Essentials for Occupational Health Nursing provides a highly practical and accessible guide for nurses entering or already engaged in this important field. The text begins with the foundations for occupational health practice, covering the domain of occupational health and the role of the many professionals within the specialty. Subsequent chapters address program development, professional development, workplace regulatory requirements, workplace injury management and managing health and productivity. Case studies pertaining to fitness for duty and medical monitoring provide real-life scenarios to aid in learning. This title is also available as a mobile App from MedHand Mobile Libraries. Buy it now from iTunes, Google Play or the MedHand Store.
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Seitenzahl: 674
Veröffentlichungsjahr: 2013
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Contents
Copyright page
Preface
1 Foundations for Practice
OCCUPATIONAL HEALTHCARE PROFESSIONALS
THE OCCUPATIONAL HEALTH NURSE
THE ADVANCED PRACTICE REGISTERED NURSE IN OCCUPATIONAL HEALTH
THE DOMAIN OF OCCUPATIONAL HEALTH
2 Professional Issues
PROFESSIONAL ISSUES
MEDICAL DIRECTION
REGISTERED PROFESSIONAL NURSES
ADVANCE PRACTICE REGISTERED NURSES
OTHER OCCUPATIONAL HEALTH TEAM MEMBERS
LEGAL ASPECTS
LICENSURE
SCOPE OF PRACTICE FOR THE OHN
STANDARDS OF PRACTICE FOR THE OHN
COMPETENCE
PROFESSIONAL DEVELOPMENT
PROFESSIONAL LIABILITY
CONFIDENTIALITY
SUMMARY
3 Workers and Workplaces
WORKFORCE CHARACTERISTICS
WORKFORCE POPULATIONS
MANAGING DIVERSITY
WORKPLACES
FUTURE TRENDS IN OCCUPATIONAL HEALTH AND RESEARCH
4 Program Development
MANAGEMENT COMMITMENT
WORKPLACE ASSESSMENT
DEVELOP A PLAN
SELLING THE PLAN
IMPLEMENT THE PLAN
5 Facilities and Resources
BUDGET ISSUES
THE OCCUPATIONAL HEALTH FACILITY
LICENSURE
SUPPLIES
PHARMACY
STAFFING
LABORATORY
X-RAY
STANDARDS, POLICIES, PROCEDURES
SERVICES
AFTER-HOURS APPOINTMENTS
FORMS
HEALTH RECORDS
COMPUTER TECHNOLOGY
AUDITS
SUMMARY
6 Workplace Regulatory Requirements
OCCUPATIONAL SAFETY AND HEALTH ACT
OSHA STANDARDS FOR GENERAL INDUSTRY
COMMUNICABLE DISEASE REPORTING
HEALTH INFORMATION PORTABILITY AND ACCOUNTABILITY ACT—PUBLICLAW 104-191 (HIPPA)
ENVIRONMENTAL PROTECTION AGENCY (EPA)
FEDERAL TRANSPORTATION REGULATIONS
SUMMARY
7 Promoting and Maintaining a Safe Workplace
INTRODUCTION
MANAGEMENT COMMITMENT AND EMPLOYEE INVOLVEMENT
JOB HAZARD ANALYSIS
HAZARD PREVENTION AND CONTROL
SAFETY AND HEALTH TRAINING
INCIDENT INVESTIGATION
SAFETY AND HEALTH RECORD KEEPING
SUMMARY
8 Fitness for Duty
A RATIONALE FOR OCCUPATIONAL HEALTH SERVICES
ISSUES AFFECTING FITNESS FOR DUTY
SUBSTANCE TESTING
HEALTH EVALUATIONS
PHYSICAL ABILITIES TESTING
DETERMINING FITNESS FOR DUTY
THE FITNESS FOR DUTY POLICY AND PROCEDURE
SUMMARY
9 Drug-Free Workplace
STATISTICS
EFFECT ON THE WORKPLACE
DRUG-FREE WORKPLACE REGULATIONS
DETERMINING THE NEED
IDENTIFYING RESOURCES
DEVELOPING A DRUG-FREE WORKPLACE POLICY
WORKER EDUCATION AND AWARENESS
TYPES OF TESTING
SUBSTANCE TESTING—WHAT CAN BE TESTED?
SUBSTANCES COMMONLY TESTED
HOW A DRUG TEST IS CONDUCTED
SUMMARY
10 Workplace Injury Management
WORKERS’ COMPENSATION INSURANCE
WORKPLACE INJURY AND ILLNESS CALCULATION
BENEFITS FOR THE INJURED WORKER
MANAGEMENT OF CLAIMS
THE ROLE OF THE OHN
KEY PRINCIPLES IN MANAGING CLAIMS
STRATEGIES FOR SUCCESS
SUMMARY
11 Managing Health
WORKPLACE HEALTH AND PRODUCTIVITY
WORKERS’ COMPENSATION
WORKPLACE DISABILITY MANAGEMENT
PRINCIPLES OF DISABILITY MANAGEMENT
BRINGING THE CASE TO CLOSURE
SUMMARY
12 Managing Productivity
INTEGRATED ABSENCE MANAGEMENT
AMERICANS WITH DISABILITIES ACT (ADA)
FAMILY AND MEDICAL LEAVE ACT (FMLA)
SUMMARY
13 Promoting Health and Well-Being
WELLNESS IN THE WORKPLACE
WELLNESS—HOW DOES IT REALLY WORK?
WORK—A PLACE TO CALL HOME
SUMMARY
14 Leadership and Change
CHANGE FROM WITHIN
BE A LEADER
SUMMARY
A1 General Definitions and Terms
A2 Sample Occupational Health Nurse Job Description
A3 Sample Agreement for Professional Services
I. COMPENSATION
II. PERFORMANCE AND PROFESSIONAL RESPONSIBILITIES
III. ADDITIONAL SERVICES PROVIDED BY MEDICAL DIRECTOR
IV. INSURANCE
V. OWNERSHIP AND MAINTENANCE OF DOCUMENTS AND TREATMENT OF PROPRIETARY AND CONFIDENTIAL MATERIALS
VI. MEDIATION AND ARBITRATION OF DISPUTES:
VII. TERMINATION
VIII. NOTICES AND INVOICING
IX. GENERAL PROVISIONS
A4 Sample Practice Guidelines for the Registered Occupational Health Nurse
A5 Sample Medical Direction Prescription Release Authorization
A6 Sample Program Development Checklist
A7 Sample Documentation of Health Services Visits
A8 Things to Consider
A9 Sample Mobile Equipment Operator Health Evaluation
A10 Nationally Notifiable Infectious Conditions
A11 Sample Safety Policy
WORKPLACE SAFETY POLICY
A12 OSHA’s Strategic Map for Change and Continuous Improvement for Safety and Health
A13 OSHA’s Responsibility, Authority, and Accountability Checklist
A14 Common Hazards and Descriptions
A15 Guide to Recordability of Cases under OSHA
A16 OSHA Recordable Reference
A17 Health History Form
A18 Policy & Procedure
A19 Sample: Drug-Free Workplace Policy
PURPOSE AND GOAL
DEFINITIONS
COVERED WORKERS
APPLICABILITY
PROHIBITED BEHAVIOR
NOTIFICATION OF CONVICTIONS
SEARCHES
DRUG TESTING
CONSEQUENCES
ASSISTANCE
CONFIDENTIALITY
SHARED RESPONSIBILITY
COMMUNICATION
A20 Urine Drug Screen Collection Checklist
A21 Sample Request for Workplace Accommodation
A22 Notice of Intermittent FMLA Absence
A23 Sample Fitness for Duty Form
A24 Sample Wellness Program
MILLION HEARTS: PREVENTION AT WORK
A25 Service Provider Service Delivery Activity Report May 2012
A26 Occupational Health Services Service Delivery Evaluation Criteria
A27 Professional Resources Related to Occupational Health
Index
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Guzik, Arlene.Essentials for occupational health nursing / Arlene Guzik.p. ; cm.Includes bibliographical references and index.
ISBN 978-0-8138-0689-1 (pbk. : alk. paper) – ISBN 978-1-118-51762-8 (epdf/ebook) – ISBN 978-1-118-51766-6 (mobi) – ISBN 978-1-118-51767-3 (epub)I. Title. [DNLM: 1. Occupational Health Nursing. WY 141]610.73′46–dc23
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DEDICATIONTo John and Master Toby.For your patience and support.I thank you.
Preface
This story was once told to me years ago and it has continued impress upon me the importance of an “upstream approach” to safety.There was once a small town, with few hundred residents who all knew one another. Folks who were born in this town generally stayed in the town for most of their lives. Everyone knew everyone. One big happy community . . . until one day.A picnic was being held in the town park. Most everyone was there.All were laughing and having fun, until someone shouted“There is a body floating down the stream!”Everything stopped. No one knew what to do. Panic ensued.Some people jumped in the stream in attempt to save the victim.To no avail. The stream was flowing swiftly. Few knew how to swim well.No one knew CPR.The precious life of a community member was lost.The town folks were devastated.They could never let something like this happen again in their town.So a community meeting was called the following week. Nearly everyone came.Plans ensued. Swimming lessons were planned. CPR training would be offered.The town commission approved a budget for a trained rescue squad, a rescue vehicle, and the best rescue equipment. A community disaster plan was put in place.Plans were coordinated with the neighboring city’s hospital emergency department for transfer of victims. Thousands of dollars were invested in saving future victims.Nothing was considered too expensive if it saves a life.Time went on and another picnic was held. Everyone was having a great time.But sure enough that afternoon, someone shouted“There is a body floating down the stream!”The plan would be put to its first test. Everyone jumped to action.“Call the squad and bring in the equipment!!”Rescuers jumped into the stream with ropes and rafts and made the rescue.The body was brought to shore. CPR was initiated.The rescue squad arrived and transported the victim to the neighboring city’s ER.The life was saved!!!This called for a celebration!“Let’s have another picnic!”Yes, a picnic to celebrate their success at saving the drowning victim.Everyone came. This time there was a parade. There were bands.Everyone was singing and dancing in celebration of their success.Until someone shouted“There is a body floating down the stream!”Again, all jumped to action to take their role in rescuing yet another victim.When suddenly, someone stopped to ask:“How are all these bodies getting in the stream in the first place”?
This story has continued to have significance throughout my career, not only in the aspect of safety, but in the aspects of health and well-being, as well. Although people do not generally work to have their behavior changed or their health improved, the workplace is an excellent place to establish individual and population-based efforts, not only for safety, but also for health and productivity enhancement. These efforts take place at the micro-level, focused on the workers (the picnic), to discover specific problems or issues requiring attention. But the beauty of occupational health is that efforts also are aimed at the macro-level (upstream), focused on the broad, global improvements in health, safety, and productivity of the business . . . the population. As you read through this book, remember that you can make a difference in a little way and in a really big way. As nurses, we have been educated to address our interventions on individuals, families, and groups. As an occupational health nurse, one of the best outcomes of your efforts will be to make a difference, not only for the health and well-being of individuals and groups, but also for the health and well-being of the business.
Let’s take a trip upstream . . .
1 Foundations for Practice
“The mission of occupational health nursing is to assist individuals and workplaces in achieving higher levels of personal and workplace health and safety.”
(Guzik, 2005)
Nursing professionals have long been important assets in various aspects of healthcare, including hospitals, public and community health settings, military and educational settings, and in industrial and workplace settings. Occupational health nursing was originally known as “industrial nursing,” evolving during the Industrial Revolution. Throughout the years, occupational health nursing has taken on a variety of roles, and the scope of practice has expanded considerably, giving rise to opportunities for nurses to care for workers in various workplace settings.
Occupational health is a small healthcare specialty that was initially devoted to the prevention and management of occupational and environmental injury, illness, and disability. The specialty has grown to encompass other dimensions of healthcare, including the promotion of health and productivity along with the support for a safe workplace. The specialty of occupational health is focused on policy and issues relevant to health and safety by devoting attention to individuals and groups in the workplace.
Occupational health nursing is the nursing practice that provides for and delivers clinical service to workers and workplaces. Occupational health nurses (OHNs) also provide health education, case management, and safety programs. The practice of occupational health is focused on promotion and restoration of health, prevention of illness and injury, and protection from work-related hazards.
Registered nurses provide an array of services to business and industry and fill diverse roles in occupational health, including those of clinician, educator, case manager, corporate director, and consultant (AAOHN, 2007). The first record of occupational health nursing in the United States dates back to 1888. The profession has since evolved with the growth of industry and service and today provides a valued role in the workplace. According to the findings from the 2008 National Sample Survey of Registered Nurses Health Resources and Services Administration of the U.S. Department of Health and Human Services (2010), approximately 7.8% of all licensed registered nurses are working in public and community health, including occupational health.
The use of healthcare professionals has long been supported, and these professionals have demonstrated value in supporting the health and safety of the workplace and the workforce. With today’s workforce becoming increasingly diverse, these demographic changes result in new safety and health issues. As a result, workers are more likely to have increased risks of work-related diseases and injuries. With the shift from industrial to service-related occupations, changes are occurring in the way work is organized and accomplished. This may result in the need for longer work shifts, more hours worked than in the typical workweek, workweeks with longer days but fewer days per week, increased need for shift work, and increased use of part-time and temporary workers. In addition, new chemicals, materials, processes, and equipment are being implemented that may pose new and additional risks to worker health (U.S. Department of Labor, 2010).
OCCUPATIONAL HEALTHCARE PROFESSIONALS
Many types of healthcare professionals work in occupational health. The physician specialty of occupational medicine dates back to the 1500 s when the dangers of mining and diseases of miners were of great concern (Gochfeld, 2005). The specialty of occupational health has continued to evolve and is now focused on the recognition and prevention of injury and disease and the promotion of health. Occupational medicine arises from the principles of general medicine yet adds three dimensions of expertise: industrial hygiene, epidemiology, and toxicology (Gochfeld, 2005).
According to the American College of Occupational and Environmental Medicine (ACOEM, 2011), physicians working in occupational health “enhance the health of workers through preventive medicine, clinical care, disability management, research, and education.” In recent years, the role of the physician continues to change as greater emphasis is placed on health promotion and wellness in the workplace. The role of the physician has expanded, contributing new scientific research and new clinical guidelines for healthcare, and public health initiatives focused on the workforce and on the health of the environment (ACOEM, 2011).
In large businesses, physicians may hold administrative roles, and they are involved with developing company-based healthcare policy and procedures. These physicians may also provide oversight for company health, safety, and disability programs. Physicians in occupational health may work in private practice, offering clinical services such as physical examinations, drug testing, injury management, and medical monitoring services. Private physicians may also provide consultative services to workplaces to assist in the design and development of health and safety policies and procedures.
Occupational health physicians may also be employed by government agencies or in academic settings that focus on research, consultation, or education related to occupational health.
The physician’s assistant (PA) also has a role in occupational health. The PA working in occupational health, supervised by a physician, and is able to provide a broad range of healthcare services, such as diagnosis, treatment, and health promotion activity. The scope of practice for the PA is determined by the medical practice statutes specific to the state in which the PA is practicing (AAPAOM, 2010). The PA is able to practice autonomously within the scope of practice and authority delegated by the supervising physician.
The licensed practical nurse (LPN) also may hold a role in occupational health. LPNs are educated at the technical or vocational level, and their functions are generally performed under the direction of a registered nurse, a licensed physician, or a licensed osteopathic physician. The LPNs’ duties must fall within the scope of practice of the state in which they are licensed to practice.
The role of the LPN in occupational health may include first aid response and the administration of treatments and medications. AAOHN recommends that LPNs be assigned only those duties and responsibilities that their skills, knowledge, and competencies warrant as defined within their state licensure and that LPNs work exclusively in health organizations under the supervision of a registered professional OHN who can provide professional supervision (AAOHN, 2003). By using professional judgment, the registered nurse must determine the appropriate activities to delegate and must consider the associated professional responsibility and liability when overseeing the activities of assistive personnel.
The registered professional nurse holds a predominant position in occupational health in a variety of roles. The American Nurses Association’s Nursing’s Social Policy Statement (2003) states that the profession of nursing encompasses the “protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations.” This definition encompasses the scope of practice for the role of the OHN. Figure 1.1 depicts the relationship of the OHN within the company and within the community.
Figure 1.1 Occupational health services program.
THE OCCUPATIONAL HEALTH NURSE
The American Association of Occupational Health Nurses (AAOHN) specifies the following qualifications for the OHN: (1) graduation from an accredited professional nursing program; (2) current license to practice as a registered professional nurse in the state(s) of employment; (3) minimum of 2 years’ experience in a primary care setting, such as public/community health or ambulatory, emergency, or critical care; and (4) bachelor’s degree as the preferred educational preparation (AAOHN, 2012a).
The role of the OHN includes health teaching and counseling, safety education, the promotion of wellness and education in regard to the maintenance of health, and prevention of illness. The greatest number of OHNs work as clinicians, in clinical roles, and are involved with direct worker contact. In addition, OHNs hold administrative roles as program managers and disability managers within their employer organization. Another subset of OHNs work as case managers and consultants. Some may work for worker’s compensation or disability insurance companies, healthcare consulting companies, or as a self-employed independent contractors. A smaller subset of OHNs work in education or research (Thompson, 2010).
Clinician
The duties of the OHN may include first aid and emergency response, along with the administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized under the laws of his or her respective state of practice. The role of the OHN may also include the supervision and teaching of other personnel in the performance of any of the above acts. These personnel may include licensed practical nurses and emergency response team members.
As a clinician in occupational health, the OHN not only assesses the health of individuals, but also holds a significant role in assessing the health of the work environment and the health of workers as a group. The responsibilities of this role are conducted through health assessments, physical examinations, medical monitoring, and through direct nursing care. The OHN also strives to deliver health promotion programs that focus on the needs of groups within the workplace. Based on the identification of need, therapeutic plans for intervention are established and implemented with a focus on enhancing the overall health of the worker as well as the workplace.
As a clinician, the OHN also serves as adviser or counselor to individuals in the workplace. The OHN has the ability to address occupational as well as nonoccupational health issues, focusing on physical as well as psychosocial needs. The OHN uses a wealth of resources to meet the health needs of the worker and the workforce.
A significant aspect of the role as clinician includes health education. The OHN may prepare health education programs and establish outreach services that support the needs of the worker within the overall health benefits program of the company. The OHN has the opportunity to teach not only workers, but also management about aspects of personal, workplace, and public health and safety.
Manager or Administrator
There is a role for the OHN as a business leader. The OHN has the opportunity to implement strategies that will maximize employee productivity and reduce costs for the company. The OHN may serve to educate management on the impact of worker’s health issues, absences, and disability that adversely effect production, staffing, budgeting, and profitability. The OHN plays a key role in assisting with the development of corporate policies and procedures that may have a positive impact on worker health, safety, and productivity, thus maximizing the bottom line (Randolph, 2004).
According to the AAOHN Position Statement on Delivery of Occupational and Environmental Health Services, OHNs should strive to develop and implement a comprehensive health program that promotes better employee health, decreases health-related cost, improves employee morale, increases productivity, decreases absenteeism, and facilitates continuity of care (AAOHN, 2004). Therefore, the OHN’s primary responsibilities should focus on the following:
Promoting a safe and healthy workforce and workplace
Identifying health problems and hazards in the workplace and developing health and safety programs, benefits, and interventions focused on reducing risk and hazard
Assuring that health and safety programs are in compliance with federal, state, and local regulations
Assessing and monitoring health status and interventional outcomes for employees
Serving as a resource for employees and for the employer regarding the selection of appropriate and cost-effective healthcare resources
Monitoring outcomes as a measure of effectiveness
Case Manager
The OHN routinely coordinates and manages the healthcare of workers. The role of case manager initially began when OHNs managed the care and treatment of workers injured on the job, coordinating the treatment, follow-up, referrals, and emergency care for injuries and illnesses. The role has since become more comprehensive with the coordination, management, and consultation regarding nonoccupational issues, which encompasses aspects related to group health, medical leaves of absence, and disability benefits. In addition, the OHN manages services related to rehabilitation, return-to-work, and disability management. These functions are “key to employers’ healthcare quality and cost containment strategies” (Randolph, 2004).
As a case manager, the OHN coordinates healthcare services for a worker from beginning of injury or illness to return to work or optimal outcome. The goal of case management is to strive for the delivery of quality care in a cost-efficient manner. Since case management may be used for both occupational and nonoccupational health situations, the activities of case management can be conducted on-site in the workplace or by telephone.
The OHN also acts as consultant, advising on the process for evaluating and developing health and safety services in the workplace. A key role of the OHN as manager or administrator is to develop program assessment tools and conduct evaluations of the occupational health and safety program. The OHN should gather this information, identify opportunities for improvement, communicate findings to company officials, and assist in the development of future programs and services. The OHN may also act as or provide significant support to safety and industrial hygiene managers, risk managers, benefits managers, and human resources professionals.
Table 1.1 Percentage of time spent occupational health nursing.
Source: COHN, Certified Occupational Health Nurse; COHN-S, Certified Occupational Health Nurse Specialist.
Role Category
Percent of Time
Direct CareCOHNCOHN-S
31%25%
Manager/CoordinatorCOHNCOHN-S
23%28%
Case ManagerCOHNCOHN-S
21%19%
Educator/AdvisorCOHNCOHN-S
14%13%
ConsultantCOHNCOHN-S
6%10%
OtherCOHNCOHN-S
5%5%
Roles and activities vary significantly based on company needs and the environment in which the OHN practices. A 2004 Practice Analysis Report (Strasser et. al., 2006) indicated the percentage of time spent by OHNs in each of five general role categories. The results of the study indicated that direct care accounted for the largest percentage of the OHN’s time, and that the greatest focus of activity was on safety. See Table 1.1.
THE ADVANCED PRACTICE REGISTERED NURSE IN OCCUPATIONAL HEALTH
According to the Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education (NCSBN,2008), “Advanced Practice Registered Nurses (Nurse Practitioners) have expanded in numbers and capabilities over the past several decades with Nurse Practitioners being highly valued and an integral part of the healthcare system.”
As in the practice of registered professional nursing, the performance of advanced practice registered nursing acts are approved by each state board of nursing, which also defines the specialized education, training, and experience appropriate to the scope of practice. Nurse practitioners generally may perform acts of medical diagnosis and treatment, prescribing, and procedures based on their education and experience.
Although most of the medical care in the clinical arena in occupational health has traditionally been delivered by physicians, nurse practitioners are now filling valuable roles as clinicians. In the earliest literature addressing nurse practitioners in the occupational health setting, Grimes and Garcia (1997) analyzed the new role for nurse practitioners who applied principles of primary care in the occupational setting. The Occupational Health and Safety Administration (OSHA) first addressed the role of the nurse practitioner in the occupational health setting in 1999 in a publication that addressed the qualifications of occupational health professionals (OSHA, 1999). In this publication there was an indication that nurse practitioners, certified in occupational health as a specialty area, are capable of independently performing many health evaluation and care activities traditionally provided by physicians.
The nurse practitioner role in the occupational health setting was first addressed by AAOHN in an advisory report in 1999. The advisory report, updated in 2004 (AAOHN, 2007), addresses the various roles of the advanced practice registered nurse in the occupational health setting, including the role of healthcare provider. Opportunities for nurse practitioners have since evolved within the occupational health setting, yet little research is found in which this nurse practitioner role has been evaluated (Guzik et al., 2009).
THE DOMAIN OF OCCUPATIONAL HEALTH
Occupational health is founded on a variety of scientific principles, including public health, medicine, nursing, epidemiology, toxicology, industrial hygiene, safety, and social and behavioral sciences. As a result, it is an interdisciplinary practice. The U.S. civilian workforce employed approximately 140 million people in 2009 (U.S. DOL, 2010). Workers spend up to 50% of their waking lives at work; therefore, the workplace provides a captive audience for the promotion of health and wellness. Despite improvements in occupational safety and health over the last several decades, workers continue to suffer work-related deaths, injuries, and illnesses. The workplace, therefore, provides a unique subsector for sustaining public health initiatives.
In 1979, the U.S. Surgeon General initiated efforts to address the health of the U.S. population and published a report titled Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention. Since that time, the U.S. Department of Health and Human Services had led a science-based initiative defining 10-year national objectives for promoting health and preventing disease. The initiative is referred to as “Healthy People.”
The Healthy People report establishes public health initiatives based on data from the past decade, along with current data, trends, and advances. The Healthy People 2020 goals and objectives are based on current “risks to health and wellness, changing public health priorities, and emerging issues related to our nation’s health preparedness and prevention” (U.S. Department of Health and Human Services, 2010).
The goals include improving access to comprehensive, quality healthcare services. On-site occupational health programs staffed with an OHN support this goal by providing workers efficient access to a healthcare professional at their worksite. The OHN promotes the health and safety of people at work through prevention, early intervention, and directed referrals. With a focus on environmental health, the OHN addresses physical workplace risks and exposures, such as the use of hazardous chemicals and the potential of injury or illness, in order to reduce occupational deaths and needless disability. While supporting this Healthy People initiative, the OHN also supports the productivity of the workforce. Other goals and objectives of Healthy People call for an increase in comprehensive worksite health promotion programs, including educational programs and strategies for substance abuse and stress.
The strategies of occupational health nursing are based on the principles of evaluation, protection, promotion, and restoration of health, thus leading to an enhanced quality of life. Table 1.2 outlines the essential services of the occupational health professional in relation to public health initiatives.
The OHN is “central to the management and coordination of occupational health activities” (Rogers, 2003). The OHN must recognize the need to draw knowledge, experience, and resources from a variety of aspects and disciplines and be committed to continuing education to develop knowledge and skills within the domain of occupational health nursing. This includes basic nursing principles, clinical competence, and knowledge of the legal, regulatory, and ethical aspects impacting occupational health. Because the OHN typically practices in workplaces outside the traditional clinical venue of the healthcare environment, OHNs must also augment their value by holding a basic knowledge of management concepts and principles.
Occupational health professionals work with a variety of workers and work populations in a multitude of various work environments. This variety brings into play not only physical issues, but also social, cultural, organizational, economic, political, and interpersonal issues. The OHN must develop competence in performing activities customized to workers as well as the occupational and business environment. The OHN must develop an awareness of the impact of actions and interventions not only with the worker, but also within the greater context of the business environment.
The OHN will interact with a variety of other professionals in the work setting. These professionals include human resources and benefits professionals, safety and environmental specialists, business managers, and executive staff, including finance and legal professionals. It is therefore important that the OHN develop an understanding of the variety of perspectives that impact decisions in the workplace.
Safety and health promotion provide the foundation of an effective occupational health program. Occupational health nursing has evolved well beyond first aid treatment of injuries and emergencies to include comprehensive health and safety programs that are focused on promotion of worker health, increased productivity, and decreased health-related cost to the employer.
Table 1.2 Essential services.
Source: Public Health Functions Steering Committee. Public Health in America, Fall 1994. http://www.health.gov/phfunctions/public.htm (December 17, 2010).
Essential Public Health Services
Essential Occupational Health Services
Monitor health status to identify community health problems.
Monitor health status of the workforce.
Diagnose and investigate health problems and health hazards in the community.
Assess health risks and hazards in the workforce and workplace.
Inform, educate, and empower people about health issues.
Increase awareness and educate workers about health and safety issues.
Mobilize community partnerships to identify and self-health problems.
Establish community partnerships for health and safety interventions.
Developed policies and plans that support individual and community health efforts.
Develop health and safety policies and procedures.
Enforce laws and regulations that protect health and ensure safety.
Ensure compliance with applicable regulations related to health and safety.
Link people to needed personal health services and ensure the provision of healthcare when otherwise unavailable.
Improve access to and facilitate the delivery health services.
Assure a competent public health and personal healthcare workforce.
Support optimum health of the workforce.
Evaluate effectiveness, accessibility, and quality of personal and population-based health services.
Evaluate the effectiveness of safety and health interventions, benefits, and services.
Research for new insights and innovative solutions to health problems.
Identify continued opportunities for improvement and enhancement of health and safety in the workplace.
“Health” is not only related to the individual worker, but also should encompass a philosophy related to healthy populations and healthy work environments. It is therefore critical that the OHN support a solid foundation for an occupational health program that supports this philosophy.
REFERENCES
American Academy of Physician Assistants in Occupational Medicine (AAPAOM). (2010). Information for PAs in occupational medicine. Retrieved from www.aapaoccmed.org/Default.aspx?pageId=770960
American Association of Occupational Health Nurses (AAOHN). (2003). Position Statement. The licensed practical nurse (LPN) in occupational health. Retrieved from http://www.aaohn.org
American Association of Occupational Health Nurses (AAOHN). (2004). Position statement. Delivery of occupational and environmental health services. Retrieved from https://www.aaohn.org/position-statements/delivery-of-occupational-and-environmental-health-services.html
American Association of Occupational Health Nurses (AAOHN). (2007). Nurse practitioners in occupational and environmental health. Retrieved from https://www.aaohn.org/component/option,com_docman/task,cat_view/gid,132/
American Association of Occupational Health Nurses (AAOHN). (2012a). Occupational and environmental health nursing: Your key to health care cost containment. Retrieved from https://www.aaohn.org/dmdocuments/Your-Key-to-Health-Care-Cost-Containment%5B1%5D.pdf
American Association of Occupational Health Nurses (AAOHN). (2012). Occupational and environmental health nursing profession fact sheet. Retrieved from www.aaohn.org/component/option,com_docman/task,cat_view/gid,129
American Association of Occupational Health Nurses (AAOHN). (2012). Standards of occupational and environmental health nursing. Workplace Health & Safety, 60(3), 97–103.
American Association of Occupational Health Nurses (AAOHN). (2012). The licensed practical/vocational nurse in occupational and environmental health. Workplace Health & Safety, 60(3), 104.
American Nurses Association. (2003). Nursing’s social policy statement (2nd ed.). Silver Spring, MD: Nursesbooks.org.
American College of Occupational and Environmental Medicine (ACOEM). (2011). Scope of occupational and environmental health programs and practice. Updated March 03, 2011. Retrieved from http://www.acoem.org/Scope_HealthPrograms_Practice.aspx
Dirksen, M. E. (2001). Occupational and environmental health nursing: An overview. In M. K. Salazar (Ed.), Core curriculum for occupational and environmental health nursing (2nd ed., pp. 3–32). Philadelphia: W.B. Saunders.
Felton, J. S. (1996). Medical direction in occupational health nursing. The American Journal of Nursing, 66(9), 2019–2022.
Gochfeld, M. (2005).Chronologic history of occupational medicine. Journal of Occupational and Environmental Medicine, 47:96–114.
Goetzel, R. Z., Shechter D., Ozminkowski R. J., Marmet P. F., Tabrizi M. J., & Roemer E. C. (2007). Promising practices in employer health and productivity management efforts: Findings from a benchmarking study. Journal of Occupational and Environmental Medicine, 49(2), 111–130.
Grimes, D. E. & Garcia, M. K. (1997) Advanced practice nursing and worksite primary care: challenges for outcomes evaluation. Advance Practice Nursing Quarterly, 3(2), 19–28.
Guzik, A., Menzel, N. N., Fitzpatrick, J., & McNulty, R. (2009). Patient satisfaction with nurse practitioner and physician services in the occupational health setting. AAOHN Journal, 57(5), 191–197.
Hanna, J. K. (2012). Occupational health nursing around the world. Workplace Health & Safety, 60(6), 251–252.
Institute of Medicine, Committee for the Study of the Future of Public Health. (1988). The future of public health. Washington, DC: National Academies Press.
Institute of Medicine, Committee to Assess Training Needs for Occupational Safety and Health Personnel in the United States. (2000). Safe work in the 21st century: Education and training needs for the next decade’s occupational safety and health personnel. Washington, DC: National Academies Press.
Lukes, E. (2007). Epidemiology basics for occupational health nurses. AAOHN Journal, 55(1), 26–31.
McCauley, L. A. (2012). Research to practice in occupational health nursing. Workplace Health & Safety, 60(4), 183–189.
McCullagh, M. C. (1994). Occupational health nursing education for the 21st century. Public Health Functions Steering Committee. Public Health in America. Retrieved from http://www.health.gov/phfunctions/public.htm
McCullagh, M. C. (2012). Occupational health nursing education for the 21st century. Workplace Health & Safety, 60(4), 167–176.
National Council of State Boards of Nursing (NCSBN). (2008). APRN Joint Dialogue Group Report. Consensus model for APRN regulation: Licensure, accreditation, certification & education. Retrieved from https://www.ncsbn.org/7_23_08_Consensue_APRN_Final.pdf
Occupational Safety and Health Administration (OSHA). (1999). The occupational health professional’s service and qualifications: questions and answers. Retrieved from http://www.osha.gov/Publications/osha3160.pdf
Ramos, E. I. (2006). Occupational health nurses and case management. Nursing Economics, 24(1), 30–40, 3.
Randolph, S. A. Occupational and environmental health nursing. (2004). Retrieved from www.nsna.org/Portals/0/Skins/NSNA/pdf/Career_Randolf2.pdf
Reidel, J. E., Lynch, W., Baase, C., Hymel, P., Peterson, K. W. (2001). The effect of disease prevention and health promotion on workplace productivity: A literature review. American Journal of Health Promotion, 15(3), 167–191.
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Salazar, M. K. (2002). Defining the roles and functions of occupational and environmental health nurses: Results of a national job analysis. AAOHN Journal, 50(1), 16–25.
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2 Professional Issues
“Occupational and Environmental Health Nursing is the specialty practice providing for and delivering health and safety services to employees, employee populations and community groups. The practice focuses on promotion and restoration of health, prevention of illness and injury and protection from work-related and environmental hazards.”
(AAOHN, 2009)
PROFESSIONAL ISSUES
Awareness of issues surrounding professional nursing is important in defining the scope of practice and supervision in the occupational health setting. The scope of occupational health service delivery depends on the practice setting, the size of the workforce, and the number, diversity, and health characteristics of workers. The size and geographic location of the practice setting is also significant. In addition, consideration must be given to the community resources available near and around the practice setting.
The type of industry or work setting served will also dictate the scope of service, taking into consideration the types of processes and services provided at the work place. Potential health and safety risks associated with specific industries and job tasks will also dictate the need for specific interventions, medical surveillance, and workforce education and training.
In establishing an occupational health program, it is critical to understand the company philosophy and how the occupational health services relate to the overall organizational structure, process, and goals. The ability to assess specific health needs of the work population and potential hazards in the environment will drive the resources needed to establish an effective occupational health service, thus providing support for the corporate mission. Because occupational health services are not core to most company operations, it is important to develop a program built on a solid foundation of core principles related to worker and workplace health and safety This requires diligence, communication, and consistent justification of goals and outcomes of the program.
Several resources are available for development of an occupational health program for both nurses and physicians. Two renowned associations that serve as the primary resources in the United States are the American Association of Occupational Health Nurses (AAOHN) and the American College of Occupational and Environmental Medicine (ACOEM).
AAOHN is a professional association for healthcare professionals working in or interested in the specialty of occupational health. The vision of AAOHN is to “create a positive economic impact through workers’ health and well-being” that assists the occupational health nurse in supporting a productive workforce. AAOHN provides resources and support through education, research, and support for public policy by providing practice resources for occupational health nurses and through the development of strategic specialty alliances (AAOHN, 2010).
ACOEM is a professional association “dedicated to promoting the health of workers through preventive medicine, clinical care, research, and education.” ACOEM’s mission is to support the education of health professional and the public, support research, enhance the quality of practice, and to guide the development of public policy in order to advance the specialty of occupational and environmental medicine (ACOEM, 2010).
Both associations, along with other health and safety associations dedicated to the specialty of occupational health, provide support for the development of clinical practice, leadership development, and specialty education and research that is focused on promoting the health and safety of workers, workplaces, and the community.
MEDICAL DIRECTION
Since Registered Professional Nurses work under the supervision of a physician, medical direction for the occupational health program is important. Medical Direction for the occupational health program may be achieved through a direct relationship with a company-based medical director or may be facilitated through a contractual arrangement with a community-based physician familiar with the principles of occupational health and safety. In selecting a supervising medical director, the occupational health nurse (OHN) should define specific criteria expected from the relationship before identifying potential candidates.
In a document covering pertinent guidelines, best practices, and professional opinions, specific criteria that include skills and competencies expected of the physician practicing in occupational health are outlined (Russi et al., 2010). These criteria include interpersonal, administrative, and management skills; grounded knowledge of safety management; a willingness to interact with safety and workplace managers; knowledge of the principles of industrial hygiene and toxicology; focus on preventive and evidence-based medicine, including medical monitoring, assessment, diagnosis, and treatment of common workplace injuries and illnesses; and a strong focus on return to work and productivity. The credentials of the selected candidate for the supervising medical director role should be validated through the state board of medicine or state department of health. Required criteria include an active license to practice medicine in the specific State, medical license free of actions, disciplinary action or review, and absence of legal proceedings against the physician.
Figure 2.1 Organizational chart for company medical direction: corporate medical director.
The physician, as medical director, should not be expected to provide services without fair compensation. Since the medical director’s liability exposure and insurance premium may be impacted by the number of staff overseen directly and indirectly, compensation should be considered with this in mind.
The company must first decide the role of the medical director and make it worth the investment. The reporting relationship within the organization should be determined to provide clear lines of authority and responsibility. A company-based corporate medical director may hold responsibility for all aspects of environmental health and safety and will report to a member of senior management (see Figure 2.1). Commonly, the corporate medical director will report to the same member of senior management who is responsible for human resources or risk management. In a contractual arrangement, a consultant medical director would have a reporting relationship as an advisor to the company, while providing consultant supervision of the occupational health nurse, but hold no direct responsibility within the company (see Figure 2.2). A written agreement between the company and the medical director should outline the reporting relationships, terms, conditions, and expectations of performance. A sample contract for medical direction is provided in Appendix 3.
Figure 2.2 Organizational chart for company medical direction: consultant medical director.
Table 2.1 Medical direction documents.
Medical Director Agreement
Defines the role and scope of services for the program’s medical director and outlines the terms and agreements of the contractual relationships.
Clinical Practice Guidelines
Defines the specific health conditions and provides guidelines for the assessment and intervention that are within the scope of practice of the OHN. Also defines the nonprescription and prescription medications that can be administered.
Prescription Release Authority
Defines the specific medication that may be ordered through the pharmaceutical supply vendor under the medical director’s professional license.
A contracted medical director should perform to the level of the company’s expectations and should be compensated accordingly. The medical director may be paid on an hourly basis or may be paid through a monthly retainer that is reasonable and includes compensation for on-call, on-site visits, case management meetings, and writing/approving protocols and directives. Table 2.1 outlines the required documents for medical direction and their purposes.
The medical director’s performance should be evaluated regularly to establish and evaluate clear expectations according to the employment the agreement. The company should hold the medical director accountable for meeting or exceeding performance expectations. You can never “pay too much” for medical directorship. Compensation hinges on expectations and the value having a medical director brings to the occupational health and safety program.
The medical director should have an established relationship with the senior management of the company. This includes key officials and day-to-day managers of departments such as safety, human resources, industrial hygiene, engineering and facilities management, environment services, and the company’s health and disability insurance carriers (ACOEM, 2008). The medical director may participate in applicable committee meetings related to occupational health and safety and should also play an active role in the development of health and safety policies and procedures.
The success of an occupational health medical director affiliation is largely dependent on the relationship with occupational health nurses and other occupational health program staff. This relationship requires a strong philosophical alignment and commands respect for the skills and opinions of all members of the occupational health team.
The greatest issues to be considered with medical directorships are:
Each state board of nursing defines the scope of practice for registered professional nurses and nurse practitioner. Nurses working in occupational health must maintain knowledge of the regulatory requirements that apply to their practice in occupational health and assure appropriate medical oversight and supervision. There are distinct differences in the scope of practice for registered professional nurses and nurse practitioners. The scope of medical director supervision must be appropriate to the occupational health team members and comply with regulatory statutes guiding the practice of professional nursing.
REGISTERED PROFESSIONAL NURSES
The registered professional nurse must work under written medical directives from the supervising physician. These directives provide standing orders, protocols, prescriptive release authority, and levels of clinical intervention that guide the clinical practice of the registered nurse. These medical directives should be reviewed and signed annually by the occupational health nurse and by the supervising medical director.
The medical directives should define the general conditions for practice including but not limited to the following:
Prescriptive authority release with pharmacy provider
List of authorized prescription drugs, including oxygen
Clinical practice protocols
Use of the supervisory medical director’s license and Drug Enforcement Administration (DEA) certificate
Role and scope of service of the supervising medical director
ADVANCE PRACTICE REGISTERED NURSES
The delivery of occupational health services by nurse practitioners may take place in various practice venues. Examples include business or workplace settings, independent practice, collaborative practice with physicians or other healthcare professionals, community-based clinics, and institutional or academic clinic-based settings (AAOHN, 2007).
Each state has differing statutory requirements for practice as a nurse practitioner. The nurse practitioner working in an occupational health setting must maintain an awareness of the legal scope of practice and the practicing state’s statutory requirements for supervisory oversight. The state statutes, the practice setting in which the nurse practitioner functions, along with the scope of clinical practice, dictates the extent to which the nurse practitioner requires supervisory or collaborative oversight from the medical director. The scope of clinical practice will depend on populations served and the needs of the community or workforce population.
Nurse practitioners may practice as independent on-site providers or may function as a member of an interdisciplinary healthcare group practice.
OTHER OCCUPATIONAL HEALTH TEAM MEMBERS
The medical director may also hold responsibility for the delegation and supervision of tasks rendered by support staff in the occupational health setting. This includes licensed practical nurses, medical assistants, emergency medical technicians, and emergency response team members. The roles, duties, and responsibilities of these team members should be clearly outlined in policies and job descriptions in order to assure compliance within their scope of practice, education, and experience. The OHN, working under the supervision of the medical director, may have the authority to provide delegation and supervision of other occupational team members
Medical directives
Since a physician is typically not in regular attendance in most occupational health settings, both legal and ethical considerations dictate that the duties of the OHN concerning patient care should be established in a written set of medical directives. These medical directives should address the types of minor injuries or exposures that might be incurred by workers in the work setting and specify the level of healthcare to be rendered. Medical directives include: (1) practice guidelines and (2) prescription release authorization (see Appendix 4 and 5).
The medical directives guide the practice of professional nursing in the occupational health setting. These directives include written protocols or practice guidelines, along with standing orders, and are intended to assist the OHN and other team members in providing safe, quality healthcare to workers. Practice guidelines enable the occupational health staff to practice independently in the occupational health setting by defining the parameters of healthcare and treatment.
Medical directives strive to assure consistency, provided the same procedure is followed each time under the same set of circumstances. These written practice guidelines should cover the necessary healthcare services to be rendered in both emergency and routine situations. The practice guidelines should specify who can do what, assuring the actions match the scope of practice for each job category.
Medical directives are intended to provide legal guidance for healthcare delivery by defining the minimum requirements for safe, effective, and appropriate care. The written directives should be approved and signed by the medical director and by each OHN practicing under the medical directives. The signed medical directives should be readily available for reference in the occupational health setting, should be reviewed annually by the OHN and the medical director, and be updated as appropriate.
Standing orders are signed instructions from the medical director that describe the scope of practice under which the occupational health staff may act. They contain specific orders related to addressing symptoms or emergencies, outlining the assessment and interventions that the occupational health staff may perform, including the administration of nonprescription and prescription medications in the occupational health setting. See sample in Appendix 5.
Prescription release authorization from the medical director is also usually required by the pharmacy supplier in order to distribute prescription medications to the OHN in the occupational health setting. This form is signed by the medical director and details a list of prescription medications that may be ordered and administered by the OHN. See sample in Appendix 5.
The duty of the medical director is to give the occupational health staff all necessary and proper medical oversight. Failure to do so could be negligence on the part of the physician and could also imply that the OHN and support staff are practicing without appropriate medical direction.
LEGAL ASPECTS
In the United States, nursing practice is regulated at the state level through a standard titled “The Nurse Practice Act.” Each state’s Nurse Practice Act defines and regulates the practice of nursing, describing the legal scope and authority of the nurse, indicating that each nurse is directly accountable and responsible to the consumer for the quality of nursing care rendered. As a result, all staff members in the occupational health setting are responsible for practicing within the scope of practice set forth by their respective regulatory state board.
LICENSURE
All members of the occupational health team must maintain appropriate licensure and/or certification related to their scope of practice and state regulations. In the occupational health setting, the OHN often holds multistate responsibilities. In today’s business environment, OHNs may work for companies with multiple corporate locations. Typically, the OHN’s primary location is at the corporate headquarters, yet the OHN may have oversight for the occupational health program in multiple other locations. As a result, the OHN must have provisions for professional licensure and medical direction for those locations outside his or her primary state of residency. The OHN often conducts activities that guide and direct patient care such as performing health screenings, case management to determine the healthcare needs of employees, administering medications/vaccinations, and consulting with other healthcare professionals regarding an employee health issue. In order for the OHN to conduct these types of activities, OHNs must hold an active nursing license with each state in which they are practicing professional nursing. Activities that may not require professional license within the state would include activities that are primarily administrative in nature, such as designing healthcare programs, developing policies and procedures, and training.
Some states are members of the Nurse Licensure Compact (NLC). This compact allows nurses to hold multistate licensure. According to the National Council for State Boards of Nursing (NCSBN, 2007), the NLC permits nurses to have one license, usually in their state of residency, and to practice nursing in other compact states, both physical and virtually.
SCOPE OF PRACTICE FOR THE OHN
AAOHN (2012) defines seven specific functions involved in the practice of occupational health nursing. These functions guide the scope of practice of the OHN and serve as a foundation of practice.
