AAOHN Certificate
Program
Barb Maxwell RN, MHA, COHN-S, CCM, CWCP, QRP, FAAOHN
Chad Rittle DNP, MPH, RN
Debbie Bush RN, COHN-S/CM
Marianne Allen RN, BSN, COHN-S (authored)
Kerri L. Rupe ARNP, FNP-C, COHN-S, DNP, FAANP
Tonya F. Grayson, LPN
Copyright 2012 American Association of Occupational Health Nurses
Welcome to the Certificate
Program
•This is a 2 ½ day course
•Partially satisfy AAOHN Certificate
•Other requirements will be discussed
•Study Guide and other certifications
Copyright 2012 American Association of Occupational Health Nurses
Opening Statement
• The Occupational Health Nurse specialty has depth and
breadth and requires a variety of skills that are seldom
attained in an associate or bachelor’s education.
• The value of the AAOHN Certificate:
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Gives prestige and legitimacy to the occupational health specialty.
Allows satisfaction of employer and regulatory requirements.
Promotes the recruitment and retention of certificants.
Certification is a voluntary process that involves the formal recognition
of specialized knowledge, skills, and experience demonstrated by
achievement of standards.
– Periodic renewal of the certificate will require continuing education.
Copyright 2012 American Association of Occupational Health Nurses
Obtaining an AAOHN certificate
• To obtain an AAOHN certificate, the OHN must
also show successful completion of:
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Pulmonary Function, including fit testing
Audiometry
Ergonomics
Health coaching
Copyright 2012 American Association of Occupational Health Nurses
QUESTIONS??
Copyright 2012 American Association of Occupational Health Nurses
Occupational and
Environmental Nursing –
an Overview
Debbie Bush, RN, COHN-S/CM
Copyright 2012 American Association of Occupational Health Nurses
Objectives
• Discuss the evolution of occupational health
and its basic concepts
• List common terms and definitions
Copyright 2012 American Association of Occupational Health Nurses
Clients and Customers We Serve
The mission of occupational health is to
“assure as far as possible every Man and
Woman working in the Nation safe and healthful
working conditions”.
(United States Congress, Occupational Health
and Safety Act, 1970)
Copyright 2012 American Association of Occupational Health Nurses
Our Primary Focus
Occupational Health is a complex encompassing
social, cultural, political and economical content
of work.
– Social: The meaning of work
– Cultural: Beliefs, attitudes, and values
– Political: The ideology in a society, the
distribution of power, and government support
– Economical: Unemployment, wages, etc
Copyright 2012 American Association of Occupational Health Nurses
Occupational Health Nursing
• A “specialty practice that provides for and delivers
health care services to workers and worker
populations”.
• Has focus on the ‘promotion, protection, and
restoration of worker’s health within the context of a
safe and health work environment.
• Advocates for workers and encourages and enables
them to make informed decisions about health care
concerns.
Copyright 2012 American Association of Occupational Health Nurses
Essential Elements of
Occupational Health
Workplace Hazards
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physical – noise, radiation, ergonomics, lasers
chemical – Lead, Xylene, Chlorene
biological – Hep B and C, HIV
mechanical – machines/guarding and electrical
shock
• psychosocial – stress, fatigue, and burnout
Copyright 2012 American Association of Occupational Health Nurses
Work-Related Injuries / Illnesses
• Any injury that results from a single incident in
the work environment
• Injuries are more likely to be reported than
illnesses
• Both tend to be under reported over all
• Injury Rate Measurements can serve as an
indicator that need to be targeted
Copyright 2012 American Association of Occupational Health Nurses
Our History
• 19th Century Great Britain and the US
• 1880s – Department stores were the first to
hire industrial nurses as were coal mines
• 1909 - Milwaukee Nurse Assoc. placed a
nurse in their plant to offer services
• 1916 - Florence Wright delivered an address
to the National Safety Counsel
Copyright 2012 American Association of Occupational Health Nurses
Our History
• 1913 – The first industrial nurse registry was
opened in Boston for the purpose of supplying
factory emergency room nurses.
• 1997 – AAOHN Core Curriculum for
Occupational Health Nursing published
Copyright 2012 American Association of Occupational Health Nurses
IT IS A FOREIGN LANGUAGE
• OSHA
• STS
• Medical/Health
Surveillance
• MSDS
• BBP
• STD/LTD
• FMLA
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HCP
NIOSH
WC
Reserves
OSHA Recordkeeping
IH
PEL
TLV
Learning a New Language:
OSHA
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Occupational Safety and Health Administration
Federal agency formed in 1971 charged with the
enforcement of safety and health legislation to
assist employers in providing a safe working
environment
Only agency with the power to fine employers for
non-compliance
Is housed in the Department of Labor and Statistics
Copyright 2012 American Association of Occupational Health Nurses
NIOSH
• A federal agency created along with OSHA whose
main responsibility is conducting research into
occupational safety and health matters and making
recommendations for the prevention of work-related
injury and illness
• Is part of the Centers for Disease Control and
Prevention (CDC) and is housed in the Department of
Health and Human Services
• Has no powers of enforcement
Copyright 2012 American Association of Occupational Health Nurses
Workers’ Compensation (WC)
• Developed by the federal government to provide benefits (both medical
and indemnity) to employees injured as a result of their employment
• Medical benefits are 100% paid and are lifetime benefits
• Indemnity benefits or reduction in earnings are a scheduled percentage of
pre-injury earnings
• Indemnity benefits can be for an indefinite duration or potentially for
lifetime
• On average, 70% are medical only claims (no lost wages) with the
remaining 30% indemnity
• Is basically a state program administered by state agencies
• Workers’ compensation laws are “no fault” in nature
Copyright 2012 American Association of Occupational Health Nurses
Reserves
• Worker’s compensation insurance covers the cost of
medical care and rehabilitation for workers injured
on the job
• A portion of the total WC monies are carefully
calculated, state by state, and injury by injury, and
placed in “reserve” should the money become
necessary for the care of the employee
• These reserves may be continually adjusted up or
down depending on the medical status of the
employee
Copyright 2012 American Association of Occupational Health Nurses
OSHA Recordkeeping
– Part of the OSHA act that requires certain employers to
prepare and maintain records of all work-related injuries
and illnesses
– Covered employers must record, on prescribed forms or
equivalents, work-related injuries or illnesses that result in:
• Death
• Loss of consciousness
• Days away from work
• Restricted activity or job transfer
• Medical treatment (beyond first aid care)
Copyright 2012 American Association of Occupational Health Nurses
Industrial Hygiene (IH)
A science or art devoted to the recognition,
evaluation, prevention and control of those
environmental factors or stressors arising in or
from the workplace which may cause sickness,
impair health or wellbeing, or cause significant
discomfort among workers or citizens of the
community
Copyright 2012 American Association of Occupational Health Nurses
Permissible Exposure Limit (PEL)
• OSHA’s legal exposure limits for airborne
contaminants (vapors, dusts, etc)
• Are 8-hour, time-weighted averages of
airborne exposure
• Employers who use regulated substances
must keep air contaminants breathed by
employees below the PELs for these
substances
Copyright 2012 American Association of Occupational Health Nurses
Threshold Limit Value (TLV)
• The amounts of chemicals in the air that most healthy adult workers are
predicated to be able to tolerate without adverse effects
• These are suggested limits recommended by the American Conference of
Governmental Industrial Hygienists (ACGIH) on an annual basis
• Are 8-hour, time-weighted averages with the following exceptions:
• Ceiling levels, or uppermost TLV levels, cannot be exceeded
• Short-term exposure levels are the maximum, 15-minute, time-weighted
averages permitted over a workday, with at least 60 minutes between
successive exposures
• They are the model for many other air quality limits such as OSHA’s PELs
Copyright 2012 American Association of Occupational Health Nurses
Hearing Conservation Program
(HCP)
• An OSHA program located in 29 CFR 1910.95
• Mandates “the employer shall administer a
continuing, effective hearing conservation
program…whenever employee noise exposures
equal or exceed an 8-hour time-weighted average
(TWA) sound level of 85 decibels measured on the
A scale or, equivalently, a dose of fifty percent”
Copyright 2012 American Association of Occupational Health Nurses
Standard Threshold Shift (STS)
• A term used in OSHA’s Hearing Conservation
Program that describes an average shift from
the baseline measurement in either ear of 10
dB or more at 2000, 3000, or 4000 Hz
• These frequencies are the most important
frequencies in communication and the most
sensitive to damage by noise exposure
Copyright 2012 American Association of Occupational Health Nurses
Medical/Health Surveillance
• A process of evaluating the health of employees as it
relates to their potential occupational exposures to
hazardous agents
• Includes performing required exams, identifying and
ordering required tests and interpreting and
communicating results
• OSHA mandates health surveillance for certain exposures
on a substance by substance basis
• Some companies may have their own health surveillance
requirements
Copyright 2012 American Association of Occupational Health Nurses
Material Safety Data Sheet (MSDS)
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A detailed information bulletin prepared by the
manufacturer or importer of a chemical that
describes the physical and chemical properties,
physical and health hazards, routes of exposure,
precautions for safe handling and use, emergency
and first-aid procedures, and control measures
Aids in response to daily exposure situations as well
as to emergency situations for both employees and
employers
Copyright 2012 American Association of Occupational Health Nurses
Bloodborne Pathogens (BBP)
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A term referring to pathogenic microorganisms present in
human blood that may cause disease in humans
These pathogens include, but are not limited to, hepatitis B
virus (HBV) and human immunodeficiency virus (HIV)
OSHA’s 29 CFR 1910.1030 is the standard that outlines this
program
Employers with employees having occupational exposure as
defined by the standard shall establish a written Exposure
Control Plan to minimize exposure
Copyright 2012 American Association of Occupational Health Nurses
Short Term Disability (STD)/
Long Term Disability (LTD)
• Medical leaves of absence for illness, etc.
• Each cover a certain number of weeks of
disability and percentages of employee pay
• Based on the benefit plan and company policy
• Some companies have policies to terminate
employment once they move onto LTD
although benefits may continue
Copyright 2012 American Association of Occupational Health Nurses
Family Medical Leave Act (FMLA)
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Is the federal law of 1993 that provides unpaid, jobprotected leave to eligible employees, both male
and female, in order to care for their families or
themselves for specified family or medical
conditions
In January of 2009 new provisions were made to
cover employees in the military
Copyright 2012 American Association of Occupational Health Nurses
Questions??
Copyright 2012 American Association of Occupational Health Nurses
Worker Population Who's on First?
Tonya F. Grayson, LPN
Copyright 2012 American Association of Occupational Health Nurses
Introduction
Icebreaker
Copyright 2012 American Association of Occupational Health Nurses
Objectives
• Name 3 variations of programs that may be
needed within your workforce.
• Identify geographical concerns of your
workplace.
Copyright 2012 American Association of Occupational Health Nurses
The 5-W’s
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Who?
What?
When?
Where?
Why?
Copyright 2012 American Association of Occupational Health Nurses
WHO?
Who is worker population?
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Copyright 2012 American Association of Occupational Health Nurses
Minority
Ethnicity
Pregnant
International workers
Multiple Job Holders
WHY?
Why are they important to you?
Copyright 2012 American Association of Occupational Health Nurses
Changes that Affect our Worker
Population
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Fertility rate
Job demands
Technology
Gender rate
Minority rate
Copyright 2012 American Association of Occupational Health Nurses
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Aging Workforce
Contingent workers
Union Workers
Disabled Workers:
World Health
WHEN?
• When is it important to know and understand
worker population?
• As OHN developing, implementing and
evaluating programs and services, we must
ALWAYS consider worker population and
current state.
Copyright 2012 American Association of Occupational Health Nurses
WHERE?
• Where are you located and what concerns
should you have for that location?
• Natural Disasters: Perhaps the most
unpredictable of all environmental factors.
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Hurricane Zone
Tornado Alley
Flood Zone
Forest Fire
Snow
Copyright 2012 American Association of Occupational Health Nurses
Other Groups
the OHN has to Consider
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Military Installation/High Security Area
Virtual Office
Ethnic Groups
Union Workers
Agricultural Workers
Biological Hazards
Copyright 2012 American Association of Occupational Health Nurses
WHAT?
What is the OHN role related to worker
population?
Copyright 2012 American Association of Occupational Health Nurses
SUMMARY
We are VITAL to the success of our companies!
Copyright 2012 American Association of Occupational Health Nurses
Bibliography
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Salazar, M. (2011) Core Curriculum for Occupational & Environmental Health Nursing, 3rd
edition. Pensacola, FL: AAOHN
Department of Labor Futurework-Trends and Challenges for Work in the 21st Century,
Exectutive Summary and An Overview of Economic, Social and Demographic Trends Affection
the US Labor Market. Retrieved on November 10, 2012
http://www.dol.gov/oasam/programs/history/herman/reports/futurework/welcome.html
Rogers, C.D. Environmental Forces that Affect Business. Retrieved November 10, 2012.
http://www.dol.gov/oasam/programs/history/herman/reports/futurework/welcome.html
Dun & Bradstreet (2011) 2011 Impact Report of Joplin, Missouri Tornado. Retrieved
December 1, 2012. http://www.dnbgov.com/pdf/2011_Impact_Report_of_Joplin_v4.pdf
Fleury, Michelle (December 7, 2012) Hurricane Sandy expected to impact on US job growth.
Retrieved December 9, 2012. http://www.bbc.co.uk/news/business-20637524
Copyright 2012 American Association of Occupational Health Nurses
Prevention and
Work-Related
Injuries and Illnesses
Debbie Bush, RN, COHN-S/CM
Copyright 2012 American Association of Occupational Health Nurses
Objectives
• Distinguish the difference between an
occupational injury and illness
• List 2 economical impacts to an organization
that relates to an occupational injury or illness
• Name 2 prevention techniques the OHN can
implement to reduce injuries/illnesses
Copyright 2012 American Association of Occupational Health Nurses
Is there a Difference between
Occupational Injuries and Illnesses?
• Occupational Injury – any injury that results
from a single instantaneous exposure or
incident in the work environment
• Occupational Illness – any abnormal condition
or disorder which over time through repetitive
exposure resulting in an acute or chronic
condition
Copyright 2012 American Association of Occupational Health Nurses
Levels of Prevention
Primary prevention:
–Immunizations
–Pre-placement physical
Copyright 2012 American Association of Occupational Health Nurses
Levels of Prevention
Secondary prevention:
– Screening
– Early diagnosis and treatment of injury
and illness
– Surveillance
Copyright 2012 American Association of Occupational Health Nurses
Levels of Prevention
Tertiary prevention relates to disability & case
management
Copyright 2012 American Association of Occupational Health Nurses
Prevention
Recognition
• The process of identifying and describing
existing workplace hazards.
• Hazard is the ‘potential’ for harm or damage
to people, property, or the environment.
• Recognizing hazards requires knowledge of
the workers, the worksite, the work practices
and processes, and industrial materials used.
Copyright 2012 American Association of Occupational Health Nurses
Prevention
Anticipation
• ‘The foresight to recognize hazards in
equipment and processes during the planning
stages so they can be eliminated from the
design.’ (Manuele,1994)
Copyright 2012 American Association of Occupational Health Nurses
Methods of Identification
• Site Survey/Walk thru
– Get a lay out of the building and have a person of interest with you
• Inspections
– Pull all those performed in the previous one – three years
• Records Review
– Look all OSHA 300 logs for the past five years for trends
• Job Hazard Analysis
– Have any been performed?
• Accident Investigations
– These are critical and will go along with the OSHA Log review
Copyright 2012 American Association of Occupational Health Nurses
Types of Hazards
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Physical
Chemical
Biological
Mechanical
Psychological
Copyright 2012 American Association of Occupational Health Nurses
Physical
• Material Handling - lifting devices, conveyors,
lift truck operations, cranes, hoists,
• Buildings and Structures - windows, aisles,
floors, stairs, and exit signs
• Temperature controls – check logs
• Noise – sound level measurements
Copyright 2012 American Association of Occupational Health Nurses
Chemical
• Chemical Inventories – look for full lists
• MSDS – location?
• PPE – where located, condition, training
Copyright 2012 American Association of Occupational Health Nurses
Biological
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Exposure Control Plan
OSHA 300 Log/ Sharp Injury Log
Accident Investigation
Hep B Program
Copyright 2012 American Association of Occupational Health Nurses
Mechanical
• Machinery - guarding of moving parts and
pinch points, barrier safety shields, automatic
shut offs
• Material handling – lifting devices, conveyors,
lift truck operations, cranes, hoists
• Electrical – cords, outlets, electrical gear
clearance, shock hazards.
Copyright 2012 American Association of Occupational Health Nurses
Psychological
• Stress – competition, personality issues
• Fatigue – shift work, overtime
• Workplace violence – harassments, threats,
physical assaults
Copyright 2012 American Association of Occupational Health Nurses
Solutions
• Analysis of the job hazards to prioritize issues
• Exposure monitoring whether for chemicals, sound, or
temperature will give the OHN a baseline to start a program
• A firm handle of OSHA regulations such as BBP and
Respiratory Program along with PPE ( personal protective
equipment
• NIOSH Lifting Guidelines to reduce strains/sprains
• Ergonomics Analysis to evaluate issues related to
musculoskeletal disorders
• A full review of all data for trends
Copyright 2012 American Association of Occupational Health Nurses
Questions??
Break
Copyright 2012 American Association of Occupational Health Nurses
Information
Management in
Occupational Health
Kerri L. Rupe ARNP, FNP-C, COHN-S, DNP, FAANP
Copyright 2012 American Association of Occupational Health Nurses
Objectives
• Describe the collection and management of
protected health information (PHI) in the
occupational health setting
• Discuss the importance of confidentiality of PHI in
the practice setting.
• Describe the professional and ethical issues related
to PHI in the occupational health setting
• Discuss the use of social media in occupational
health.
Copyright 2012 American Association of Occupational Health Nurses
Content Outline
• Review the AAOHN position statement on protecting confidentiality of
health information
• Review the Health Insurance Portability and Accountability Act (HIPPA) of
1996
• Outline the use of electronic medical records in the occupational health
setting and the electronic transmission of PHI.
• Define the circumstances when public benefit from disclosure of PHI
outweighs the individuals privacy
• Present the opportunities and concerns associated with the use of social
media for health information.
• Present ethical dilemmas that occur in the occupational health setting
Copyright 2012 American Association of Occupational Health Nurses
What is Protected Health
Information (PHI)?
Personal information obtained about a
client related to his/her health status
• Past health conditions
• Familial health conditions
• Current health issues
Copyright 2012 American Association of Occupational Health Nurses
Why is confidentiality important?
• Morality
• Professional Ethics
• It is the law
Copyright 2012 American Association of Occupational Health Nurses
When is it Appropriate
to Release PHI?
• When providing treatment, the coordination of care or
management of care requires the sharing of the information.
• To get reimbursed for services provided
• The operations of health care
• USDHHS determines the public health benefit outweighs the
individuals privacy
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Life threatening emergencies
Worker’s compensation
DOT mandated medical examinations
OSHA mandated medical surveillance
Occupational Injury/Illness evaluations
Compliance with gov’t regulations
Copyright 2012 American Association of Occupational Health Nurses
What is the role of the occupational health
nurse in maintaining confidentiality of PHI
at the workplace?
AAOHN Position Statement (2006)
• States “the confidentiality of PHI is integral and central
to the practice of the occupational health…and is
maintained in accordance with professional codes, laws
and regulations”. (p.1)
• Asserts confidentiality of PHI is necessary to ensure the
publics’ trust
• OHN’s have a professional obligation to prevent
inappropriate and/or unauthorized PHI disclosure
Copyright 2012 American Association of Occupational Health Nurses
What is the role of the occupational health
nurse in maintaining confidentiality of PHI
at the workplace?
AAOHN Code of Ethics (2004)
– OHN’s “strive to safeguard employees’ right to privacy by protecting
confidential information and releasing information only upon written
consent of the employee or as required by law”. (p.1)
Standards of Practice of Occupational &
Environmental Health Nursing (AAOHN, 2012)
– Issue of confidentiality of PHI is addressed related to assessment,
diagnosis and ethical decision making
Copyright 2012 American Association of Occupational Health Nurses
Electronic Medical Record (EMR)
in Occupational Health
Wide range of health information is collected,
organized, processed and managed by the OHN
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Work Injury and Illness data
Post-employment physical examinations
Surveillance screenings
Fitness of duty information
Employee health records
Copyright 2012 American Association of Occupational Health Nurses
EMR
• Allows for management of clinical data
sets
• Efficient access to information when
needed
• Easier storage of large amounts of data
• Data Security
Copyright 2012 American Association of Occupational Health Nurses
EMR – Data Security
Data Security
• Externally
⁻ Hackers
• Internally
⁻ Non-essential personnel access to PHI
⁻ Administrative/Management access to PHI
• Develop policies and procedures
⁻ Limit access by use of pass codes, screen savers, work station
placement
⁻ Restrict access
⁻ Establish and maintain security standards for storage,
transmission and destruction of the EMR
⁻ Back up data
Copyright 2012 American Association of Occupational Health Nurses
Social Media in
Occupational Health
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Immediate sharing and access of information
worldwide
Individuals and groups can communicate in real
time wirelessly
Utilization of hand-held devices to access up-todate clinical references
Utilization of this technology to upload or
download PHI from anywhere
Confidentiality Issues
Copyright 2012 American Association of Occupational Health Nurses
References
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American Association of Occupational Health Nursing. (2009). AAOHN Code of Ethics and Interpretive
Statements.
American Association of Occupational Health Nursing. (2004). AAOHN Advisory: Confidentiality of
Employee Health Information.
American Association of Occupational Health Nursing. (2012). Standards of Occupational & Environmental
Health Nursing.
American Association of Occupational Health Nursing. (2006). Position statement: Roll of the occupational
and environmental and nurse case managers in protecting confidentiality of health information.
Damrongsak, M., Brown, K. C.,(2008). Data Security in Occupational Health. AAOHN Journal. 56(10), 417421.
Rogers, B. (2003). Occupational and Environmental Health Nursing: Concepts and Practice. 2nd edition.
Philadelphia: Pa. Elsevier Science.
Salazar, M. (2011). Core Curriculum for Occupational & Environmental Health Nursing, 3rd edition.
Pensacola, Fl:AAOHN.
Schuren, W.S., & Livsey, K., (2001) Complying with Health Insurance Portability and Accountability Act
Privacy Standards. AAOHN Journal, 49(11), 510-507.
Copyright 2012 American Association of Occupational Health Nurses
Questions??
Lunch on Your
Own
Copyright 2012 American Association of Occupational Health Nurses
Direct Care and Clinical
Decision Making
Debbie Bush, RN, COHN-S/CM
Copyright 2012 American Association of Occupational Health Nurses
Objectives
• Name 3 direct care givers needed for a
population
• List 2 advantages of on-site clinical
management
Copyright 2012 American Association of Occupational Health Nurses
Direct Care
in the Occupational Setting
• Direct care consists of activities involved in the
delivery of clinical care to individual clients
who are at the on-set basically healthy
• Activities include the steps necessary for
appropriate clinical decision making, such as:
– taking a health history
– conducting a physical exam
– ordering diagnostic or screening studies
Copyright 2012 American Association of Occupational Health Nurses
Direct Care
Professional Practice Concepts
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Direct care: defined as hands-on clinical care
Advanced practice nursing
Primary care
Professional & regulatory parameters of
practice: AAOHN competencies in
occupational and environmental health
nursing
Copyright 2012 American Association of Occupational Health Nurses
Overview of Direct Care
• Care for Occupational and/or nonoccupational conditions
• First aid, emergency care, minor acute care,
chronic illness management, full service and
24 hour call
• Prevention based services
• Case Management
Copyright 2012 American Association of Occupational Health Nurses
Overview of Direct Care
• Offered to all workers:
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full time employees
Contractors
Retirees
volunteers
• Who may deliver the care:
– LPNs, RNs, ARNPs, Physicians
Copyright 2012 American Association of Occupational Health Nurses
Reasons For On-Site Care
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Greater convenience
Less down time
Greater opportunity for case management
Fast & accurate determination of work
relatedness
• Ability to make accommodations
• Opportunity to reinforce safe work practices
Copyright 2012 American Association of Occupational Health Nurses
Ethical, Legal & Professional
Considerations for Direct Care
Ethical:
1. Confidentiality of personal health info
2. Must balance the “duty to warn” against right to
privacy
3. Resources dedicated to OH&S are often limited
4. Workers have a right to know about the
workplace hazards
Copyright 2012 American Association of Occupational Health Nurses
Ethical, Legal & Professional
Considerations for Direct Care
Legal:
1. Documentation must be done according to
professional codes of conduct & AAOHN
standards
2. ARNPs can prescribe meds, pharmacy laws must
be followed. Other staff can carry out.
3. Must comply with OSHA standards
Copyright 2012 American Association of Occupational Health Nurses
Ethical, Legal & Professional
Considerations for Direct Care
Professional:
1. All providers must be competent
2. AAOHN’s Standards of Occupational &
Environmental Nursing guide practice
3. Outcomes of clinical care must be measured
4. Secure data management systems
Copyright 2012 American Association of Occupational Health Nurses
Knowledge Needs for Direct Care
in Occupational Health
• Knowledge of the physical and mental
requirements of the worker’s job
• Knowledge of the work processes, potential
hazards & PPE requirements
• Recognition of the link between work site
exposure & adverse health effects
• Familiarity with clinical practice & evidence
based practice
Copyright 2012 American Association of Occupational Health Nurses
Operational Requirements
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Facility/equipment requirements
Private space to maintain confidentiality
Client gowns & sheets
Hand washing facilities
Locked file cabinet for medical records
Emergency response equipment
Supplies
Administrative needs: recordkeeping
Copyright 2012 American Association of Occupational Health Nurses
Health History
• Establish a health care relationship
• Identify active & potential physical & mental
health problems
• Determine a risk profile for preventable health
concerns
Copyright 2012 American Association of Occupational Health Nurses
Components of Comprehensive
Health History
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Client profile
Chief complaint
History of present illness ( HPI)
Supportive positive/negative data
– PMH, prior workup, significant prior injury/illness
– Family history
– Social history
Copyright 2012 American Association of Occupational Health Nurses
Components of Comprehensive
Health History
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Occupational/Environmental history
Review of Systems (ROS)
Past Medical History
Medications & allergies
Copyright 2012 American Association of Occupational Health Nurses
Purpose of Occupational &
Environmental Exposure History
• Identify asymptomatic occ/env illness
• Provide epidemiological correlation symptoms
& exposures
• Help to correctly diagnosis occ or env health
problems
• Aid in teaching & counseling
Copyright 2012 American Association of Occupational Health Nurses
Screening ~ “WHACS”
• What do you do?
• How do you do it?
• Are you concerned about any exposures on or
off the job?
• Co-workers or others exposed?
• Satisfied with your job?
Copyright 2012 American Association of Occupational Health Nurses
Comprehensive Exposure History
• Exposure survey
• Work history
• Environmental history
Copyright 2012 American Association of Occupational Health Nurses
Critical Aspects of Exposure
History
• Quantifying the amount, duration & frequency
of exposure ( dose )
• Detailing route of exposure
• Separating acute vs. chronic exposures
• Separating acute vs. chronic health effects
• Taking an environmental exposure history
Copyright 2012 American Association of Occupational Health Nurses
Physical Exam
• Identify disease
• Detect disease process in pre-symptomatic
stage
• Determine biological markers
• Determine any impairment that may impact
the ability to do the job
• Document baseline objective findings
Copyright 2012 American Association of Occupational Health Nurses
Techniques for Physical Exam
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Inspection
Palpation
Percussion
Auscultation
Copyright 2012 American Association of Occupational Health Nurses
Clinical Decision Making
• Identify the abnormal findings
• Cluster findings into logical groups
• Localize the findings anatomically
Copyright 2012 American Association of Occupational Health Nurses
Clinical Decision Making
• Recordable/reportable conditions
• OSHA 300 Log
Copyright 2012 American Association of Occupational Health Nurses
Evaluating Outcomes
• Health outcomes are the result or
consequences of a process of care
• Satisfaction with care
• Use of health care resources
• Clinical outcomes, such as changes in health
status & in the length & quality of life as a
result of detecting or treating disease
Copyright 2012 American Association of Occupational Health Nurses
Continuous Quality Improvement
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Identify values
Identify work
Identify standards
Secure measurements
Make interpretations and apply results
Set goals for improvement
Copyright 2012 American Association of Occupational Health Nurses
Questions??
Copyright 2012 American Association of Occupational Health Nurses
Safety &
Environmental
Health Programs
Tonya Grayson, LPN
Copyright 2012 American Association of Occupational Health Nurses
Objectives
• Recognize the components of environmental
health history
• Identify resources and peer professionals for
environmental health programs
Copyright 2012 American Association of Occupational Health Nurses
Introduction
• The science and practice of occupational
safety and environmental health nursing are
based on the merging of knowledge gained
from many disciplines such as nursing, safety,
environmental science, industrial hygiene and
public health.
• It is vital for nurses in this field to understand
the principles and the sciences of
Environmental Health.
Copyright 2012 American Association of Occupational Health Nurses
What is Environment?
Environmental health addresses all the physical,
chemical and biological factors external to a
person, and all the related factors impacting
behaviors.
Copyright 2012 American Association of Occupational Health Nurses
What are environmental risks?
Significant environmental conditions capable of
harming the health of a human are experienced
at work, where exposures are higher than in
other settings.
Copyright 2012 American Association of Occupational Health Nurses
Risk Matrix
A Risk Matrix is a matrix that is used during Risk
Assessment to define the various levels of risk as
the product of the harm probability categories
and harm severity categories.
– Catastrophic - Multiple Deaths
– Critical - One Death or Multiple Severe Injuries
– Marginal - One Severe Injury or Multiple Minor
Injuries
– Negligible - One Minor Injury
Copyright 2012 American Association of Occupational Health Nurses
Safety & Environmental Risk
Analysis
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Risk Assessment
Health Hazards
Qualitative Risk Assessment
Observational Risk Assessment
MSDS
Hazard Analysis
Risk model
Management System
How to sustain
Copyright 2012 American Association of Occupational Health Nurses
What is our social responsibility?
We do have a professional and legal
responsibility to ensure the safety of our worker
population and their families.
Copyright 2012 American Association of Occupational Health Nurses
The OHN Role
• Competencies:
– Understand
– Access and refer: i.e.,
– Advocate
Copyright 2012 American Association of Occupational Health Nurses
Recommendations
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Support
Participate
Communication
Advocacy
Research
Generate Data
Conduct studies
Visibility
Education
Copyright 2012 American Association of Occupational Health Nurses
Cause of Illneses/Injuries
• Hazard- substance capable of causing harm
• Risk- probability that harm will occur
• Epidemiology-study of causes of health
related events
• Incidence rate- a rate in incident per unit of
time
• Prevalence-frequency of event
Copyright 2012 American Association of Occupational Health Nurses
Cause of Illnesses/Injuries
• Target Organ- specific organ affected by specific toxin
• Asphyxiants- chemical that deprives the body tissue
of oxygen
• Corrosive- causes irreversible tissue death
• Irritants- cause temporary but sometimes severe
inflammation
• Sensitizer- causes allergic reaction after repeated
exposure
Copyright 2012 American Association of Occupational Health Nurses
Cause of Illnesses/Injuries
• Carcinogens- capable of causing cancer
• Mutagens- causing changes to genetic material of
cells (harming future generations)
• Teratogens- causes malformation of unborn child
• Inhalants- route of exposure, breathed in
• Cutaneous- route of exposure, absorbed through
skin
• Ingestion- least common route of exposure, taken in
through digestive tract
Copyright 2012 American Association of Occupational Health Nurses
Cause of Illnesses/Injuries
• Lethal dose- dosage that produces death in 50% of population
tested
• Lethal concentration- strength of dose that produces death in
50% of population tested
• Half Lift- describes times it takes for ½ of the absorbed
amount to be eliminated from the body
• PEL- permissible exposure limits (OSHA) legally enforceable
• TLV- threshold limit value (ACGIH) 8 hr, time weighted
averages
Copyright 2012 American Association of Occupational Health Nurses
Cause of Illness/Injuries
• REL- recommended exposure level (NIOSH), levels of exposure
will not cause adverse effects
• Engineering controls- devices or methods used to stop
hazards at their source
• Administrative controls- supervisory and management
practices
• Personal Protective Equipment- safety equipment
Copyright 2012 American Association of Occupational Health Nurses
How to perform environmental
health history?
• The Occupational Health History is a systematic way to gather
information about work history and past or present exposure
to actual or potential health hazards in that work
environment. It can also provide information to help the
clinician assess the individual risk and counsel the worker
regarding hazards and how to reduce their exposure before
problems begin or to alleviate growth of health issues.
• Provides:
– Information
– Documentation
– opportunities
Copyright 2012 American Association of Occupational Health Nurses
Components of the Health History
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Demographic
Work History
Home Exposure
Community Exposure
Occupational Exposure
Environmental Exposure
Physical Assessment
Copyright 2012 American Association of Occupational Health Nurses
Why is Environmental Health
Relevant?
Environmental health impacts the clinical
health of all the working population
Copyright 2012 American Association of Occupational Health Nurses
Example of Exposures and Their
Effects
Hazards can be classified in many different
ways like by their chemical properties.
Copyright 2012 American Association of Occupational Health Nurses
Examples
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Metals
Respirable Dust
Solvents
Pesticides
Asphyxiants
Copyright 2012 American Association of Occupational Health Nurses
Metals
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Arsenic
Beryllium
Cadmium
Chromium
Lead
Mercury
Maganese
Copyright 2012 American Association of Occupational Health Nurses
Respirable Dust
• Respirable Dust are solid particles that are
able to be suspended in the air and ultimately
inhaled into the body.
– Asbestos
– Coal-Dust
– Silica
Copyright 2012 American Association of Occupational Health Nurses
Solvents
• Solvents are chemicals able to dissolve other
substances.
• Mostly liquid and therefore can cross cell
membranes easily.
Copyright 2012 American Association of Occupational Health Nurses
Examples of Solvents
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Benzene
Carbon disulfide
Ethylene oxide
Formaldehyde
n-Hexane
Methylene Chloride
Toluene
Tricholoroethylene
Metabolite Dichloracetylene
Tricholoroethylene
Copyright 2012 American Association of Occupational Health Nurses
Pesticides
Pesticides made
to destroy pests but may have potentially
harmful effects on humans
Copyright 2012 American Association of Occupational Health Nurses
Asphyxiants
• Asphyxiants are substances that deprive the
tissue of oxygen, they are inhaled. Chemical
asphyxiants interfere with the body's ability to
transport or use oxygen. 2 examples below:
– Carbon monoxide
– Hydrogen Cyanide
Copyright 2012 American Association of Occupational Health Nurses
Regulatory Agencies
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EPA
DOT
USDA
FDA
DOE
DOD
OSHA
Copyright 2012 American Association of Occupational Health Nurses
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NIOSH
DHHS
CDC
National Center for
Environmental Health,
Agency for Toxic
Substance and Disease
Registry
Bibliography
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•
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•
•
•
•
•
•
http://en.wikipedia.org/wiki/Environmental_health December 17,2012
http://www.radford.edu/~wkovarik/envhist/womens.movement.html
Women in Environmental Timeline December 17, 2012
Rogers, B., Randolph, S., Mastroianni, K., (2009) Occupational Health
Nursing Guidelines for Primary Clinical Conditions, 4th Edition, Beverly
Farms, Massachusetts. OEM Press
Salazar, M. (2011). Core Curriculum for Occupational & Environmental
Health Nursing, 3rd edition. Pensacola, FL: AAOHN
www.epa.gov
www.osha.gov
www.cdc.gov
www.cdc.gov/niosh
Copyright 2012 American Association of Occupational Health Nurses
Emergency Preparedness
for the OHN
Kerri L. Rupe ARNP, FNP-C, COHN-S, DNP, FAANP
Copyright 2012 American Association of Occupational Health Nurses
Objectives
• Discuss the need for emergency preparedness
in the OHN setting
• Describe both internal and external disaster
preparation and planning for the OHN
• Review the AAOHN Position Statement
outlining the role of the OHN in All-Hazard
Preparedness.
Copyright 2012 American Association of Occupational Health Nurses
Content Outline
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Definitions of emergencies, disaster, and acts of terrorism.
Planning for the Unexpected
– Risk
– Resources
– Coordination of efforts
AAOHN Position Statement of the OHN’s Role in All-Hazard Preparedness
– Risk Assessment
• Internal
• External
– Resource Inventory
• Internal
• Community
– Coordination of Effort
– All-Hazard Plan Development and Preparedness
Copyright 2012 American Association of Occupational Health Nurses
Why is disaster planning so
important in Occupational Health?
Multiple levels of impact
– September 11, 2001
– Hurricanes Katrina and Sandy
– Mass Shootings at Sandy Hook Elementary
School and Aurora Colorado Theater
– BP oil rig disaster along US Gulf coast
Copyright 2012 American Association of Occupational Health Nurses
Emergency
Emergency Definition –
Sudden, unexpected, or impending situation
that may cause injury, loss of life, damage to the
property, and/or interference with the normal
activities of a person or firm and which,
therefore, requires immediate attention and
remedial action. (Webster, 2012)
Copyright 2012 American Association of Occupational Health Nurses
Disaster
Disaster Definition –
An occurrence that has resulted in
property damage, deaths, and/or
injuries to a community (FEMA, 1990)
Copyright 2012 American Association of Occupational Health Nurses
Acts of Terrorism
Acts of Terrorism Definition –
The unlawful use of force against persons or
property to intimidate or coerce a government,
the civilian population, or any segment thereof,
in the furtherance of political or social
objectives . (Code of Federal Regulations, 2001)
Copyright 2012 American Association of Occupational Health Nurses
Internal and External Disaster Plan
a. Ongoing and evolving as more information
becomes available
b. Multidisciplinary
c. Interacts with local, community, regional and
national efforts
Copyright 2012 American Association of Occupational Health Nurses
AAOHN ‘s Position Statement
The Occupational Health Nurse’s Role in
All-Hazard Preparedness (AAOHN, 2004)
AAOHN states :
“Work and community environments will be
healthy and safe”. (p.1)
Copyright 2012 American Association of Occupational Health Nurses
The Occupational Health Nurse’s
Role in All-Hazard Preparedness
OHN has a role in addressing hazardous situations
• Review and expand current work-place emergency response plans to include allhazards
• Participate in the assessment of potential hazards in the community surrounding
the workplace and prepare a plan to address the larger community response to
an event.
• Clear definition of roles and responsibilities will be made proactively within the
larger community context.
• During the event the OHN will work collaboratively to identify, manage and
evaluate the emergency response.
• The OHN will actively participate in the identification and management of the
delayed reactions to hazardous events to aid the workers to overcome trauma
and resume productive lives.
• Improve future response
Copyright 2012 American Association of Occupational Health Nurses
References
• American Association of Occupational Health Nursing. (2004).
Position Statement: The
• Occupational Health Nurse’s Role in All-Hazard Preparedness
• American Association of Occupational Health Nursing. (2012).
Standards of Occupational & Environmental Health Nursing.
• Rogers, B. (2003). Occupational and Environmental Health
Nursing: Concepts and Practice. 2nd edition. Philadelphia: Pa.
Elsevier Science.
• Salazar, M. (2011). Core Curriculum for Occupational &
Environmental Health Nursing, 3rd edition. Pensacola,
Fl:AAOHN.
Copyright 2012 American Association of Occupational Health Nurses
Questions??
Break
Copyright 2012 American Association of Occupational Health Nurses
Nursing Research and
Evidenced-Based
Practice for the OHN
Kerri L. Rupe ARNP, FNP-C, COHN-S, DNP, FAANP
Copyright 2012 American Association of Occupational Health Nurses
Objectives
• Describe nursing research and its’ use in the
OHN setting
• Discuss evidenced-based practice for the OHN
• Review the AAOHN and National Occupational
Research Agenda (NORA)
Copyright 2012 American Association of Occupational Health Nurses
Content Overview
• Nursing research basics for the OHN
• Utilization of evidence-based practice
guidelines in occupational health
• Identification future research needs in
occupational health
Copyright 2012 American Association of Occupational Health Nurses
Why is nursing research in
occupational health important?
Research seeks to support and expand the
knowledge base needed to practice
– Improve worker outcomes
– Improve working conditions
Copyright 2012 American Association of Occupational Health Nurses
Standards of Practice of Occupational &
Environmental Health Nursing (AAOHN, 2012)
States “the foundation for occupational and environmental
health nursing is research-based”. (p. 1)
– Standard X. Research
• The OHN uses research findings in practice
• Contributes to the scientific base in occupational health nursing to improve practice
• Advance the profession as a whole
– Criteria
• Practice reflects the integration of currently validated research findings
• Research activities are participated in at levels appropriate to the individual’s education and
experience
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Identifying researchable problems
Preparing proposals for support of research projects
Participating in data collection
Protecting the rights of research participants
Critically reviewing and evaluating reported research
Using research findings in the development of policies, procedures and practice guidelines
Sharing research findings and activities
Collaborating with other disciplines in the development of research studies and the dissemination
of research findings
Copyright 2012 American Association of Occupational Health Nurses
Competencies in Occupational Health and
Environmental Health Nursing (AAOHN, 2007)
Category 8: Research
• Competent
• Proficient
• Expert
Copyright 2012 American Association of Occupational Health Nurses
History of Nursing Research
Florence Nightingale
• Provided care to soldiers during the Crimean War in
1884
• Found the environments of the hospitals to be filthy
• Organized recordkeeping system for mortality and
morbidity of soldiers in her care
• Instituted sanitary reforms
• Within months after reforms instituted mortality
dropped by 60%
Copyright 2012 American Association of Occupational Health Nurses
Scientific inquiry
• Identifying current issues and problems needing
answers in the clinical setting
• Deriving solutions to these issues and problems
utilizing a scientific process of inquiry
• Establishing a Research Agenda for Occupational
and Environmental Health Nursing
Copyright 2012 American Association of Occupational Health Nurses
AAOHN Nursing Research
Priorities
• AAOHN funded a study to establish nursing research priorities within
the profession
• 12 priorities emerged:
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Effectiveness of primary health care delivery at the worksite
Effectiveness of health promotion nursing intervention strategies.
Methods for handling complex ethical issues related to occupational health.
Strategies to minimize work-related health outcomes (e.g. respiratory diseases)
Health effects resulting from chemical exposures at the workplace
Occupational hazards of health-care workers (e.g. latex allergies, bloodborne pathogens).
Factors influencing workers’ rehabilitation and return to work,
Effectiveness of ergonomic strategies to reduce worker injury and illness.
Effectiveness of case management approaches to in occupational illness/injury.
Evaluation of critical pathways to effectively improve worker health and safety and enhance
maximum recovery and safe return to work.
– Effects of shift work on worker health and safety.
– Strategies for increasing compliance with motivating workers to use personal protective
equipment.
Copyright 2012 American Association of Occupational Health Nurses
National Occupational Research
Agenda (NORA-NIOSH, 1996)
• Developed by NIOSH with over 500
people/agencies contributing
• 21 research priorities identified in 3 broad
categories:
• Disease and Injury
• Work Environment and Workforce
• Research Tools and Approaches
Copyright 2012 American Association of Occupational Health Nurses
NORA - Disease and Injury
• Allergic and irritant dermatitis
• Asthma and COPD
• Fertility and Pregnancy Abnormalities
• Hearing Loss
• Infectious Disease
• Low Back disorders
• Musculoskeletal Disorders of the Upper
Extremities
• Traumatic Injuries
Copyright 2012 American Association of Occupational Health Nurses
NORA - Work Environment and
Workforce
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Emerging Technologies
Indoor Environment
Mixed Exposures
Organization of Work
Special Populations at Risk
Copyright 2012 American Association of Occupational Health Nurses
NORA - Research Tools and
Approaches
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Cancer Research Methods
Control Technology and Personal Protective Equipment
Exposure Assessment Methods
Intervention Effectiveness Research
Risk Assessment Methods
Social and Economic Consequences of Workplace
Injuries and Illness
• Surveillance Research Methods
Copyright 2012 American Association of Occupational Health Nurses
Evidenced-Based Practice
• Utilizing the best and most current evidence in making decisions about
healthcare delivery for clients incorporates each of the following:
• Systematic search for and critical appraisal of the most relevant
evidence to answer a clinical question
• Clinical expertise
• Client values and preferences
• Provides for professional accountability
• Failure to follow established clinical guidelines without reason
• Third party reimbursement increased for following best practice
guidelines
• Improves patient outcomes by 25-30%
Copyright 2012 American Association of Occupational Health Nurses
Evidenced-Based Practice
Five steps of EBP
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Clinical question
Collecting best and relevant evidence available
Critically appraising the evidence
Integrate evidence with clinical judgment, client
preferences and values and make practice decision
• Evaluate the decision or change
Copyright 2012 American Association of Occupational Health Nurses
References
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American Association of Occupational Health Nursing. (2007). Competencies in
Occupational and Environmental Health Nursing. AAOHN Journal. 55(11).442-447.
American Association of Occupational Health Nursing. (2012). Standards of
Occupational &Environmental Health Nursing.
Melnyk, B.M., & Fineout-Overholt, E., (2005). Evidenced-Based Practice in Nursing
and Healthcare: A Guide to Best Practice. Philadelphia, Pa. Lippincott Williams &
Wilkins
McCauley, L. (2012). Research to Practice in Occupational Health Nursing.
Workplace Health and Safety. 60(4). 183-189.
Rogers, B. (2003). Occupational and Environmental Health Nursing: Concepts and
Practice. 2nd edition. Philadelphia: Pa. Elsevier Science.
Salazar, M. (2011). Core Curriculum for Occupational & Environmental Health
Nursing, 3rd edition. Pensacola, Fl:AAOHN.
Copyright 2012 American Association of Occupational Health Nurses
Questions??
Adjourn
Copyright 2012 American Association of Occupational Health Nurses
Health Promotions and
Different Medical Models
–What is in our Horizon?
Barb Maxwell RN, MHA, COHN-S, CCM, CWCP, QRP,
FAAOHN
Copyright 2012 American Association of Occupational Health Nurses
Objectives
• List 3 new proactive strategies to enhance the
different medical models that are presented today to
organizations.
• Describe Healthy People 2020 and why it is
important to the OHN
• Describe the goals and objectives one needs to
implement a safety program within their respective
workplace
• Discuss two wellness models
Copyright 2012 American Association of Occupational Health Nurses
Current initiatives
• Prevention – we are responsible – just ask
AAOHN 
• Development of strategies for behavioral
change
• Hold Employees accountable
• Look at costs and productivity
• Comprehensive health program
• EAP
Copyright 2012 American Association of Occupational Health Nurses
Health and Safety Programs
Include
• Programs that Affect Worker Health and
Productivity
• Health Promotion
• Screening Programs
Copyright 2012 American Association of Occupational Health Nurses
Changes for the OHN
• Changes in our economy
• Factors affecting national and global
competiveness
• Global market – growing
• Major Business Issues
• Health Care Reform
• Managed Care
Copyright 2012 American Association of Occupational Health Nurses
Health Models
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Health Belief
Health Promotion
Health Promotion Planning
Health Promotion Behavior
Harm Reduction
Copyright 2012 American Association of Occupational Health Nurses
Health Belief Model
• Perceived susceptibility – is for one’s
subjective estimation regarding their own
personal risk of developing health problems.
• Perceived severity – own judgment of how
serious the health condition is.
Perceived susceptibility + Perceived severity =
Perceived threat
Copyright 2012 American Association of Occupational Health Nurses
Health Promotion
• Increasing the level of well-being and selfactualization.
• Must be an integral part of the individual’s
llifestyle.
Copyright 2012 American Association of Occupational Health Nurses
Health Promotion Planning
Help plan and evaluate health promotion
activities.
– Example: Behavior lifestyle and environmental
Copyright 2012 American Association of Occupational Health Nurses
Health Promotion Behavior
• Optimal health represents a balance between
physical, emotional, social, spiritual and
intellectual health.
• Targeted 3 different levels:
– Awareness
– Lifestyle and behavior changes
– Supportive environments
Copyright 2012 American Association of Occupational Health Nurses
Harm Reduction
• Health risks can be decreased by behavior
changes and well informed consents on the
behalf of the individual.
Copyright 2012 American Association of Occupational Health Nurses
Levels of Prevention
• Primary
• Secondary
• Tertiary
Copyright 2012 American Association of Occupational Health Nurses
Components of Prevention/Wellness
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Physical
Mental
Emotional
Psycho-Social
Copyright 2012 American Association of Occupational Health Nurses
Prevention Programs Levels
• Basic
– Educational
• Moderate
– Education & Monitoring
• Complex
– Education, Monitoring, & Intervention
Copyright 2012 American Association of Occupational Health Nurses
Basic Level Program
• Education
– Group Instruction
– Individual Counseling
– Health & Safety Alerts
– Newsletters
– Fliers/Pamphlets
Copyright 2012 American Association of Occupational Health Nurses
Moderate Level Program
• Educational (As in Basic)
• Monitoring
– Vital Signs
– Weight
– Body Mass Index
– Fitness (aerobic capacity, strength, endurance,
flexibility)
– Blood Sugar & Cholesterol
Copyright 2012 American Association of Occupational Health Nurses
Complex Level Program
• Educational (As in Basic)
• Monitoring (As in Moderate)
• Intervention
– Implement exercise or nutrition program
– Immunizations
– More complex testing
• Audio, vision, PFT, etc.
Copyright 2012 American Association of Occupational Health Nurses
Identify Needs
• Needs of all involved must be addresses
– Management
– Employees
– Labor Unions
Copyright 2012 American Association of Occupational Health Nurses
Program Task Force
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Representation from all involved.
Identifies needs.
Develops plan of action.
Take information back to their respective
peers.
• Assist in implementation.
Copyright 2012 American Association of Occupational Health Nurses
Benefits
Management
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Safety
Decreased lost work days/overtime costs
Decreased medical expenses
Improved morale
Cost Containment
Increased productivity
Copyright 2012 American Association of Occupational Health Nurses
Benefits
Employees
– Heightened job performance & enjoyment from
work.
– Improved performance in physical activities.
– Reduction of anxiety, stress, tension, &
depression.
– Enhanced self-esteem.
– More restful & refreshing sleep.
Copyright 2012 American Association of Occupational Health Nurses
Benefits
Labor Unions
– Program is educational, non-punitive.
– Program will help members perform their
duties.
– Program will allow members to enjoy the
fruits of their labor when they retire.
Copyright 2012 American Association of Occupational Health Nurses
What is Healthy People 2020?
• Provides science-based, 10-year national objectives for
improving the health of all Americans.
• For 3 decades, Healthy People has established benchmarks
and monitored progress over time in order to:
– Encourage collaborations across communities and sectors.
– Empower individuals toward making informed health
decisions.
– Measure the impact of prevention activities.
Copyright 2012 American Association of Occupational Health Nurses
Healthy People 2020
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Access to Health Services
Healthy Aging
Adolescent Health
Chronic Health Conditions
Health Communication – and technology
Global Health
OSHA
And lots more………
Copyright 2012 American Association of Occupational Health Nurses
Why is Healthy People 2020
important?
Directly related to health promotion activities
and the goals associated with:
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increasing physical exercise
obesity and weight loss
tobacco use
substance use
mental health
injury
violence
immunizations
Copyright 2012 American Association of Occupational Health Nurses
Why is this important to the OHN?
• We have to promote, educate and be there for
the working force
• Health People 2020 is the “blue print” every
regulatory body will access
• Read the document and start a strategic plan
on how “you and your team are going to get
there”
• Be proactive and not reactive
Copyright 2012 American Association of Occupational Health Nurses
Health Models
• On site OHN
• On site Clinics
• Near site Clinics
• Out sourcing to independent providers
Copyright 2012 American Association of Occupational Health Nurses
What is Next?
• We need to become full members of the healthcare team
• Base of Baccalaureate education for professional practice:
– leadership content, knowledge of the care delivery system, teamwork collaboration
within and across disciplines and settings, client advocacy skills, practicing within an
ethical framework, theories of innovation and foundation for quality and client safety.
• Promoting of Nursing organizations to play a critical role in
health policy and mentoring role to develop nursing
leadership skills
• Coordination among multiple professional organizations with
the goal of identifying a shared agenda
• Need to be politically active
• Business savvy
Copyright 2012 American Association of Occupational Health Nurses
Bibliography
• Health Care Advisory Board: Hardwiring for Service Excellence, 2007
• Daly-Gawenda, Hudson, Perea: Occupational Health Nursing Care
Guidelines, Berger, S. Fundamentals of Healthcare Financial
Management. (2nd Edition). San Francisco, CA.: Jossey-Bass, 2002
• Rogers, B. Occupational and Environmental Health Nursing, Concepts
and Practice. (2nd Edition). Philadelphia, PA.: Saunders, 2003
• Wolper, L. Health Care Administration – Planning, Implementing and
Managing Organized Delivery Systems. (3rd Edition). Gaithersburg, MD.:
Aspen, 1999
• http://www.sixsigmabenchmarking.com/
• Studor Group. “Taking you and your organization to the next level.”
January 15-16, 2002.
Copyright 2012 American Association of Occupational Health Nurses
Business Components for
the OHN to Utilize in the
Workplace
Barb Maxwell RN, MHA, COHN-S, CCM, CWCP, QRP,
FAAOHN
Copyright 2012 American Association of Occupational Health Nurses
Objectives
• Describe 3 “new” added value services the OHN can
demonstrate to their employer
• List 2 future options the OHN can use in their
workplace to enhance their professional
relationships with others
• Name 2 “tips” and “tricks” the OHN can use to
enhance their role
• Discuss data to collect and how to do a ROI
Copyright 2012 American Association of Occupational Health Nurses
Opening statement
Uncertainty impacts all of us during “trying times”. While there
are no easy answers, there are definite ways you can “think out if
the box” to preserve your role in the workplace. In today’s
economy it is critical for the OHN to be maintained in the
workplace. Your role can become stronger and indispensable.
You can move from just “surviving” the economic dilemma to
preparing your organization the worth you bring to your
company. This can be done through smart strategic planning and
what worth we bring to any organization.
Copyright 2012 American Association of Occupational Health Nurses
“New” Added Value Services
“Thinking out of the Box” can bring more added
services for the OHN to offer their employer:
• Knowledge of other specialties acronyms –
Financial, Strategic Planning, Budgeting
• Build new “skill sets”
• “Beneficial” effects the OHN brings
Copyright 2012 American Association of Occupational Health Nurses
Other Duties as Assigned:
New Terminology
• The OHN must be knowledgeable regarding a new
language – called finance.
• We must be business savvy to compete within our
own corporations.
• Presentation style is an art!
• Communication skills are a must.
• We are perceived as Leaders within our corporations
– and if we aren’t – we have to get there!!!
Copyright 2012 American Association of Occupational Health Nurses
Benchmarking
• Compare BDP of your Corporation – Nationally and
Locally
• Look at specific programs or services and compare to
others
• Create trending reports
• DOR
• Perform cost analysis – P&L
• Perform SWOT
• Document, Document, Document
• Be the Leader……
Copyright 2012 American Association of Occupational Health Nurses
Strategic Planning and How to
Implement
Assessment data
– Worker population and Environmental
Assessment tools to be used
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Questionnaires
HRA
Walk-through reports
WC
Case Management reports
OSHA records/logs
Copyright 2012 American Association of Occupational Health Nurses
Program Planning
• Personnel
• Financial resources
• Equipment
• Supplies
• Facilities and Space
Copyright 2012 American Association of Occupational Health Nurses
Performing a Strategic Meeting
• Bring all respective parties involved
together
• No cell phones or pagers
• Safe environment
• Brain Storm
• Lunch and Snacks
Copyright 2012 American Association of Occupational Health Nurses
Program Implementation
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Monitor activities
Personnel
Educational Processes
Management Support
Timetables
Progress to be monitored
Copyright 2012 American Association of Occupational Health Nurses
Program Evaluation
• Identify and improve services, processes, and
personnel
• Chart audits
• Concurrent reviews
• Interviews
Copyright 2012 American Association of Occupational Health Nurses
Beneficial Effects of the OHN
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Marketable
Leadership skill set
Communication
Recognize success
ROI
Copyright 2012 American Association of Occupational Health Nurses
Beneficial Effects of the OHN
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Disease Management
Environmental Health
Emergency Preparedness/Disaster planning
Employee Treatment/Follow up and Referrals
Emergency Care for job-related injuries and
illnesses
• Gatekeeper for Healthcare Services
• Rehabilitation/Return-to-Work issues
Copyright 2012 American Association of Occupational Health Nurses
Future Options
• Future options can be derived for the OHN
through “networking” with other respective
professionals
• Learn new “skill sets”
• Enhance professional relationships with others
Copyright 2012 American Association of Occupational Health Nurses
Future Options Continued
• Marketing
• Business Building
• Financial Knowledge
Copyright 2012 American Association of Occupational Health Nurses
Marketing
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Credibility
Communication
Time saving
Big picture
First impression
Copyright 2012 American Association of Occupational Health Nurses
Business Building
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Business savvy
“Talk the Talk”
Understand the “bottom line”
Create meaningful projects
Create shared leadership roles
Consultant
Copyright 2012 American Association of Occupational Health Nurses
Financial Knowledge
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Understand service volumes
Understand expenses and costs
Understand revenue
The Budget cycle
DOR Analysis
Global measures of success
Accounting policy guidelines
Copyright 2012 American Association of Occupational Health Nurses
Cost Classifications
Costs are classified according to:
– Traceability
– Variability
– Controllability
– Time period in which they are examined
Copyright 2012 American Association of Occupational Health Nurses
Understanding Service Volumes
Analysis of Service Delivery Volumes:
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Actual as reported (current month and YTD)
Budgeted
Historical (1 year prior)
Comparative data from other facilities
Copyright 2012 American Association of Occupational Health Nurses
How Service Volumes are
Measured
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Number of patients seen
Number of procedures performed
Number of service interactions completed
Which are called……….stats, encounters,
industrials, etc.
Copyright 2012 American Association of Occupational Health Nurses
Units of Service (UOS)
• Clinics: Visits, procedures
• Physical Therapy : ¼ hour increments (15 minutes
sessions)
• Dietary: equivalent meals
• ED: # of visits
• Hospitals: MHAA (man hours per adjusted
admission) This includes inpatient as well as out
patient combined
Copyright 2012 American Association of Occupational Health Nurses
Understanding Expenses & Costs
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Fixed costs
Variable costs
Semi-variable
Combined – variable and semi-variable
Copyright 2012 American Association of Occupational Health Nurses
Labor Expense (SWB)
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Salaries
Wages
Benefits
OHN’s will see this information on first notice
of injury
– Productive hours
– Non-productive hours
– Paid hours
Copyright 2012 American Association of Occupational Health Nurses
Understanding Revenue
• Gross Revenue = Charges
• Gross Revenue – Departmental Operating
Expenses = Gross Profit
• Another key point:
• Gross profit does not equal Net Revenue
Copyright 2012 American Association of Occupational Health Nurses
The Budget Cycle
• Present strategic initiatives
• Project the balance of the year
• DOR Analysis
Copyright 2012 American Association of Occupational Health Nurses
Global Measures of Success
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Outpatient Factor = gross patient revenue
APD = Adjusted Patient Days
AA = Adjusted Admissions
ADC = Adjusted Daily Census
MHAA = Man Hours per Adjusted Admission
Copyright 2012 American Association of Occupational Health Nurses
Accounting Policy Guides
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APG Review
Accounting Policy Guides
Company Policies for accounting standards
Heightened integrity for financial information
Contains:
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Fixed assets (capital $$’s)
Leases
Inventory
Inter-company
Copyright 2012 American Association of Occupational Health Nurses
ICD – 10
• It seems there are many changes taking place and the ICD-10
is one of many.
• It should not be scary and the changes will not be as bad as
some may say
• International Classification of Diseases, 10th Revision, Clinical
Module (ICD-10-CM) becomes effective in 2013.
• ICD-10-CM is a huge change for diagnosis coding. We have to
prepare for this change so that we don’t fail the providers
who depend on this for their practice success.
Copyright 2012 American Association of Occupational Health Nurses
“Tips and Tricks”
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Success Cards – Score Cards
Teamwork
Communication
Integrity
Innovation
Customer Service
Copyright 2012 American Association of Occupational Health Nurses
Teamwork
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Set clear goals
Clarity of responsibility
Decision making includes entire team
Open communication
Build trust
Empower
Give + feedback
Copyright 2012 American Association of Occupational Health Nurses
Communication
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#1 Priority
Use honest discussion
Ask forthright questions
Ask for clarification
Communicate directly with person
Say “Thank You”
Smile
Copyright 2012 American Association of Occupational Health Nurses
Integrity
• Honest
• Ethical/Moral
• Credentialed
• Unimpaired/Soundness
• Whole/Undivided
• Completeness
Copyright 2012 American Association of Occupational Health Nurses
Innovation
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“High-five” all ideas
Focus on all customers
Willingness to fail
Know when to be stubborn and when to be
flexible
– Stubborn with vision
– Flexible with tactics
Copyright 2012 American Association of Occupational Health Nurses
Customer Service
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Don’t criticize or complain
Give honest, sincere appreciation
Arouse in others an “eager want”
Be interested
Smile
Remember names
Good listener
Make others feel important
Copyright 2012 American Association of Occupational Health Nurses
Change creates FEAR
• The OHN needs to be ready for change and
think “out of the box”
• Along with change comes FEAR
• Not knowing the “unknown”
• What are the expectations?
Copyright 2012 American Association of Occupational Health Nurses
Alleviate Fears
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People in change experience the following fears:
Failure
Invisibility
Chaos
Losing power
Support failure
Going unrewarded
Copyright 2012 American Association of Occupational Health Nurses
Greater Benefits for Lesser Costs
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On-site Case Management
Ergonomic site assessments
Drug Screens
Flu vaccines
Immunization program
Wellness
Stay away from Quality, Popularity of Services verbiage
“Talk the Talk” like CFO’s
Stay with hard numbers
Copyright 2012 American Association of Occupational Health Nurses
Bibliography
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•
•
www.dol.gov
www.nachc.org
www.standupforhealthcare.org
Loher, Jim: The Power of Story, 2007
Newkirk, William L. M.D., Editor: Occupational Health Services – Practical Strategies for Improving Quality and
Controlling Costs
Health Care Advisory Board: Hardwiring for Service Excellence, 2007
Nelson, David: Get Over It!, 2001
Daly-Gawenda, Hudson, Perea: Occupational Health Nursing Care Guidelines,
Berger, S. Fundamentals of Healthcare Financial Management. (2nd Edition). San Francisco, CA.: Jossey-Bass, 2002
Kongstvedt, P. Essentials of Managed Health Care. (2nd Edition). Gaithersburg, MD.: Aspen, 1997
Rogers, B. Occupational and Environmental Health Nursing, Concepts and Practice. (2nd Edition). Philadelphia, PA.:
Saunders, 2003
Wolper, L. Health Care Administration – Planning, Implementing and Managing Organized Delivery Systems. (3rd
Edition). Gaithersburg, MD.: Aspen, 1999
http://www.sixsigmabenchmarking.com/
http://www.reportcenter.com/reportcenter-su.html
http://www.acpa.nche.edu/corcouns/PI/bestpracticescriteria/html
Nursing Spectrum, July 12, 2004, “Gearing Up for a Management Position.”
Studor Group. “Taking you and your organization to the next level.” January 15-16, 2002.
Copyright 2012 American Association of Occupational Health Nurses
Questions??
Break
Copyright 2012 American Association of Occupational Health Nurses
Essentials of
Exceptional
Leadership Skills
Barb Maxwell RN, MHA, COHN-S, CCM, CWCP, QRP,
FAAOHN
Copyright 2012 American Association of Occupational Health Nurses
Objectives
• Identify the difference between Leadership
and Management
• Define 3 Leadership approaches and styles
• Define Emotional Intelligence and name the
different components
• Identify 2 behavioral and personality types for
Leaders and Managers
Copyright 2012 American Association of Occupational Health Nurses
Opening Statement
Leaders and Managers are not born into their
roles; they are developed. In today’s work
environment it is very challenging to be in a
management position, facing the on-going
changes people face every day. Leadership style
impacts others within the organization and can
attribute to turn-over rates – good and bad –
personnel morale, and even the evolution of
“grooming” others to become leaders.
Copyright 2012 American Association of Occupational Health Nurses
A Perspective of Leadership
Traditional definition:
– “Leadership is creating, and influencing others to contribute to a
shared set of goals.”
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Not just use of power, coercion or mandating
Not just exercise of positional authority
Some Additions
Leadership is all about taking ownership
Leadership is a journey – not a destination
Requires a commitment to continued learning and
development
Copyright 2012 American Association of Occupational Health Nurses
Leadership Approaches
• Various Leadership approaches are used in
business and industry:
• Tactical
• Transactional
• Collaborative
• Transformational
• Servant
Copyright 2012 American Association of Occupational Health Nurses
Is there a difference between
Leadership and Management?
“Management is doing things right;
Leadership is doing the right things”
Copyright 2012 American Association of Occupational Health Nurses
Difference between Leadership
and Management
• Leadership
– Sets a direction
– Aligns people
– Role Model
• Management
– Plans and Budgets
– Organizes and Staffs
– Day-to-Day
Copyright 2012 American Association of Occupational Health Nurses
Leadership vs. Management
• Both involve:
– Deciding what needs to be done.
– Creating networks of people and relationships to
accomplish an agenda.
– Ensuring that people actually get the work done.
• Both are necessary for success.
• Management and Leadership, however accomplish
their work in very different ways.
Copyright 2012 American Association of Occupational Health Nurses
Leadership vs. Management
Directors and Supervisors:
– Translate the vision into operational action, set direction,
and monitor results.
– Storytellers and keepers of the organizational culture.
– Mentors and develop others.
– Take risks and challenges the status quo.
– Tackle underlying problems – step back to see the big
picture – resist solving the problem.
– Possess an ability to work with and through others.
Copyright 2012 American Association of Occupational Health Nurses
Sets a Direction
• Gather data; look for patterns, trends, to help
explain things
• Ensures vision becomes operational action
• Creates strategies for change needed to
achieve that vision
Copyright 2012 American Association of Occupational Health Nurses
Leaders – Aligns People
• Communicates the new direction to create coalitions
that understand the vision and are committed to its
achievement
– Talk with people both inside and outside the
organization
– Find the right fit between people and the vision
Copyright 2012 American Association of Occupational Health Nurses
Managers – Plans and Budgets
• Sets goals for the future
• Establish steps to achieve goals
• Allocate resources to accomplish goals
Copyright 2012 American Association of Occupational Health Nurses
Managers – Organizes and Staffs
• Establish an organizational structure that
facilitates implementation of plans as
efficiently as possible:
• Have the right people in the right jobs
• Communicate plans to workforce
• Delegate responsibility
• Develop system/process to monitor
implementation
Copyright 2012 American Association of Occupational Health Nurses
The Powerful Four
• Eisenhower/Veterans/Traditionalists/Silent
– 1922-1945
• Baby Boomers
– 1946-1964
• Generation X’ers
– 1965-1980
• Generation Y’ers
– 1981 - present
Copyright 2012 American Association of Occupational Health Nurses
Strategic Planning
• Vision
• Mission
• Strategic plans address the following:
– Assessing internal/external
– Identify SWOT
– Indentify strategies
– Implement
– Evaluate
Copyright 2012 American Association of Occupational Health Nurses
Crucibles
• Crucibles are key opportunities to develop
leadership but only help us do so if we take
the time to reflect and learn from them.
– Warren Bennis & Robert Thomas, Geeks and
Geezers
Copyright 2012 American Association of Occupational Health Nurses
Leadership Crucible
• Leadership Crucible: Concentrated forces interact to cause or
influence change - “A major life event from which you learned
lessons that will shape your leadership behavior in the
future”.
• Examples:
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Coping with the death of a loved one
Losing a job
Overcoming a big adversity
Taking action in an emergency
Not taking action in an emergency
Copyright 2012 American Association of Occupational Health Nurses
Emotional Intelligence (EI)
• EI is the ability to manage yourself and your
relationships effectively.
• Consists of 5 components:
– Self Awareness
– Self Management
– Motivation
– Empathy
– Social Skill
Copyright 2012 American Association of Occupational Health Nurses
Leadership Styles
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Coercive
Authoritative
Affiliative
Democratic
Pacesetting
Coaching
Copyright 2012 American Association of Occupational Health Nurses
Coercive
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Demands immediate compliance
Style in a phrase: “Do what I tell you”
EI – Drive to achieve, initiative, self-control
Style works best – crisis, kick start a
turnaround, or with problem employees
• Overall impact – Negative
Copyright 2012 American Association of Occupational Health Nurses
Authoritative
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Mobilizes people toward a vision
Style in a phrase: “Come with me”
EI – Self confidence, empathy, change catalyst
Style works best – when change require a new
vision or clear direction
• Overall impact – Most strongly positive
Copyright 2012 American Association of Occupational Health Nurses
Affiliative
• Create emotional bonds and build consensus
• Style in a phrase: “People come first”
• EI – Empathy, building relationships,
communication
• Style works best – heal rifts in a team or to
motivate people during stressful times
• Overall impact – Positive
Copyright 2012 American Association of Occupational Health Nurses
Democratic
• Forges consensus through participation
• Style in a phrase: “What do you think”
• EI – Collaboration, team leadership,
communication
• Style works best – build buy-in, get input from
valuable employees
• Overall impact – Positive
Copyright 2012 American Association of Occupational Health Nurses
Pacesetting
• Sets high standards for performance
• Style in a phrase: “Do as I do, now”
• EI – Conscientiousness, drive to achieve,
initiative
• Style works best – obtain quick results from a
highly motivated and competent team
• Overall impact – Negative
Copyright 2012 American Association of Occupational Health Nurses
Coaching
• Develops people for the future
• Style in a phrase: “Try this”
• EI – Developing others, empathy, selfawareness
• Style works best – to help and improve
employee performance or develop long-term
strengths
• Overall impact – Positive
Copyright 2012 American Association of Occupational Health Nurses
Leadership traits and Personalities
• Dominance – ability to take charge
• High Energy – drive, tolerate stress, and have
enthusiasm
• Self-confidence – self assured in judgments,
decision making, and ideas
• Locus of Control – Control over your own
destiny
Copyright 2012 American Association of Occupational Health Nurses
Continuance of Traits and
Personalities
• Stability – emotionally in control of themselves,
secure, and positive
• Integrity – behavior that is honest, ethical, and
trustworthy
• Intelligence – cognitive ability to think clearly
• Flexibility – ability to adjust to different situations
• Sensitivity to Others – understanding the difference
between handling individuals and groups
Copyright 2012 American Association of Occupational Health Nurses
Management Process
• Management process is a sequence of steps
that enhances the operations on how leaders
exert influence.
• This is performed through Task Cycles.
Copyright 2012 American Association of Occupational Health Nurses
Task Cycles and what is involved
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Making clear and important goals
Planning and Problem Solving
Facilitating the work of others
Obtaining and providing feedback
Monitoring and adjusting the process
Reinforcing performance
Copyright 2012 American Association of Occupational Health Nurses
Making Clear and Importance Goals
• SMART
• PURE
• CLEAR
Copyright 2012 American Association of Occupational Health Nurses
Planning and Problem Solving
Many people will have an initial reaction and ask
themselves “How do I do it?”
• Steps to follow:
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Project Management
Budget
Budget Process
Decision making and ethical considerations
Copyright 2012 American Association of Occupational Health Nurses
Facilitating the Work of Others
• You may ask, “How do I carry out the plan
once it is established?”
– Mentoring
– Model
– Challenge
Copyright 2012 American Association of Occupational Health Nurses
Obtaining and Providing Feedback
Skill set for Leaders include:
• Communication
– Listening
– Negotiating
– Conflict Resolution
– Effective Writing
• Performance Management Process
– Job descriptions
– Evaluations
Copyright 2012 American Association of Occupational Health Nurses
Monitoring and Adjusting the
Process
Another question that Leaders asked is:
“How to I fix my mistakes?
How do I exercise positive control to serve the
commitments made?”
– Set Policies and Procedures
– Protocols
– Benchmarking
Copyright 2012 American Association of Occupational Health Nurses
Reinforcing Performance
It is critical to recognize employee
contributions
• Rewards and Recognition
• Basic Praise
– Personal
– Written
– Public
– Electronic
Copyright 2012 American Association of Occupational Health Nurses
Bibliography
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Accel-Team. (2004). Employee motivation, the organizational environment and productivity.
Retrieved on November 15, 2004, from
http://www.accelteam.com/humanrelations/hrels_05_herzberg.html.
Clark, D. (2000). Concept of leadership. Retrieved October 9, 2004, from
http://www.nwlink.com/donclark/leader/leadcon.html.
Bradberry, Travis and Greaves, Jean. (2009). Emotional Intelligence 2.0.
Kersten, Denise. “Today’s Generations Face New Communications Gap,”USA Today,
November 15, 2002
Sago, Brad. “Uncommon Threads: Mending the Generation Gap at Work,” Executive Update,
July 2000
Lancaster, Lynne C.; Stillman, David. When Generations Collide: Who They Are, Why They
Clash, How to Solve the Generational Puzzle at Work. HarperCollins Publishers, Inc. 2002
Karp, Hank; Fuller, Connie; Sirias, Danilo. Bridging the Boomer Xer Gap: Creating Authentic
Teams for High Performance at Work. Palo Alto, CA.: Davies-Black Publishing, 2002
Covey, S. R.. The eighth habit: From effectiveness to greatness. New York, NY: FranklinCovey
Co. 2004
Copyright 2012 American Association of Occupational Health Nurses
Questions??
Lunch on Your
Own
Copyright 2012 American Association of Occupational Health Nurses
Scientific Foundations of
Occupational and
Environmental Health Nursing
Practice
Epidemiology
Chad Rittle DNP, MPH, RN
Copyright 2012 American Association of Occupational Health Nurses
265
Objectives
• Introduction to Epidemiology
• Distinguish between incidence rate and
prevalence.
Copyright 2012 American Association of Occupational Health Nurses
266
Important Epidemiology Terms
• Distinguish between incidence rate and
prevalence.
• Strength of Association
• Relative Risk
• Odds Ratio
• Attributable Risk
• Inferential Statistics
• Confidence Interval
• Power of a Study
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267
Content Overview
• Community health nursing, epidemiology and toxicology play key roles in
OHN.
• Incidence rate is an epidemiological term that describes the occurrence of
new disease or injury per unit of time among persons at risk.
• Prevalence is an epidemiological term that describes the proportion of the
population with the condition at a given point in time in a given period.
– NOTE: The majority of the information for this section was developed using information
extracted from Chapter 5 of the Third Edition of “Core Curriculum for Occupational &
Environmental Health Nursing.
– Salazar, M. (2011). Core Curriculum for Occupational & Environmental Health Nursing,
3rd edition. Pensacola, Fl:AAOHN.
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268
Reference Sources
Additional detail for this presentation may be found
at:
• Gordis, L. (2000). Epidemiology, 2nd edition.
Philadelphia: Saunders.
• Salazar, M. (2011). Core Curriculum for Occupational
& Environmental Health Nursing, 3rd edition.
Pensacola, Fl:AAOHN.
Copyright 2012 American Association of Occupational Health Nurses
269
Occupational Health Nursing
• Current approaches to occupational and
environmental health nursing can be viewed
according to a model of public health
developed by the Section of Public Healh
Nursing of the Minnesota Department of
Health (Keller et al., 2004).
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Wheel of Public Health Interventions
Wheel of Public Health Interventions:
A Collection of “Getting Behind the
Wheel” Stories, 2000-2006. Retrieved
on December 4, 2012 from:
http://www.health.state.mn.us/divs/cf
h/ophp/resources/docs/wheelbook20
06.pdf
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271
Wheel of Public Health Interventions
Occupational and environmental health nurses perform interventions
depicted by the Intervention Wheel model. Some examples include:
– Surveillance, investigation, outreach, and screening functions at system,
community and individual levels – e.g. heavy metal screening programs and
registries
– Working with health departments, worker populations and high risk
individuals to identify cases of tuberculosis, treatment, and prevent further
spread of disease
– Teaching, counseling and consultation about the risks of agricultural hazards
– Create safe play areas for urban children are examples of collaboration,
coalition building and community organizing
– Promote and enforce employer policies to prevent transmission of workplace
hazards into the home environment: for example – clothing changes, shower
facilities, and worker training.
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272
Epidemiology – What Are We
Studying?
• Biological factors – genetic background as well as physical
and mental health status
• Behaviors – occur in response to an individual’s experiences
and may either cause biological changes or be influenced by
biology. Example – smoking (behavior) may cause lung
cancer (biology)
• Social Environment – includes interaction with others,
housing, community services, schools and places of worship.
• Physical Environment – can be the source of exposure to
harmful agents, chemicals, pathogens or physical hazards.
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Epidemiology – Other Areas
• Other factors – include policies and interventions relating to
health behaviors and health outcomes AND access to quality
care – essential for optimizing the health of all.
• Hazard – a substance capable of causing harm. Example –
asbestos
• Risk – the probability that harm will occur
• Epidemiology – The study of the distribution and
determinants of health-related states or events in specified
populations, and the application of this study to the control of
health problems
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274
Incidence Rate – A Key Term!
Incidence rate – describes the occurrence of new
disease or injury per unit of time among persons at risk
• The numerator – includes only new cases of disease during a given time
period
• The denominator – includes everyone at risk of developing disease
• Incidence rates – are useful for tracking trends in the development or
resolution of disease.
• Example: For an incidence rate per thousand people:
No. of new cases in the population during a specified period of time
No of persons at risk during that period of time
Copyright 2012 American Association of Occupational Health Nurses
X 1000
275
Prevalence
– Prevalence – describes the proportion of the population with
the condition at a given point in time or during a given time
period.
– The numerator – includes new and existing cases
– The denominator – includes all who are at risk of developing the disease, including
those who have it.
– Prevalence – measures the current burden of disease and is useful for measuring and
projecting health care and health resource needs
– Example: For a prevalence rate per thousand people:
No. of cases in the population during a specified period of time
No. of persons in the population during that period of time
Copyright 2012 American Association of Occupational Health Nurses
X 1000
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Examples of Epidemiologic Research
– Controlling infectious diseases – tuberculosis
– Controlling the effects of chemical hazards – asbestosis, mesothelioma,
lung cancers related to asbestos
– Understanding genetic susceptibility to disease, such as coronary heart
disease or cancer – often a combination of heredity and environmental
factors
– Understanding the effects of nutritional status – link between calcium
intake and osteoporosis
– Linking pathogens to specific disease processes – West Nile virus
– Identifying risk factors for illness or injury, such as work factors that lead
to back injuries in health care workers
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Why is Epidemiology Important?
– It serves as a tool for recognizing, identifying and
preventing hazardous exposures
– Findings from epidemiological studies of worker
and community populations are often reported in
the occupational and environmental health
literature
– Epidemiological studies help occupational and
environmental health nurses provide high-quality
health services.
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Measures of Association
Measures of Association – Evaluation of associations among
exposures and health outcomes is central to epidemiology.
The criteria to evaluate causality based upon observed
association includes the following:
– Strength of the association
– Consistence of the association
– Temporality of the association
– Dose-response relationship
– Plausibility of the association
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Sources of Epidemiologic Data
– Census data
– Vital statistics
– National health surveys
– NHANES – National Health and Nutrition Examination Surveys
– Mandatory reporting systems to capture data
– NEDSS – National Electronic Disease Surveillance System
– OSHA-recordable illnesses and injuries
– Disease and death registries
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Exposure Data – How Is It Collected?
Exposure data are often more difficult to obtain, especially in
environmental and occupational settings
– Air monitoring data and biomarkers of exposure
– Data can be obtained from exposure registries such as
heavy metal exposure, certain pharmaceuticals, and
needle-stick injuries
– Exposure status is sometimes estimated indirectly from
information such as occupational history, occupational
history, or location of residence
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281
Relative Risk
Relative Risk – (rate ratio) a measure of the relationship
between two incidence rates, that of the exposed and that of
the unexposed population
Example:
Relative risk = Incidence in exposed
= 28.0 = 1.61
Incidence in non-exposed
17.4
Therefore, the exposed group is 1.61 times more likely to
develop the disease.
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282
Odds Ratio
Odds Ratio – a good estimate of relative risk, but is derived from
case control or cross-sectional studies
• If the exposure is not related to the disease, the odds ratio
will equal 1
• If the exposure is positively related to the disease, the odds
ratio will be greater than 1
• If the exposure is negatively related to the disease, the odds
ratio will be less than 1
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Attributable Risk
Attributable Risk – a measure of the difference between two
rates, one for the exposed and one for the unexposed
population. It describes the increased amount of risk attributed
to the exposure.
• To look at this from the other side – How much of the risk
(incidence) or disease can we hope to prevent if we are able
to eliminate exposure to the agent in question?
• OR – what would happen to the incidence of lung cancer if
we eliminated smoking in the population?
Source for this Section 8 – Gordis, L. (2000). Epidemiology, 2nd edition.
Philadelphia: Saunders.
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Types of Rates
– Crude Rates – based on the actual number of events for a
given time period but do not reflect true differences in risk
among subgroups in the population
– Characteristic-specific rates – allow one to compare rates for
similar subgroups of two or more populations (e.g., agespecific or gender-specific rates).
– Adjusted (or standardized) rates – reflect population
differences by taking into consideration the distribution of
important characteristics that may affect the group (e.g., ageadjusted rates)
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Inferential Statistics
• Inferential Statistics – are taken from a sample of a
population, and are used to make inferences about the entire
target population.
• Hypothesis – a supposition, resulting from observation or
reflection
• A hypothesis leads to predictions that can be tested
• Hypothesis testing involves conducting a test of
statistical significance and quantifying the degree to
which sampling variability may account for the
observed results.
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Inferential Statistics – Typical Tests
– The t-test and the chi-square test are very commonly used.
– The t-test assesses whether the means of two groups are
statistically different from each other. This analysis is
appropriate whenever you want to compare the means of two
groups.
• Source: http://www.socialresearchmethods.net/kb/stat_t.php
• The chi-square test is used to determine whether there is a significant
difference between the expected frequencies and the observed
frequencies in one or more categories.
– Source: http://www.enviroliteracy.org/pdf/materials/1210.pdf
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Inferential Statistics – More Info
– p-value is a quantitative statement of the probability that the
observed difference (or association) in a particular study
could have heppend by chance along.
• p<0.05 means that the probability that the observed difference
occurred by chance is less than 5%
• p<0.05 is a frequently used level for referring to an association as
statistically significant
– Confidence interval – describes the magnitude of the effect
and the inherent variability in an estimated statistic
• 95% Probability
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Power
Power of a study – is its likelihood of detecting a real
association if one exists; power is affected by the following four
variables
•
•
•
•
The magnitude of the effect (or association) or difference
The variability of the measures of interest
The level of statistic significance selected
The size of the sample studies
– Larger sample sizes increase the stability of measurements
made in an epidemiologic study
– Power calculations based on the above variables suggest the
appropriate sample size needed for an epidemiologic study
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Study Designs
• Experimental designs – preferred for determining
causality
• Randomized clinical trials and intervention studies
• Limited by ethical constraints; that is, purposeful
exposures of study subjects are not always
appropriate
• Non-experimental designs – attempt to simulate the
results of an experiment (had one been possible).
Also known as descriptive studies or analytic (ex
post facto) studies
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Descriptive Studies
Descriptive studies – generate a hypothesis and
are not intended to determine causality
• Cross-sectional study – examines the relationship between
diseases (or other health-related characteristics) and other
variables of interest as they exist in a defined population at
one point in time
• Ecologic study – looks at the group rather than the
individual as the unit of analysis, usually because
information is not available at the individual level
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Analytic Studies
Analytic studies – the investigator systematically determines
whether the risk of, or a health-related condition is different for
exposed and non-exposed individuals
– Cohort study (also called a prospective study or longitudinal study) – an
analytic study in which persons who are initially free of the disease (or
outcome) but vary in one or more factors (such as exposure or potentially
protective factors) are followed over a period of time for the occurrence of
the disease (or outcome)
– Case-control study – a group of persons with a disease (cases) are
compared with a group without the disease (controls) to study the
characteristics (such as exposure) that might predict, cause, or protect
against the disease
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Bias and Confounding in
Epidemiological Studies
Bias refers to systematic error in an epidemiologic study that
results in an incorrect estimate of the association between
exposure and the risk of disease
• Selection bias – the identification of subjects for inclusion in the study
• Information (or observation) bias – systematic differences in the way
data on exposure or outcomes are obtained from various study groups
–
–
–
–
–
–
Information bias
Recall bias Interviewer bias
Lost to follow-up
Misclassification
Selection
Self-selection
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Types of Bias
Type of Bias
Description
Exposure and outcome data are ascertained differently from study
groups
Information
Individuals with negative outcomes are more likely to remember and
report exposure
Recall
Interviewers' prior knowledge of outcome status affects ascertainment
of exposure information in the interview
Interviewer
Lost to
Prospectively, those with negative outcomes may be lost to follow-up
Follow-up
at a greater rate than controls
Misclassifica Ascertainment of either exposure or outcome status is incorrect form
tion
some subjects
Entry into the study or control group is affected by factors related to
exposure (case-control) or outcome (cohort)
Selection
SelfIndividuals' participation is affected by their knowledge of disease or
selection
exposure status
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Confounding
Confounding – results when the estimate of the effect of the
exposure of interest is distorted because it is mixed with the
effect of an extraneous factor
• Example – age, gender, and smoking status are often important
confounding variables
– Methods to avoid/manage bias and confounding
• Strict study protocol with attention to how subjects are selected
• Systematic, standardized data collection techniques that are
consistent for all participants
• Making comparisons only among individuals with the same level of
confounding variables
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Screening
The practice of testing people who are asymptomatic to
classify them with respect to their likelihood of having a
disease
• Sensitivity – the ability of a test to correctly identify those who have a
disease
⁻ A sensitive test yields few false negatives
• Specificity – the ability of a test to correctly identify those who DO NOT
have the disease
⁻ A specific test yields few false positives
• Sensitivity and specificity do not change when the prevalence of the
disease in the population changes
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Predictive Value
Predictive value of screening tests is the ability to predict disease
status from test results
• Positive predictive value – likelihood that an individual with a positive test truly
has the disease
• Negative predictive value – likelihood that an individual with a negative test
truly does not have the disease
• Levels of predictive value change when the prevalence of disease in a
population changes
– As the prevalence of disease in a population increases, the positive
predictive value of the test will increase
– As the prevalence increases, the negative predictive value will decrease
• Examples of screenings:
– Asbestos, cadmium, cotton dust (OSHA medical surveillance)
– Breast cancer, prostate cancer, colon cancer (early detection)
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References
• Gordis, L. (2000). Epidemiology, 2nd edition.
Philadelphia: Saunders.
• Salazar, M. (2011). Core Curriculum for
Occupational & Environmental Health Nursing,
3rd edition. Pensacola, Fl:AAOHN.
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Scientific Foundations of
Occupational and Environmental
Health Nursing Practice
Injury Epidemiology
Chad Rittle DNP, MPH, RN
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Objectives
• Injury Epidemiology
• Name three (3) examples of source
injury
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Content Overview
Examples of sources of injuries:
–
–
–
–
–
–
Mechanic or kinetic
Thermal energy
Electric energy
Radiation
Chemical energy
Absence of energy
NOTE: The majority of the information for this section was developed using information extracted
from Chapter 5 of the Third Edition of “Core Curriculum for Occupational & Environmental Health
Nursing.
– Salazar, M. (2011). Core Curriculum for Occupational & Environmental Health Nursing,
3rd edition. Pensacola, Fl:AAOHN.
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Occupational Injury Epidemiology
Occupational Injury Epidemiology – The study
of the natural history of injuries helps to define
the host, agent, vector, and environmental
(psychosocial and physical) factors that
contribute to injury.
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Characteristics of Occupational
Injuries
• They are not random events
• They are predictable and preventable
• Injuries result when energy is exchanged in a
manner and dose sufficient to overcome the
host’s threshold of resistance in the presence or
absence of certain environmental conditions
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Example of Risk Factor Analysis for
Injury Occurrence: A Fracture
Host
Injury
Agent
Vector
Exposure
Event
Fracture
Kinetic
Energy
Cement
Floor
Slip and
fall
Physical Environment
Sociocultural Environment
oil, grease, dirt and
water on the floor
attitude toward housekeeping
* Age
painted cement floor
costs associated with injuries and lost
time not accounted for under
department budget
* Sex
equipment and supplies
on floor
* Health
Status
lighting
* Physical
Condition
integrity of floor
Individual
Source: Salazar, M. (2011). Core Curriculum for Occupational & Environmental Health Nursing, 3rd edition. Pensacola, Fl:AAOHN.
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Examples of Sources of Injuries
•
•
•
•
•
•
Mechanical or kinetic energy
Thermal energy
Electric energy
Radiation
Chemical energy
Absence of energy-producing mechanisms
The energy-exchanging event causing an injury can be studied
as a sequence of interactions viewed in pre-event, event, and
post-event phases.
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Haddon Matrix
Case example of control countermeasures –
slips and falls on the same level in a maintenance area.
Source: Haddon, 1963 and 1979, 1990. Salazar, M. (2011). Core Curriculum for Occupational & Environmental Health Nursing, 3rd edition.
Pensacola, Fl:AAOHN.
Phase
Human factors
Environmental and engineering
factors
Pre-event
* Shoes - non-skid soles;
* Safety training increase awareness;
* Establish work
practices, including
housekeeping
* non-skid floor (paint strips);
* Oil/grease absorbing material for
spills;
* Good lighting;
* Proper storage and use of
equipment and supplies
* OSHA inspections and regulation
compliance;
* Safety audit;
* Risk management - insurance losses and
litigation
Event
* Padded clothing;
* Optimal physical
condition of workers
* Energy absorbing floors (with
nonskid surface;
* Emergency notification system
* Injury investigation, reporting and tracking; *
Coordination of medical care
Post-event
* Effective first-aid
response;
* Interaction with
ambulance and hospital
emergency services
* Prompt access to work location;
* Access to first-aid equipment and
supplies
* Emergency response system - triage, first aid,
evaculation, and definitive medical care
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Social, legal and political factors
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Implications for Occupational and
Environmental Health Nurses
– An understanding of occupational injury
epidemiology will enable occupational and
environmental health nurses to analyze,
characterize and minimize the potential for injury
in the work setting.
– The occupational and environmental health nurse
can use injury prevention and control principles to
study, prevent and control the occurrence of
injury-producing events and the extent of injury.
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Effects of Social Conditions and
Behavior on Health
Modern approaches to health services have been
influenced by a variety of factors:
• Life expectance has substantially increased
• Patterns of disease have changed
• Traditional approaches such as the medical model
are not responsive to many modern-day health
problems
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Effects of Social Conditions and
Behavior on Health
Research in the behavioral sciences has examined the
relationship between human behavior and the
occurrences of illness and injury:
• People often make choices that they know are not good for
their health
• The key to effecting behavioral change is understanding the
human thought processes that affect behavior
• Focusing on behavioral strategies may result in healthier
behavioral choices
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Effects of Social Conditions and
Behavior on Health
•
•
•
•
Behavioral approaches to research may also
facilitate a better understanding of the neurologic
and behavioral effects of certain exposures
Theories and models have been developed to help
us understand behavior
Models provide a rich source of ideas that can be
used to further our understanding of behavior
Models enable health care providers to develop
more effective intervention
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Effects of Social Conditions and
Behavior on Health
Research in the social sciences has examined the contribution of
social environments to the occurrence of illness and injury
• Increased recognition of the relationship of social
phenomena to health in illness outcomes
• Examples include rates of violence, divorce and
unemployment, and the degree to which individuals
have care-giving responsibilities or hold multiple jobs
• The provision of appropriate health services depends
on complete understanding and appreciation of the
nature of work and the social context of the workplace
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Health Promotion and
Risk Reduction
• There is a need to develop organizational
“healthy policy” as a strategy to improve
workers’ health
• Healthy policy facilitates and supports healthy behaviors
• Health-promoting and health-damaging policies of
organizations are likely to receive increased scrutiny in the
coming years
• Organizational change is a critical factor in achieving a
healthy occupational work environment
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Health Promotion and
Risk Reduction
• An important area that would benefit from
the attention of the social and behavioral
sciences is health promotion that reduces the
effects of occupational and environmental
exposures.
• The true benefit of this approach may not be apparent
until several years later
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Health Promotion and
Risk Reduction
Social and behavioral sciences can identify and examine factors that threaten
the health of workers
•
The psychosocial environment of the workplace plays a critical role in the
occurrence of occupational injury and illness
⁻
•
The organization of work in influenced by the ideologies, values and beliefs of
people within the organization (managers and workers) and outside of the
organization (scientists and governments
⁻
•
•
Examples include workplace violence, homicide, mistreatment and harassment, unemployment
and underemployment, shift work, workload, role stress, technostress and occupational stress –
stresses that occur when the requirements of the job fail to match the capabilities, resources, or
needs of the worker.
These ideologies affect the social dimensions of the workplace
The organization of work has been identified as a research priority by NIOSH
Implementing strategies based on findings from social and behavioral
investigations is likely to result in cost savings to employers and result in a better
quality of life for workers
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Scientific Foundations of
Occupational and
Environmental Health
Nursing Practice
Toxicology
Chad Rittle DNP, MPH, RN
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Objectives
• Describe three (3) toxic agents by their
classification on the biological system
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Content Overview
– Asphyxiants – deprive the body of oxygen
– Corrosives – cause irreversible tissue death
– Irritants – cause temporary, but sometimes severe,
inflammation
– Sensitizers – cause allergic reactions after repeated exposure
– Carcinogens – capable of causing cancer
– Mutagens – cause changes in genetic makeup
– Teratogens – cause malformation in an unborn child
–
–
NOTE: The majority of the information for this section was developed using information extracted from Chapter 5 of the Third
Edition of “Core Curriculum for Occupational & Environmental Health Nursing.
Salazar, M. (2011). Core Curriculum for Occupational & Environmental Health Nursing, 3rd edition. Pensacola, Fl:AAOHN.
Copyright 2012 American Association of Occupational Health Nurses
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Toxicology
– Toxicology – the study of the adverse effects of chemicals on
biologic systems
– A target organ – the organ that is selective affected by a
harmful agent
– A chemical is toxic, meaning it can cause harm, if all of the
following five conditions are met:
•
•
•
•
•
Its properties make it capable of producing harm
It is present in sufficient amount
It is present for sufficient time
It is delivered by an exposure route that allows it to be absorbed
It reaches the target body organ(s)
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Toxic Agent Classification
Toxic agents can be classified by their form of action on the
biologic system
• Asphyxiants – deprive the body tissue of oxygen
• Corrosives – cause irreversible tissue death
• Irritants – cause temporary, but sometimes severe, inflammation or the
eyes, skin, or respiratory tract
• Sensitizers – cause allergic reactions after repeated exposures
• Carcinogens – are capable of causing cancer
• Mutagens – are toxins that cause changes to the genetic material of cells
that can be passed on to future generations
• Teratogens – cause malformations in an unborn child
• Toxins may have more than one form of action and may act at more than
one biologic site
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Potential toxic effects by system,
with examples of toxins
System
Respiratory
Dermatologic
Nervous System
Hearing and Vision
Hematopoietic
Hepatic
Renal and Bladder
Reproductive
Effects
Irritation
Sensitization
Fibrosis
Carcinogens
Irritation
Corrosive burns
Sensitization
Carcinogenesis
Depressed/altered consciousness
Behavior and mood disturbance
Cognitive disturbance, cerebellar impairment
Peripheral neuropathy
Acid burns of eyes
Alkali burns of eyes
Blindness
Deafness
Bone marrow supression
Red cell lysis
Necrosis
Cirrhosis
Malignancy
Nephrotoxicity
Renal cancer
Bladder cancer
Decreased sperm production
Decreased female fertility
Spontaneous abortions
Congenital defects
Copyright 2012 American Association of Occupational Health Nurses
Sources of Exposure
Hydrogen chloride, ammonia
Isocyanates
Silica, asbestos, beryllium
Asbestos, arsenic, chromium VI
Acetone, carbon disulfide
Alkali, hydrogen flouride
Chromate, nickel
Ultraviolet light, arsenic
Carbon monoxide, solvents, lead, mercury, manganese
Lead, solvents, toluene, mercury
Carbon monoxide, manganese, pesticides
Acrylamide, n-hexane, methyl n-butyl ketone
Hydrochloric and tannic acid
Sodium hydroxide, calcium oxide
Methanol
Noise
Ionizing radiation, benzene
Arsine, trinitrotoluene (TNT), naphthalene
Carbon tetrachloride, chloroform, tetrachloroethane
Carbon tetrachloride
Vinyl chloride monomer
Heavy metals, carbon tetrachloride, chloroform
Coke oven emissions
Benzidine, B-naphthylamine
Ionizing radiation, heat
Ionizing radiation, carbon disulfide
Ethylene oxide
Rubella, varicella
320
Dose of Toxic Agent
The dose of an agent is the amount that reaches the
target organ
– The dose is usually impossible to determine accurately
– The dose is usually estimated by measuring the amount
administered (as with drugs) or the amount in the
environment to which the person has been exposed
– Another means of estimating dose is by measuring
biomarkers in body tissues
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Indicators of Exposure
• Vapors or gases in the environment are normally measured as
parts per million (ppm)
• Solids (dusts or fumes) are expressed according to their
weight per volume of air (mg/m3)
• Higher concentrations are generally absorbed in greater
amounts
• Longer or more-frequent periods of exposure also lead to
greater absorbed doses
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Exposure
• Acute exposure occurs when exposure is shortterm and absorption is fairly rapid
• Chronic exposure refers to longer duration or
repeated periods of contact
• In general, acute toxic exposures tend to be at
higher levels, and chronic exposures tend to occur
at lower concentrations
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Industrial Hygiene
Refers to the anticipation, recognition, evaluation and control
of environmental factors or stresses arising in or from the
workplace, which can cause injury, sickness, impaired health
and well-being, or significant discomfort among workers or
among citizens
– Includes engineering, physics, chemistry and
biology
•
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Assessments
– Qualitative Assessments
• Communication with key personnel – plant
management and supervisors to learn about materials
and processes
• Communication with occupational and environmental
health professionals to learn about health problems
related to exposures
• Communication with workers and their representatives
to learn about their perceptions of the exposures
– Observational Assessments
• walk-through surveys, focused inspections, and job
hazard analysis
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Material Safety Data Sheets
(MSDS)
•
•
•
•
•
•
•
•
•
•
Identify the material
Hazardous chemicals and their common names
Physical and chemical properties
Routes of exposure
Acute and chronic health effects
First aid information
Exposure limits
Precautions for safe handling and use
Control measures
Organization responsible for preparing the MSDS and contact
information
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MSDS Precautions
• The quality is variable – information can be
outdated and unclear, may be inconsistent among
manufacturers.
• Recommended protective measures must be
considered in the context of the material’s actual
use and the control measures in effect
• An MSDS for a mixture may not include all chemical
components, particularly if their concentration is
low or if they are not recognized as hazardous
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Sampling
• Sampling methods – some measure exposure before absorption has
occurred
– Skin wipes or cloth patches – measure amounts of materials that come in contact with
the skin
– Noise dosimeters – record work-site noise levels
– Airborne contaminants – personal monitoring of the worker’s breathing zone or
environmental monitoring in the work area
• Factor to consider when sampling
–
–
–
–
Location of the sampling device. Take into account worker movements and location
Workers to be sampled should be those most highly exposed
Timing – consider seasonal changes, shifts, unintentional releases, and other variations
Length of sampling time – should represent a full shift
• Number of samples required include type of instrument, concentration of
the contaminant, and the purpose of sampling
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Exposure Records
Exposure records should be maintained for at least 30 years
Guidelines and standards:
• Threshold limit values- reflects the level of exposure that the typical worker can
experience without an unreasonable risk of disease or injury. TLVs® are not
quantitative estimates of risk at different exposure levels or by different routes of
exposure.
• Permissible exposure limits- the maximum amount or concentration of a
chemical that a worker may be exposed to under OSHA regulations.
• Guidelines and standards indicate upper limits of exposure concentrations that
are not felt to pose a danger to workers who are exposed over normal work hours
• Published limits cannot be viewed as definitely “safe” levels
• Guidelines and standards may be controversial
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Control Strategies
– Control strategies for occupational exposures
• Engineering controls – enclose or isolate operations,
improve ventilation, and removal or substitution of
toxic materials
• Administrative controls – minimize exposure and
include monitoring or surveillance programs, worker
rotation, and training to address work practices
• Personal protective equipment – earplugs and muffs,
safety goggles, gloves, coveralls, respirators. These are
considered the least-preferred control strategy
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Three Major Exposure Routes
–Cutaneous
–Inhalation
–Ingestion
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Cutaneous
Cutaneous - the skin is an effective barrier to most substances,
but effectiveness depends upon condition, site, and the
properties of the agent
– Some agents enter through hair follicles, by trauma or injection
– In general, gases penetrate most freely, liquids less freely, and solids
insoluble in water or fats do not penetrate
– Longer contact promotes higher levels of absorption
– Damage to the skin can promote absorption
– Clothing and gloves trap substances and lead to longer exposure
periods
• Example – a “paint thinner” rag in the back pocket!
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Inhalation
Inhalation – the most important route of exposure in
the occupational environment
– Occurs in the alveoli, and influenced by rate
and depth or respirations
– Some substances (such as solvents and
carbon monoxide) are absorbed through the
lungs but exert system effects
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Ingestion
Ingestion – the least common route of entry
– Increases in importance via hand-mouth activity – food,
water, and other substances
– Caustic or irritant chemicals can have direct adverse affect
on the GI tract
– Some toxins act systemically following their absorption
– Smoking or eating at work sites can lead to consumption of
toxins by way of contaminated hands, food, or smoking
materials
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The Dose-Response Relationship
• Higher doses are generally associated with responses in a greater
proportion of individuals
• Identification of a dose-response relationship lends support to a theory
that a substance causes a given effect
• Dose-response curves provide a basis for evaluating a chemical’s relative
toxicity
• LD50 (lethal-dose, 50%) – produces death in 50 of a group of experimental
animals (Also known as LC50 (lethal concentration, 50%)
• Example – LD50 of acetone is 5,340 mg/kg, while the LD50 of cyanide (a much
more toxic compound) is 0.5 mg/kg.
• Animal studies must be interpreted cautiously because of the many
differences in response that exist among species
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The Nature of Effects
• Effects of toxins with long latency periods may not be apparent until years
after the exposure period
• Work-related exposures commonly consist of mixtures of substances
– Synergistic effects – caused by exposure to more than one toxin
• Example – smoking and asbestos exposure
– Antagonism – between toxins results in an overall effect that is less
than the sum of their separate effects
– Potentiation – a chemical has no adverse affect on its own, but its
presence increases the effect of another substance or makes that
substance capable of exerting an effect
• Often seen with carcinogens
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Fate of Toxins in the Body
• Elimination from the body
• Excretion – elimination via expired air, urine, feces, bile or perspiration
• Milk, spinal fluid, saliva, hair
• Most chemicals and their metabolic products are excreted through the
kidneys/urine pathway
• Biotransformation – can be made less toxic or more toxic prior to
elimination from the body
• The rate of biotransformation can affect individual susceptibility to a toxin
• Factors affecting the excretion of a substance
• Many agents are deposited in body tissue and slowly released and excreted over
time
• Half-life – the time it takes for one half of the total absorbed amount to be
eliminated from the body
• Length of the half-life depends on the agent and the tissue where it is stored
• Example – the half-life of lead is more than 20 years in bone, compared with 2530 days in the blood
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Endogeneous Factors
Endogeneous Factors – factors beyond the control of the
individual
• Gender
• Genetic differences
• Aging
• Pregnant women – exposure can cause perinatal
malignancies
• Pre-existing conditions can influence the effects of
exposure to toxins
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Exogeneous Factors
Exogeneous Factors – factors one may be able to control
• Nutrition factors – deficiencies can enhance or inhibit absorption
or toxic responses
• Obesity – can promote more storage of lipid-soluble substances
• Lifestyle factors – such as smoking or alcohol consumption can
increase chemical exposures that must be eliminated and may
increase susceptibility due to debilitation
• Stress – can effect organ function, such as cardiovascular, immune,
and GI systems
• Some adverse health conditions are temporary and manageable,
but may affect a person’s vulnerability to toxins
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Work-related Musculoskeletal
Disorders
•
•
•
•
Can be caused or aggravated by work-site factors
Affected areas include muscles, tendons, ligaments,
peripheral nerves, blood vessels, joints, cartilage
and bones
Can affect both the upper and lower body
Symptoms can include pain, swelling, erythema,
numbness and paresthesia
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Work-site Risk Factors
• Repetition – a series of motions
• Force – lifting weights, handling heavy tools, pinching with
fingers, applying grips
• Carpal tunnel syndrome – combines repetition and force
• Mechanical stress – worker’s direct contact with work
surfaces or tools
• Compressive forces – striking objects with hand-held tools or
from leaning against hard surfaces or corners on work tables
– nerve compression disorders
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Common Work-site
Injuries and Causes
•
•
•
•
•
Cervical spine – extreme neck flexion and twisting
Back injury – twisting at waist, lifting (below knees or above
shoulders), awkward postures, carrying, pulling, pushing
Shoulder injury – raising arm or elbow above mid torso
without support, reaching behind the body
Forearm/elbow injury – repeated rotation (supination and
pronation)
Wrist/hand – repeated wrist flexion and extension, holding
in ulnar deviation
Copyright 2012 American Association of Occupational Health Nurses
342
Other Common Risks
• Vibration – power tools or other equipment
• Whole body vibration – truck drivers, jackhammer operators
• Cold environments- can affect manual
dexterity and muscle strength
Copyright 2012 American Association of Occupational Health Nurses
343
High-risk Jobs
• Office work – associated with technology
• Manual materials handling
• Assembly work is often machine-paced
Copyright 2012 American Association of Occupational Health Nurses
344
Evaluating Risk Factors
•
Interviews or questionnaires – ask workers about their work
⁻
⁻
•
Observation and use of a checklist – observe workers noting any risk
factors
⁻
⁻
•
Advantages – worker has the most complete view of the task throughout all work
periods. May reveal factors not otherwise noted
Disadvantages – may be a high variability in how workers report their perception
of work performance.
Advantages – look at all workers in the same way, less variability
Disadvantages – workers may change behavior when they are under observation
Videotaping and analysis – done on the job and later analyzed
⁻
⁻
Advantages – does not rely on one person’s assessment
Disadvantages – expensive equipment and experienced personnel
Copyright 2012 American Association of Occupational Health Nurses
345
Ergonomic Improvements
• General environment – adequate illumination
⁻
⁻
⁻
Comfortable temperature and humidity
Good visibility of labels and signs
Clear, audible auditory signals
• Workstations and chairs – adjustable to accommodate different sized
workers
• Layout – place tools and materials in front of worker to prevent twisting,
reaching, bending
⁻
Keep work space free of obstacles
• Postures – avoid static postures
⁻
Locate and orient work to promote neutral positions
• Repetition – engineer the process or product to reduce repetition
⁻
⁻
Vary tasks or rotate workers
Allow rest time
Copyright 2012 American Association of Occupational Health Nurses
346
Ergonomic Improvements
• Forces – reduce size and weight of objects held
⁻
⁻
⁻
⁻
Use power grips vs. pinch grips
Balance tools
Correctly fitted gloves
Sharpen tools often
• Mechanical stresses – ensure handles fit the workers hands
⁻
Pad or eliminate sharp edges
• Vibration – eliminate vibrating tools if possible
⁻
⁻
⁻
⁻
Isolate sources of vibration
Keep tools properly maintained
Maintain even floor surfaces
Reduce driving speeds of vehicles, such as forklifts
• Lifting – reduce size and weight of tools and objects lifted often
⁻
⁻
⁻
⁻
Use mechanical lifting devices
Use gravity to move work
Raise or lower work for the operator
Provide grips and handles
• Work organization – staff adequately
⁻
⁻
⁻
Alternate physically and mentally demanding tasks
Vary rate and nature of tasks as much as possible
Provide breaks – more frequent breaks are better than long ones!
Copyright 2012 American Association of Occupational Health Nurses
347
Questions??
Break
Copyright 2012 American Association of Occupational Health Nurses
Case Management
“Disability Case
Management – is There a
Difference?”
Barb Maxwell RN, MHA, COHN-S, CCM, CWCP, QRP,
FAAOHN
Copyright 2012 American Association of Occupational Health Nurses
Objectives
Participants will be able to:
• List 3 Case Management terms
• List 3 common legal defenses from loss claims
under workers compensation
• Discuss the OHN role as worker advocate
• Recognize at least 2 models for coaching
Copyright 2012 American Association of Occupational Health Nurses
Case Management Definition
• Case Management is a process in coordinating
a workers’ health care services to deliver
optimal, quality care in a cost-effective
manner. (AAOHN, 2004a)
Copyright 2012 American Association of Occupational Health Nurses
Disability Case Management
Definition
Disability Case Management is:
the coordination and management of workrelated and nonwork-related injury and illness
and includes aspects related to group health,
workers’ compensation, short term disability,
Family and Medical Leave Act (FMLA), and longterm disability benefits.
Copyright 2012 American Association of Occupational Health Nurses
Benefits
Services owed an individual, as defined by law.
• Employment benefits
– Health, Dental, 401k plans
• Workers’ Compensation benefits
– Evaluation, Treatment, Rehabilitation, Retraining
Copyright 2012 American Association of Occupational Health Nurses
CASH BENEFITS
Cash that is paid –
– as part of workers’ compensation benefits.
– according to an employer’s defined disability plan.
– negotiated in a union contract to replace a
worker’s loss of income or earning capacity due to
disability resulting from an occupational or nonoccupational injury or illness.
Copyright 2012 American Association of Occupational Health Nurses
4 Classifications of Monetary WC
Disability Benefits
•
•
•
•
Temporary Total Disability (TTD)
Temporary Partial Disability (TPD)
Permanent Total Disability (PTD)
Permanent Partial Disability (PPD)
Copyright 2012 American Association of Occupational Health Nurses
TEMPORARY TOTAL DISABILITY
(TTD)
Tax-free reimbursement for partial wages when
a worker is temporarily totally disabled.
Example: Employee sustains work related injury
and requires surgery. Employee is out of work
post-op until cleared to return to work on light
duty.
Copyright 2012 American Association of Occupational Health Nurses
TEMPORARY PARTIAL DISABILITY
(TPD)
Tax-free reimbursement for partial wages when
a worker is temporarily partially disabled.
Example: Employee sustains work related injury
and is able to work light duty assignment with
restricted schedule such as half days or 3 days a
week instead of full days, 5 days per week.
Copyright 2012 American Association of Occupational Health Nurses
PERMANENT TOTAL DISABILITY
(PTD)
Tax-free reimbursement for partial wages when
a worker is permanently totally disabled.
Example: Employee sustains work related injury
has no formal education, cannot read and
physical restrictions are such that they are not
employable in any capacity.
Copyright 2012 American Association of Occupational Health Nurses
PERMANENT PARTIAL DISABILITY
(PPD)
Tax-free reimbursement for partial wages when
a worker is permanently partially disabled.
Example: Employee sustains a knee injury
working as a carpenter requiring extensive
kneeling. After surgery, permanent restriction is
no kneeling requiring he seek another career
which pays much less.
Copyright 2012 American Association of Occupational Health Nurses
DEDUCTIBLE
• The amount that a member of the health care plan
must pay for covered services per specified
period,(policy year), before the insurer will pay
benefits.
• From WC standpoint, first 40 hours of lost time
wages(full time employee), the employee will utilize
their PTO.
• Only if they are out 21 days or more, that PTO pay
will be reimbursed. (Not Time)
Copyright 2012 American Association of Occupational Health Nurses
EARNING CAPACITY
The potential wages a worker could achieve
given his or her:
–
–
–
–
–
–
–
Education
Training
Skill level
Previous experience
Medical condition
Proximity to available work
Other factors
Copyright 2012 American Association of Occupational Health Nurses
FUNCTIONAL CAPACITY
EVALUATION (FCE)
A professional assessment to specifically
determine a disabled person’s residual physical
abilities.
Copyright 2012 American Association of Occupational Health Nurses
INDEMNITY
In worker’s compensation language, generally
refers to payments made for lost wages.
Money = Indemnity
Copyright 2012 American Association of Occupational Health Nurses
INDEPENDENT MEDICAL
EXAMINATION (IME)
A second medical opinion related to a worker’s
health condition that can be legally finding in
some jurisdictions.
Copyright 2012 American Association of Occupational Health Nurses
RETURN TO WORK (RTW)
The desired goal for all workers after an
injury or illness.
(occupational and non-occupational)
Copyright 2012 American Association of Occupational Health Nurses
THIRD-PARTY ADMINISTRATOR
(TPA)
A company that handles all the administrative
tasks involved in managing claims for selfinsured employers who fund their own benefit
plans.
Copyright 2012 American Association of Occupational Health Nurses
LEGAL DEFENSES
• Before the passage of workers’ compensation
laws, injured workers and the survivors of
workers killed on the job could be
compensated for their loss or medical costs
only through litigation.
• In the United States, the first workers’
compensation law was passed in Wisconsin in
1911.
Copyright 2012 American Association of Occupational Health Nurses
LEGAL DEFENSES
Employers were historically protected from loss
claims under 3 common legal defenses:
– The assumption of risk defense
– The fellow servant rule
– The concept of contributory negligence
Copyright 2012 American Association of Occupational Health Nurses
ASSUMPTION-OF-RISK DEFENSE
Assumed that workers were aware of
occupational hazards and accepted the risk
inherent to their jobs.
Copyright 2012 American Association of Occupational Health Nurses
FELLOW SERVANT RULE
Assumed that if a co-worker contributed to an
accident or injury, that co-worker should be
responsible for compensating the injured
worker.
Copyright 2012 American Association of Occupational Health Nurses
CONTRIBUTORY NEGLIGENCE
Concept holds that the employer was not liable
if the employee contributed in any way to the
injury:
– this defense strategy argued that physical harm
would not have come to the worker had he or she
been paying attention to the task, overriding the
importance of a lack of protective devices.
Copyright 2012 American Association of Occupational Health Nurses
Objectives of W/C Laws
• Ensure prompt and reasonable benefits to injured
employees
• Relieve public and private charitable institutions
from bearing the burden of costs
• Eliminate, insofar as possible, attorney fees and
time-consuming trials
• Encourage maximum employer interest in safety and
rehabilitation through experience rating approaches
to premiums
Copyright 2012 American Association of Occupational Health Nurses
Objectives of W/C Laws
• Promote research and study in the area of
accident causes, with the aim of reducing the
occurrence and the human suffering that
results
• Ensure prompt and effective medical
treatment to reduce long-term disability
• Encourage all employers to anticipate and
manage on-the-job injuries/illnesses
Copyright 2012 American Association of Occupational Health Nurses
CONFLICTS THE OHN FACES
The Occupational Health Nurse often faces
conflicts between the role of management
consultant and client advocate.
Copyright 2012 American Association of Occupational Health Nurses
STRATEGIES TO REDUCE CONFLICT
• OHN serves as first line contact with the ill or
injured worker
• OHN provides case management with an
emphasis on return to pre-injury function.
• OHN acts as a liaison with the worker, other
health care professionals, insurers, TPA’s the
employer and the workers’ compensation
board.
Copyright 2012 American Association of Occupational Health Nurses
STRATEGIES TO REDUCE CONFLICT
• Educate the worker about the benefits of the
workers’ compensation or disability system &
importance of working as a collaborative team with
claims manager and human resources.
• OHN coordinates transitional duty assignment &
communicates with manager & HR.
• OHN maintains contact between manager, human
resources and worker during the disability.
Copyright 2012 American Association of Occupational Health Nurses
COACHING
Coaching is “a system that grows people by enabling
them to learn through guided discovery and hands-on
experience” (Renke, 1999)
“A coach is not a problem-solver, a teacher, an advisor
or even an expert: he or she is a sounding board, a
facilitator, a counselor, an awareness raiser.”
(Whitmore, 2002)
Copyright 2012 American Association of Occupational Health Nurses
COACHING
Coaching is the means of generating
responsibility, self motivation and awareness to
enhance performance.
Copyright 2012 American Association of Occupational Health Nurses
THE IDEAL COACH IS:
•
•
•
•
•
PATIENT
DETACHED
SUPPORTIVE
INTERESTED
A GOOD LISTENER
•
•
•
•
•
PERCEPTIVE
AWARE
SELF-AWARE
ATTENTIVE
RETENTIVE
(Whitmore, 2002)
Copyright 2012 American Association of Occupational Health Nurses
COACHES FACILITATE
SELF-DISCOVERY BY:
•
•
•
•
Listening for meaning rather than words.
Engaging in expert question-asking
Encouraging critical thinking
Sharing relevant experiences
Copyright 2012 American Association of Occupational Health Nurses
TAKE-AWAY STRATEGIES
• Treat injured workers with respect and dignity.
• Respect the worker’s right to confidentiality of
medical information whenever possible.
• Advocate and assist the worker with the
multitude of potential issues with the health
care system
Copyright 2012 American Association of Occupational Health Nurses
Bibliography
• Salazar, Mary K.:Core Curriculum for Occupational &
Environmental Health Nursing Third Edition.
• Renke,W.J. (1999)Manage Like a Coach Not a Cop
• Whitmore,J. (2002). Coaching for Performance: Growing
People, Performance and Purpose.
• American Association of Occupational Health Nurses. (2004a).
Standards of occupational and environmental health nursing.
Copyright 2012 American Association of Occupational Health Nurses
QUESTIONS ??
Copyright 2012 American Association of Occupational Health Nurses
Professionalism –
What Does it Take?
Debbie Bush, RN, COHN-S/CM
Copyright 2012 American Association of Occupational Health Nurses
Objectives
• List (2) aspects of professional development
• Provide the new OHN with practical tips for
networking
• Describe different audiences the OHN
presents to
Copyright 2012 American Association of Occupational Health Nurses
Professional Practice Standards
From the AAOHN Core Curriculum for Occupational
Health Nursing states under Standard I : Professional
Development/Evaluation
“The occupational health nurse assumes responsibility
for professional development and continuing education
and evaluates personal professional performance in
relation to practice standards.”
Copyright 2012 American Association of Occupational Health Nurses
Professional Practice Standards
Standard V : Ethics
“The occupational health nurse uses an ethical
framework as a guide for decision making in
practice.”
Copyright 2012 American Association of Occupational Health Nurses
OHN Legal Responsibility
• Maintain knowledge of the law – state/federal
• Be aware of actual practice and legal
guidelines
– OSHA, ADA-AA, FMLA, EOC, HIPAA
– Documentation
– Recordkeeping
Copyright 2012 American Association of Occupational Health Nurses
Your Development
Where are you?
Copyright 2012 American Association of Occupational Health Nurses
Professional Certification
•
•
•
•
Consumer protection & accountability
Employers look for credentials
SME – Subject Matter Expert
CCM, CRRN, CDMS, CRC, COHN, COHN-S/CM
Copyright 2012 American Association of Occupational Health Nurses
Presentation Style
• Approach
–
–
–
–
–
–
–
–
Professionalism image
Dress Appropriately
Think “bottom line”
Know ROI
Be brief – no rambling
Be prepared!
Frequency
Follow up communication
Copyright 2012 American Association of Occupational Health Nurses
Key Competencies
•
•
•
•
•
•
•
•
Managing relationships
Building and strengthening current ones
Have a heart-to-heart talk with your supervisor
Movement toward Upper Management
Leading
Vision and Mission
Initiative
Motivating and Influencing
Copyright 2012 American Association of Occupational Health Nurses
Key Competencies - continued
• Standards & Accountability
– Accountability
– Service orientation – Customer Focus
• Planning & Decision Making
–
–
–
–
Critical Thinking
Financial knowledge
Process Management
Prioritizing & Delegating
Copyright 2012 American Association of Occupational Health Nurses
Key competencies - continued
• Communication
– Effectively
– Giving feedback
• Developing People
–
–
–
–
–
Identify and recruit talent
Develop & Retain talent
Become active in your professional organization
Stay involved
Network
Copyright 2012 American Association of Occupational Health Nurses
Planning For Your Personal/
Professional Development
• Join AAOHN/AOHP Local Chapter
– Attend national conferences
– Attend local meetings for contact hours
– Run for office or volunteer to serve a committee
– Attend an OSHA Compliance Course in BBP,
Audiometry, Respiratory Protection, and/or
Recordkeeping
• Network with other OHNs
• Find a mentor!
Copyright 2012 American Association of Occupational Health Nurses
Question to Ask Yourself
• What is the one thing that I and only I can do,
that if done well, will make a difference?
• How do you plan to get there?
Copyright 2012 American Association of Occupational Health Nurses
Communicating Results
Reports
–
–
–
–
–
–
Monthly
Quarterly
Annually
Trip Reports*
Special Reports
Memorandums/Letters
Copyright 2012 American Association of Occupational Health Nurses
Questions??
Adjourn
Copyright 2012 American Association of Occupational Health Nurses
The Legal Aspects
of AAOHN Practice
Part 1
Chad Rittle DNP, MPH, RN
Copyright 2012 American Association of Occupational Health Nurses
399
Objectives
• Describe the scope of practice of various
healthcare professionals in the workplace.
• Discuss OSHA, HIPPA, FMLA, ADAA
Copyright 2012 American Association of Occupational Health Nurses
400
Content Overview
• The OHN may be an LPN, RN or APRN. In the workplace there may be
paramedics, MDs, Industrial Hygienists, safety and infection control
professionals, health educators, plus HR and many others. Plus, there
are implications for the nurse who engages in mobile health and/or
telemedicine
• OHN practice is impacted by many regulations and legislation that may be
unfamiliar to other nurses.
NOTE: The majority of the information for this section was developed using
information extracted from Chapter 3 of the Third Edition of “Core Curriculum
for Occupational & Environmental Health Nursing.
– Salazar, M. (2011). Core Curriculum for Occupational & Environmental Health Nursing,
3rd edition. Pensacola, Fl:AAOHN.
Copyright 2012 American Association of Occupational Health Nurses
401
Sources of Law
–
–
–
–
Common Law
Statutes
Federal Law
State Law
• Civil law
• Criminal law
Copyright 2012 American Association of Occupational Health Nurses
402
Laws vs. Rules and Regulations
• Law – This is legislation passed be either the State
Legislature or the Federal Congress.
• Regulation – regulations specify definitions,
authority, eligibility, benefits and standards.
• New regulations or existing regulations are known as
“Proposed Rules”.
• Once a regulation takes effect, it becomes a “Final
Rule”
Copyright 2012 American Association of Occupational Health Nurses
403
Legal Concepts
• Basic Legal Concepts Relevant to
Occupational and Environmental Health
Nursing Practice
– Tort
– Nursing Negligence
• Standard of Care
• Duty
• Breach of duty
Copyright 2012 American Association of Occupational Health Nurses
404
Negligence
– Examples of negligence include:
–
–
–
–
–
–
–
Failure to assess and make proper nursing diagnosis
Failure to observe and monitor
Failure to take action
Failure to communicate danger
Delay in obtaining assistance
Medication errors
Failure to obtain informed consent
Copyright 2012 American Association of Occupational Health Nurses
405
Informed Consent
• This means that a worker’s decision about a treatment or
action plan is made with a clear understanding, including
material risks, benefits, and alternative treatments (i.e.,
complete notice)
• To give informed consent, the worker must be advised of the
following:
⁻
⁻
⁻
⁻
⁻
Nature and purpose of proposed treatment
Diagnosis
Materials risks of proposed treatment
Alternative treatments
Consequences of lack of treatment
Copyright 2012 American Association of Occupational Health Nurses
406
Malpractice & Statute of Limitations
– Malpractice
• This is negligence that involves professional
misconduct or unreasonable lack of skill
– Statute of Limitations
• This is a period of time within which a lawsuit
must be filed after a tort occurs
Copyright 2012 American Association of Occupational Health Nurses
407
Legal Responsibilities
Occupational and environmental health nurses
are responsible for maintaining a current
knowledge of the laws affecting occupational
health practice in the jurisdiction (state) where
they practice.
Copyright 2012 American Association of Occupational Health Nurses
408
Legal Responsibilities
Changes in the administrative rules by the following
MAY affect the practice of occupational and
environmental health nursing
• The State Board of Nursing
• The State Board of Pharmacy
• The State Board of Medicine
• Changes in State and Federal laws
Copyright 2012 American Association of Occupational Health Nurses
409
Legal Responsibilities
• There may be inconsistencies between actual practice and
the legal guidelines of practice
• Since laws, rules and regulations that are enacted are
dynamic, they may be challenged as professional practice
evolves
• Therefore, the interpretation of laws, rules, and regulations
may change as new cases are decided (common law) and
legal precedents are established.
Copyright 2012 American Association of Occupational Health Nurses
410
Other Professionals Found Working in
Occupational and Environmental Health
•
•
•
•
•
•
•
•
EMTs and Paramedics
Physicians
Industrial Hygienists
Occupational Health and Safety Officers
Epidemiologists/Infection Control Specialists
Health Educators
Human Resources
There may be other professionals working in your
own facility.
Copyright 2012 American Association of Occupational Health Nurses
411
OHN Mobile Health or
Telemedicine
What about the OHN who does mobile health or telemedicine?
– Oil rig companies are using Telemedicine to link workers to physicians,
nurses and other health professionals
• Source – Anscombe, D. (2010). Healthcare delivery for oil rig workers plays
a vital role. Telemedicine and e-Health. 16(6):659-663.
– Smartphone apps can “interface wirelessly with medical devices such
as blood pressure and blood glucose monitors, providing patients with
recommendations based on the monitors’ readings”
• “The technology allows patients to see trends and react to them in real
time”
• Source – Hampton, T. (2012). Recent advances in mobile technology
benefit global health, research and care. JAMA. 307(19):2013-2014.
Copyright 2012 American Association of Occupational Health Nurses
412
OHN Mobile Health or
Telemedicine
“Mobile phones are emerging as an important method of
encouraging better nurse-patient communication and are
estimated to increase in use and application over coming years.”
• Health promotion areas of focus include dietary
interventions, smoking cessation interventions, and
physical activity intervention.
• Health monitoring areas include cancer, asthma, and
diabetes.
• Source – Blake, H. Innovation in practice: Mobile phone
technology in patient care. British Journal of Community
Nursing. 13(4):162-5.
Copyright 2012 American Association of Occupational Health Nurses
413
Reference
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Anscombe, D. (2010). Healthcare delivery for oil rig workers plays a vital role. Telemedicine and e-Health. 16(6):659-663.
Blake, H. Innovation in practice: Mobile phone technology in patient care. British Journal of Community Nursing. 13(4):162-5.
Bureau of Labor Statistics, EMTs and Paramedics. Occupational Outlook Handbook (n.d.) Retrieved on November 27,:
http://www.bls.gov/ooh/Healthcare/EMTs-and-paramedics.htm
Bureau of Labor Statistics, Epidemiologists. Occupational Outlook Handbook (n.d.) Retrieved on November 27, 2012 from:
http://www.bls.gov/ooh/life-physical-and-social-science/epidemiologists.htm
Bureau of Labor Statistics, Health Educators. Occupational Outlook Handbook (n.d.) Retrieved on November 27, 2012 from:
http://www.bls.gov/ooh/community-and-social-service/health-educators.htm
Bureau of Labor Statistics, Human Resources Managers. Occupational Outlook Handbook (n.d.) Retrieved on November 27, 2012 from:
http://www.bls.gov/ooh/management/human-resources-managers.htm
Industrial Hygiene, Industrial Hygienists. United States Department of Labor (n.d.) Retrieved on November 27, 2012 from:
http://www.osha.gov/dte/library/industrial_hygiene/industrial_hygiene.html
Bureau of Labor Statistics, Occupational Health and Safety Specialists. Occupational Outlook Handbook (n.d.) Retrieved on November
27, 2012 from: http://www.bls.gov/ooh/healthcare/occupational-health-and-safety-specialists.htm
Bureau of Labor Statistics, Physicians and Surgeons. Occupational Outlook Handbook (n.d.) Retrieved on November 27, 2012 from:
http://www.bls.gov/ooh/healthcare/physicians-and-surgeons.htm
Federal Regulations – The Laws Behind the Acts of Congress (n.d.) About.com: US Government Info. (Retrieved on November 27, 2012
from: http://usgovinfo.about.com/od/uscongress/a/fedregulations.htm
Hampton, T. (2012). Recent advances in mobile technology benefit global health, research and care. JAMA. 307(19):2013-2014.
Industrial Hygiene, United States Department of Labor (n.d.) Retrieved on November 27, 2012 from:
http://www.osha.gov/dte/library/industrial_hygiene/industrial_hygiene.html
Mason, D., Leavitt, J., Chaffee, M. (2012). Policy & Politics in Nursing and Health Care, 6th edition. St. Louis:Elsevier.
Salazar, M. (2011). Core Curriculum for Occupational & Environmental Health Nursing, 3rd edition. Pensacola, Fl:AAOHN.
Copyright 2012 American Association of Occupational Health Nurses
414
The Legal Aspects of
AAOHN Practice
Part 2
Chad Rittle DNP, MPH, RN
Copyright 2012 American Association of Occupational Health Nurses
415
Objectives
• Describe the scope of practice of various
healthcare professionals in the workplace.
• Discuss OSHA, HIPPA, FMLA, ADAA
Copyright 2012 American Association of Occupational Health Nurses
416
Content Overview
The OHN may be an LPN, RN or APRN. In the workplace there may be
paramedics, MDs, Industrial Hygienists, safety and infection control
professionals, health educators, plus HR and many others. Plus, there are
implications for the nurse who engages in mobile health and/or telemedicine
• OHN practice is impacted by many regulations and legislation that may
be unfamiliar to other nurses.
• NOTE: The majority of the information for this section was developed
using information extracted from Chapter 3 of the Third Edition of “Core
Curriculum for Occupational & Environmental Health Nursing.
– Salazar, M. (2011). Core Curriculum for Occupational & Environmental Health Nursing,
3rd edition. Pensacola, Fl:AAOHN.
Copyright 2012 American Association of Occupational Health Nurses
417
Occupational Safety and Health
Administration (OSHA)
Occupational Safety and Health Act (Public Law
91-596)
– Signed into law on December 29, 1970
– The purpose of the act is to “Assure so far
as possible every working man and woman
in the Nation safe and healthful working
conditions and to preserve our human
resources”.
Copyright 2012 American Association of Occupational Health Nurses
418
OSHA
A regulatory agency within the U.S. Department of Labor, was created as a
result of the OSH Act.
– The Occupational Safety and Health Administration (OSHA) is responsible for enacting,
administering, and enforcing standards to provide workplace health and safety and was
the first attempt by Congress to provide a comprehensive program to protect the health
and safety of American workers.
– States may choose to administer their own occupational health and safety program,
with the following provisions.
• OSHA approves the program
• The state program applies to all workers and includes state, local and private sector
workers
• The state’s statutes must be as strict as federal OSHA requirements, otherwise
OSHA statutes apply. (See Figure 1 where State Plans apply)
• General Duty Clause of the OSH Act
– Employers are required to furnish all workers “employment and a place of
employment which are free from recognized hazards that are causing or are
likely to cause death or serious physical harm”.
Copyright 2012 American Association of Occupational Health Nurses
419
The following states have
approved State Plans:

Alaska

New Mexico

Arizona

New York

California

North Carolina

Connecticut

Oregon

Hawaii

Puerto Rico

Illinois

South Carolina

Indiana

Tennessee

Iowa

Utah

Kentucky

Vermont

Maryland

Virgin Islands

Michigan

Virginia

Minnesota

Washington

Nevada

Wyoming

New Jersey
Copyright 2012 American Association of Occupational Health Nurses
NOTE: The Connecticut, Illinois,
New Jersey, New York and Virgin
Islands plans cover public sector
(State & local government)
employment only.
State Occupational Health and
Safety Plans. (n.d.). United States
Department of Labor.
Occupational Health and Safety
Administration. Retrieved on
November 27, 2012 from:
http://www.osha.gov/dcsp/osp/in
dex.html
Figure 1
420
Section 6 of the OSH Act states
Section 6 of the OSH Act states – OSHA has the responsibility to promulgate legally enforceable occupational
health and safety standards.
– Standards are developed to eliminate or reduce risks; compliance with standards must occur to the
technologic and economic extent possible
– OSHA standards must be reasonably necessary or appropriate to provide safe or healthful employment
and places of employment
– The development of standards is an interdisciplinary process involving individuals from the fields of
health care, epidemiology, law, economics, and industrial hygiene. Standards are written by OSHA
employees and invited consultants.
– OSHA standards are developed by a public rule-making process that includes the following features:
– OSHA has enacted published standards, a current list of which can be found at the OSHA website:
Regulations – (Standards – 29 CFR) at:
http://www.osha.gov/pls/oshaweb/owasrch.search_form?p_doc_type=STANDARDS&p_toc_level=0&p_k
eyvalue=
– OSHA can implement emergency standards as proposed permanent standards effective for 6 months.
– There are 28 standards that have medical surveillance provisions. (Figure 2)
– OSHA Part 1910 Occupational Safety and Health Standards sub-part Z is a series of tables, known as the Z
tables, which list permissible exposure limits for substances for which standards are in place and for
those for which a standard has not been generated.
» A current listing of the Z-tables can be found at the following:
http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=9992
Copyright 2012 American Association of Occupational Health Nurses
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General Industry (29 CFR 1910)
Figure 2
General Industry (29 CFR 1910)
•
1910 Subpart H, Hazardous materials
–
1910.120, Hazardous waste operations and emergency response [related topic page]
•
1910 Subpart I, Personal protective equipment [related topic page]
–
1910.134, Respiratory protection [related topic page]
•
1910 Subpart Z, Toxic and hazardous substances [related topic page]
–
1910.1001, Asbestos [related topic page]
•
Appendix H, Medical surveillance guidelines for asbestos (Non-mandatory)
–
1910.1003, 13 Carcinogens (4-nitrobiphenyl, etc.)
–
1910.1004, alpha-Naphthylamine
–
1910.1006, Methyl chloromethyl ether
–
1910.1007, 3,3'-Dichlorobenzidine (and its salts)
–
1910.1008, bis-Chloromethyl ether
–
1910.1009, beta-Naphthylamine
–
1910.1010, Benzidine
–
1910.1011, 4-Aminodiphenyl
–
1910.1012, Ethyleneimine
–
1910.1013, beta-Propiolactone
–
1910.1014, 2-Acetylaminofluorene
–
1910.1015, 4-Dimethylaminoazobenzene
–
1910.1016, N-Nitrosodimethylamine
–
1910.1017, Vinyl chloride
–
1910.1018, Inorganic Arsenic [related topic page]
•
Appendix C, Medical surveillance guidelines
–
1910.1025, Lead [related topic page]
–
1910.1027, Cadmium [related topic page]
–
1910.1028, Benzene [related topic page]
•
Appendix C, Medical surveillance guidelines for benzene
–
1910.1029, Coke oven emissions
•
Appendix B, Industrial hygiene and medical surveillance guidelines
–
1910.1030, Bloodborne pathogens [related topic page]
–
1910.1043, Cotton dust [related topic page]
–
1910.1044, 1,2-dibromo-3-chloropropane
•
Appendix C, Medical surveillance guidelines for DBCP
–
1910.1045, Acrylonitrile
•
Appendix C, Medical surveillance guidelines for acrylonitrile
–
1910.1047, Ethylene oxide [related topic page]
•
Appendix C, Medical surveillance guidelines for ethylene oxide (Non-mandatory)
–
1910.1048, Formaldehyde [related topic page]
–
1910.1050, Methylenedianiline
•
Appendix C, Medical surveillance guidelines for MDA
–
1910.1450, Occupational exposure to hazardous chemicals in the laboratories
•
Medical Screening and Surveillance.(n.d.). United States Department of Labor. Occupational
•
Health and Safety Administration. Retrieved on November 27, 2012 from:
http://www.osha.gov/SLTC/medicalsurveillance/index.html
Copyright 2012 American Association of Occupational Health Nurses
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OSHA
OSHA is authorized to enforce established standards by performing inspections, with
or without advance notice to the employer.
– Inspections may include a review of records, walk-through, and worker
interviews
– OSHA has established a system of inspection priorities in the following order:
• Imminent danger situations
• Fatalities and catastrophes resulting in hospitalization of three or more workers.
• Worker complaints of alleged violation of standards or previously identified
violations
• Planned inspections aimed at special high hazard industries, occupations or
substances.
– Workers or authorized worker representatives may request OSHA to perform
an inspection
– OSHA may issue citations identifying violations and specifying the penalty
associated with each violation
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OSHA
OSHA consults with business and industry about health and
safety issues. These consultation services primarily target small
business
– Employers can request an OSHA consultation to accomplish the
following:
• Identify and correct hazards
• Provide technical assistance related to work site hazards
• Provide education and training to health and safety personnel
– OSHA provides basic to advanced occupational health and safety
classes through the OSHA Training Institute
Copyright 2012 American Association of Occupational Health Nurses
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OSHA’s Voluntary Protection
Program (VPP)
• OSHA’s Voluntary Protection Program (VPP) was adopted in
1982. (http://www.osha.gov/dcsp/vpp/index.html)
• VPP Requirements include the following:
• A comprehensive written program demonstrating management
commitment and planning
• A thorough work site analysis
• Hazard prevention and control systems
• Safety and health training
• Active worker involvement
• A lost workday case rate of below 50% of the national average for the
specific industry (based on a review of 3 years of OSHA 300 logs)
• Periodic program evaluation with annual report submission
• Worker commitment
Copyright 2012 American Association of Occupational Health Nurses
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OSHA VPP
Participating employers are eligible for VPP awards. Award levels
are as follows:
• Star – exemplary work sites with comprehensive, successful
safety and health management systems
• Merit – effective stepping-stone to “Star”. Merit sites have
good safety and health management systems, but these
systems need some improvement to be judged excellent.
• Star Demonstration – designed for work sites with Star
Quality safety and health protection to test alternatives to
current Star requirements.
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OSHA
In 1988 OSHA instituted measures to ensure nursing
representation in policy making.
•
1988 – the first occupational and environmental health
nurse was hired by OSHA
•
1988 – an Occupational Health Nurse Intern Program was
introduced, available to nurses in graduate school who are
specializing in occupational health
•
1993 – the Office of Occupational Health Nursing was
formally recognized and established
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National Institute for Occupational
Safety and Health (NIOSH)
•
•
•
A part of the Centers for Disease Control and Prevention
(CDC), was also created by the OSH Act
Conducts or funds occupational health and safety research to
establish safe levels of toxic materials. This research is the
basis of OSHA standards.
NIOSH also provides training and education to occupational
health and safety professionals, including graduate programs
for occupational health nurses.
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The Occupational Safety and Health
Review Commission (OSHRC)
• An independent regulatory commission authorized by the
OSH act (http://www.oshrc.gov/)
• Members are appointed by the President with Senate
approval
• OSHRC is responsible for handling appeals filed by employers
who have received OSHA citations
Copyright 2012 American Association of Occupational Health Nurses
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Americans with Disabilities Act
(ADA) of 1990
The ADA is wide-ranging legislation intended to make American society more
accessible to people with disabilities. (http://www.ada.gov/)
– Disability is defined as
• A physical or mental impairment that substantially limits one or
more major life activities
• A record of such an impairment
• Being regarded as having such an impairment
– Title I of the ADA applies to employers (including public and private
employers, employment agencies, and labor unions) with more than
15 employees.
– Businesses must protect the rights of “qualified individuals with
disabilities” in all aspects of employment, including the application
process, hiring, firing, compensation and benefits, and training.
Copyright 2012 American Association of Occupational Health Nurses
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ADA
Qualified person with a disability is one who can perform the essential
functions of the job with or without “reasonable accommodation”.
– Reasonable accommodations may include the following:
• Making existing facilities used by workers readily accessible to and usable by
persons with disabilities
• Restructuring the job, modifying work schedules, or reassigning the worker to a
vacant position
• Acquiring or modifying equipment or devices; modifying examinations, training
materials, or policies; or providing qualified readers or interpreters
– Considerations related to providing reasonable accommodation
include the following (AAOHN, 1994):
• Decisions should be made by a multidisciplinary team that includes health and
safety professionals, human resource staff, and management
• The affected worker should be consulted regarding accommodations
Copyright 2012 American Association of Occupational Health Nurses
431
ADA
•
•
The ADA affects employment inquiries and medical examinations in the following
ways (Equal Employment Opportunity Commission [EEOC], 2000).
– Employers may not ask job applicants about the existence, nature, or severity
of a disability; however, they may ask about the applicants ability to perform
specific job functions.
– A medical examination may be performed after a conditional offer of
employment has been made, if examinations are required for all entering
workers in similar jobs; the post-offer examination does not have to be job
related.
– If an individual is not hired because of the post-offer examination:
• The reason for not hiring must be job-related and consistent with business
need.
• The employer must show that no reasonable accommodation was
available or that accommodation would impose an undue hardship
The EEOC enforces and regulates Title I of the ADA
Copyright 2012 American Association of Occupational Health Nurses
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Family and Medical Leave Act
(FMLA) of 1993 (29CFR825.118)
•
•
FLMA entitles eligible workers to take up to 12 weeks of unpaid, job-protected leave in a 12month period for the following reasons: (http://www.dol.gov/whd/fmla/#.ULT-C2eOwkY)
– The birth and care of the worker’s newborn child
– Adoption or foster placement of a child with the worker
– The care of a parent, spouse, or child with a serious health condition
– The worker’s inability to work because of a serious health condition
– any qualifying exigency arising out of the fact that the employee’s spouse, son, daughter,
or parent is a covered military member on “covered active duty;”
– Twenty-six workweeks of leave during a single 12-month period to care for a covered
servicemember with a serious injury or illness if the eligible employee is the
servicemember’s spouse, son, daughter, parent, or next of kin (military caregiver leave).
To be eligible for leave under the FMLA, the following conditions must be satisfied:
– The worker must work for a covered employer in a covered location (at least 50 workers
employed within 75 miles)
– The worker must have worked for the employer for a total or 12 months and worked at
least 1250 hours during the 12 months immediately before the leave.
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FMLA
• Under some conditions, workers may take FMLA leave on an intermittent
basis
– For example, in blocks of time or by reducing a normal week schedule
• A serious health condition includes the following:
(http://www.gpo.gov/fdsys/pkg/CFR-2010-title29-vol3/xml/CFR-2010title29-vol3-sec825-115.xml)
– Incapacity and treatment
– Pregnancy or pre-natal care
– Chronic conditions
– Permanent or long-term conditions
– Conditions requiring multiple treatments
– Absences plus treatment
– The full text of the regulations in included in Figure 3
Copyright 2012 American Association of Occupational Health Nurses
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FMLA
•
Rights and responsibilities under FMLA include the following:
• The worker has the right to return to the same or equivalent position with equivalent benefits,
compensation, and conditions of employment
• The worker has a responsibility to provide the employer with reasonable notice of the leave (at
least 30 days when foreseeable).
• The employer has the right to require medical certification to support the worker’s claim for
leave related to health conditions of self or a family member
• The Department of Labor has devised a “Certificate of Health Care Provider Form” to obtain
medical certification (available at http://www.dol.gov/whd/forms/WH-380-E.pdf)
• The employer has a responsibility to keep and maintain records regarding compliance with act.
They must also conspicuously post a notice containing information about the FMLA.
•
•
Several states have their own legislation governing family and medical leave
The United States Department of Labor’s (USDL) Employment Standards
Administration, Wage and Hour Division administers and enforces FLMA.
Copyright 2012 American Association of Occupational Health Nurses
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Code of Federal Regulations
Title 29 - LaborVolume: 3Date: 2010-07-01Original Date: 2010-07-01Title: Section 825.115 - Continuing treatment.Context:
Title 29 - Labor. Subtitle B - Regulations Relating to Labor (Continued). CHAPTER V - WAGE AND HOUR DIVISION, DEPARTMENT OF LABOR. SUBCHAPTER C - OTHER
LAWS. PART 825 - THE FAMILY AND MEDICAL LEAVE ACT OF 1993. Subpart A - Coverage Under the Family and Medical Leave Act.
§ 825.115
Continuing treatment.
A serious health condition involving continuing treatment by a health care provider includes any one or more of the following:
(a) Incapacity and treatment. A period of incapacity of more than three consecutive, full calendar days, and any subsequent treatment or period of incapacity relating to the same
condition, that also involves:
(1) Treatment two or more times, within 30 days of the first day of incapacity, unless extenuating circumstances exist, by a health care provider, by a nurse under direct
supervision of a health care provider, or by a provider of health care services (e.g., physical therapist) under orders of, or on referral by, a health care provider; or
(2) Treatment by a health care provider on at least one occasion, which results in a regimen of continuing treatment under the supervision of the health care provider.
(3) The requirement in paragraphs (a)(1) and (2) of this section for treatment by a health care provider means an in-person visit to a health care provider. The first (or only) inperson treatment visit must take place within seven days of the first day of incapacity.
(4) Whether additional treatment visits or a regimen of continuing treatment is necessary within the 30-day period shall be determined by the health care provider.
(5) The term “extenuating circumstances” in paragraph (a)(1) of this section means circumstances beyond the employee's control that prevent the follow-up visit from occurring as
planned by the health care provider. Whether a given set of circumstances are extenuating depends on the facts. For example, extenuating circumstances exist if a health care
provider determines that a second in-person visit is needed within the 30-day period, but the health care provider does not have any available appointments during that time
period.
(b) Pregnancy or prenatal care. Any period of incapacity due to pregnancy, or for prenatal care. See also § 825.120.
(c) Chronic conditions. Any period of incapacity or treatment for such incapacity due to a chronic serious health condition. A chronic serious health condition is one which:
(1) Requires periodic visits (defined as at least twice a year) for treatment by a health care provider, or by a nurse under direct supervision of a health care provider;
(2) Continues over an extended period of time (including recurring episodes of a single underlying condition); and
(3) May cause episodic rather than a continuing period of incapacity (e.g., asthma, diabetes, epilepsy, etc.).
(d) Permanent or long-term conditions. A period of incapacity which is permanent or long-term due to a condition for which treatment may not be effective. The employee or family
member must be under the continuing supervision of, but need not be receiving active treatment by, a health care provider. Examples include Alzheimer's, a severe stroke, or the
terminal stages of a disease.
(e) Conditions requiring multiple treatments. Any period of absence to receive multiple treatments (including any period of recovery therefrom) by a health care provider or by a
provider of health care services under orders of, or on referral by, a health care provider, for:
(1) Restorative surgery after an accident or other injury; or
(2) A condition that would likely result in a period of incapacity of more than three consecutive, full calendar days in the absence of medical intervention or treatment, such as
cancer (chemotherapy, radiation, etc.), severe arthritis (physical therapy), or kidney disease (dialysis).
(f) Absences attributable to incapacity under paragraph (b) or (c) of this section qualify for FMLA leave even though the employee or the covered family member does not receive
treatment from a health care provider during the absence, and even if the absence does not last more than three consecutive, full calendar days. For example, an employee with
asthma may be unable to report for work due to the onset of an asthma attack or because the employee's health care provider has advised the employee to stay home when the
pollen count exceeds a certain level. An employee who is pregnant may be unable to report to work because of severe morning sickness.
Copyright 2012 American Association of Occupational Health Nurses
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Health Insurance Portability and
Accountability (HIPAA) Act, 1996
The Health Insurance Portability and Accountability Act of 1996 was designed
to address industry inefficiencies related to health insurance plans and to
protect health care coverage for millions of workers and their families
– Title I – Healthcare access, portability, and renewability, which focuses on allowing
persons to qualify immediately for comparable health insurance when they change
employment
– Title II – Preventing health care fraud and abuse and providing for administrative
simplification that reduces the costs and administrative burden of health care by
providing electronic standards to be used throughout the health care industry.
– Title III – Tax-related provisions, which address various issues, including medical savings
and long-term services and contracts.
– Title IV – Application and enforcement of group health plan requirements and
clarification of continuation of coverage requirements.
– Title V – Revenue offsets, which address company owned life insurance and treatment
of individuals who lose citizenship
Copyright 2012 American Association of Occupational Health Nurses
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HIPAA
HIPAA includes important new protections for workers through:
– It limits exclusions for pre-existing conditions
– Prohibits discrimination against workers and dependents
based on their health status
– Guarantees renewability and availability of health
coverage to certain employers and individuals
– Protects many workers who lose health coverage by
providing better access to individual health insurance
coverage
Copyright 2012 American Association of Occupational Health Nurses
438
HIPAA
HIPAA’s Privacy Rule went into effect in April 2003: Covered entities” may not use or
disclose protected health information (PHI), except as allowed by the HIPAA Privacy
Rule for treatment, payment or health care operations, or under a specific
authorization from the individual who is the subject of the PHI, or for “Public Policy
Exceptions”.
• Protected Health Information (PHI) is health plan information that:
⁻ Identifies the individual
⁻ Relates to the individual’s health, health care treatment, or health care
payment
⁻ Is maintained or disclosed electronically, by paper, or orally
• The three categories of covered entities are:
⁻ Healthcare providers
⁻ Healthcare clearinghouses
⁻ Health plans
Copyright 2012 American Association of Occupational Health Nurses
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HIPAA
• Plans covered by the Privacy Rule include:
–
–
–
–
–
Medical insurance plans, including prescription drug benefits
Dental insurance plans
Vision insurance plans
Health care flexible spending accounts
Employee assistance programs (EAP) to the extent that they offer medical care
• Plans not covered by the privacy rule include:
–
–
–
–
–
–
Short-term and long-term disability
Accidental death and dismemberment (AD&D), a type of supplementary insurance
Worker’s compensation
Dependent care spending accounts
Life insurance
Other work-life benefits
Copyright 2012 American Association of Occupational Health Nurses
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HIPAA and OHNs
• OHNs must determine if they are a “covered entity”
– Are they involved in a “prior authorization” for care?
– Perform “disease management” for the plan?
– Perform health risk assessments for the plan?
– The computer system contains information that comes from the plan
(e.g., medical information, demographics)
– Provides services and submit bills to the plan
– Provides case management for persons covered by the health plans.
• Occupational and environmental health nurses who work with health plan
operation and PHI must be “fire-walled” from the rest of the company.
– Workers outside the unit cannot access PHI from the fire-walled unit
– The unit must comply with the privacy rule
Copyright 2012 American Association of Occupational Health Nurses
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HIPAA and OHN
An OHN subject to HIPAA as a “covered entity” MUST:
– Notify workers of their privacy rights and how their information can be used
– Obtain specific client authorization to use or disclose PHI for all purposes other than
treatment, payment, or healthcare operations and “Public Policy Exceptions”
– Protect PHI from inadvertent misuse and disclosure
– Train staff in appropriate administrative, physical, and technical safeguards to protect
PHI.
– Limit PHI disclosure to the “minimum necessary” to achieve the purpose, except in
limited circumstances.
– Permit individuals to review and amend health information
– Maintain an accounting of persons to whom PHI has been disclosed
– Appoint a “privacy officer”
– Establish Business Associate Contracts
– Comply with more stringent state laws.
Copyright 2012 American Association of Occupational Health Nurses
442
Public Policy Exceptions
–
–
–
–
–
–
–
–
–
–
–
As required by law
For public health
About victims of abuse, neglect or domestic violence
For health oversight activities
For judicial & administrative proceedings
For law enforcement purposes
About decedents (to coroners, medical examiners, funeral directors)
For cadaveric organ, eye or tissue donations
For research purposes
To avert a serious threat to health or safety
For specialized government functions (military, veterans, national
security, protective services, State Dept, correctional)
– For Workers’ Compensation
Copyright 2012 American Association of Occupational Health Nurses
443
HIPAA and OHN
If an independent nurse case manager is working for a “covered entity”, that nurse would be
considered a business associate and would need to sign an agreement to protect PHI in
accordance with the Privacy Rule
–
–
–
–
–
–
–
–
–
–
Even if not a “covered entity”, OHNs are affected by HIPAA regulations when they obtain PHI from other health care
providers who are covered entities
Covered health care providers will require worker authorization for release of
• Short-term and long-term disability information
• Pre-placement medical information
• Information on workers covered by the Family and Medical Leave Act and the Americans with Disabilities Act
• Fitness for duty medical information
Employers can mandate “blanket” authorizations as a condition for employment
If exams are performed in-house, authorizations are not needed
Covered health care providers should require HIPAA authorization forms
Authorization is not required for medical surveillance to comply with OSHA or for workplace injury/illness information
needed for OSHA recordkeeping
Covered health care providers must provide written notice to the worker that medical surveillance data will be
disclosed to the employer. (Notice may be posted at the worksite if the service is provided there)
Employers are not “covered entities” although their “Health Plans” are.
Worker records (including worker health records held in the occupational health department) are excluded from the
definition of PHI
Once an employer receives worker-related PHI, it is no longer protected by the Privacy Rule
•
•Copyright 2012 American Association of Occupational Health Nurses
444
References
•
•
•
•
•
•
•
•
•
•
•
1910.1000 Table Z-1 Limits for Air Contaminants (n.d.). Occupational Safety and Health Standards. Retrieved November 20,
2012 from: http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=9992
Americans With Disabilities Act (n.d.). U.S. Department of Justice. Retrieved on November 29, 2012 from:
http://www.ada.gov/
Certificate of Health Care Provider Form (n.d.). U.S. Department of Labor. Retrieved on November 29, 2012 from:
http://www.dol.gov/whd/forms/WH-380-E.pdf
Family and Medical Leave Act (n.d.). U.S. Department of Labor. Retrieved on November 29, 2012 from:
http://www.dol.gov/whd/fmla/#.ULjTk2eOwkZ
Medical Screening and Surveillance.(n.d.). United States Department of Labor. Occupational Health and Safety
Administration. Retrieved on November 27, 2012 from: http://www.osha.gov/SLTC/medicalsurveillance/index.html
Occupational Safety and Health Review Commission (n.d.). Retrieved on November 29, 2012
from:
http://www.oshrc.gov/
Regulations (Standards – 29 CFR) (n.d.). Occupational Safety & Health Administration. Retrieved November 29, 2012 from:
http://www.osha.gov/pls/oshaweb/owasrch.search_form?p_doc_type=STANDARDS&p_toc_level=0&p_keyvalue=
Salazar, M. (2011). Core Curriculum for Occupational & Environmental Health Nursing, 3rd edition. Pensacola, Fl:AAOHN.
Serious Health Condition (n.d.). 29(CFR)-Code of Federal Regulations. Retrieved on November 29, 2012 from:
http://www.gpo.gov/fdsys/pkg/CFR-2010-title29-vol3/xml/CFR-2010-title29-vol3-sec825-115.xml
State Occupational Health and Safety Plans. (n.d.). United States Department of Labor. Occupational Health and Safety
Administration. Retrieved on November 27, 2012 from: http://www.osha.gov/dcsp/osp/index.html
Voluntary Protection Programs (n.d.). Occupational Health & Safety Administration. Retrieved November on 29, 2012 from:
http://www.osha.gov/dcsp/vpp/index.html
Copyright 2012 American Association of Occupational Health Nurses
445
Ethical OHN Practice
Chad Rittle DNP, MPH, RN
Copyright 2012 American Association of Occupational Health Nurses
446
Content Overview
OHNs have confidentiality responsibilities for
personal medical information and must balance
that with injury and Personal Protected
Information (PPI)
• NOTE: The majority of the information for this section was
developed using information extracted from Chapter 3 of the
Third Edition of “Core Curriculum for Occupational &
Environmental Health Nursing.
– Salazar, M. (2011). Core Curriculum for Occupational & Environmental
Health Nursing, 3rd edition. Pensacola, Fl:AAOHN.
Copyright 2012 American Association of Occupational Health Nurses
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Objective
List ethical pitfalls encountered in a worksite
In Other Words: What Kinds Of Ethical
Conflicts Might You Encounter?
Copyright 2012 American Association of Occupational Health Nurses
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Professional Position on Ethics
• AAOHN Standards of Occupational and
Environmental Health Nursing, Standard XI,
Ethics: The occupational and environmental
health nurse uses an ethical framework for
decision-making in practice (AAOHN, 2004c).
(see Appendix I)
Copyright 2012 American Association of Occupational Health Nurses
449
Standards of Occupational and
Environmental Health Nursing*
Standards of Occupational and Environmental Health Nursing*
•
Standard I: Assessment
–
The occupational and environmental health nurse systematically assesses the health status of the client(s).
•
Standard II: Diagnosis
•
Standard III: Outcome Identification
•
Standard IV: Planning
•
Standard V: Implementation
•
Standard VI: Evaluation
–
–
–
–
–
The occupational and environmental health nurse analyzes assessment data to formulate diagnoses.
The occupational and environmental health nurse identifies outcomes specific to the client.
The occupational and environmental health nurse develops a goal-directed plan that is comprehensive and formulates interventions to attain expected outcomes.
The occupational and environmental health nurse implements interventions to attain desired outcomes identified in the plan
The occupational and environmental health nurse systematically and continuously evaluates responses to interventions and progress towards the achievement of desired
outcomes.
•
Standard VII: Resource Management
•
Standard VIII: Professional Development
•
Standard IX: Collaboration
–
–
–
•
The occupational and environmental health nurse assumes accountability for professional development to enhance professional growth and maintain competency.
The occupational and environmental health nurse collaborates with clients for the promotion, prevention, and restoration of health within the context of a safe and healthy
environment
Standard X: Research
–
•
The occupational and environmental health nurse secures and manages the resources that support occupational health and safety programs and services.
The occupational and environmental health nurse uses research findings in practice and contributes to the scientific base in occupational and environmental health nursing to
improve practice and advance the profession.
Standard XI: Ethics
–
The occupational and environmental health nurse uses an ethical framework as a guide for decision-making in practice.
Copyright 2012 American Association of Occupational Health Nurses
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Professional Position on Ethics
The AAOHN Code of Ethics (AAOHN, 2009) provides the ethical
framework to guide the conduct of the occupational and
environmental health nurse
– Ethics is synonymous with moral reasoning. Ethics is not law, but a
guide for moral action. Professional nurses, when making judgments
related to the health and welfare of the client, utilize these significant
universal moral principles. These principles are:
•
•
•
•
•
•
Right of self-determination
Confidentiality
Truth telling
Doing or producing good
Avoiding harm
Fair and nondiscriminatory treatment
Ethics is what you do when no one else is watching!
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Professional Position on Ethics
The Following Are The Code of Ethics Interpretive Statements
•
•
•
•
•
Occupational and environmental health nurses provide health, wellness, safety and other
related services to clients with regard for human dignity and rights, unrestricted by
considerations of social or economic status, personal attributes or the nature of the health
status.
Occupational and environmental health nurses, as licensed health care professionals, accept
obligations to society as professional and responsible members of the community.
Occupational and environmental health nurses strive to safeguard clients’ rights to privacy by
protecting confidential information and releasing information only as required or permitted
by law.
Occupational and environmental health nurses promote collaboration with other
professionals, community agencies, and stakeholders in order to meet the health, wellness,
safety and other related needs of the client.
Occupational and environmental health nurses maintain individual competence in nursing
practice, based on scientific knowledge, and recognize and accept responsibility for individual
judgments and actions, while complying with appropriate laws and regulations.
Copyright 2012 American Association of Occupational Health Nurses
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Ethics: Definitions
Definitions assure a common understanding of
ethical terms.
– Ethics – the philosophic study of conduct an moral
judgment.
– Morals – principles of right and wrong.
– Morality – society’s expectation as to what people
should or should not do.
– Value – an expression of worth or goodness.
– Moral justification – the reason for conduct.
Copyright 2012 American Association of Occupational Health Nurses
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Ethics: Principles – Part 1
Ethical principles underpin ethical practices
– Autonomy - means self-governance – the ability to make individual
decisions and choices, to act, and to think; self-determination
– Nonmaleficence – the principle of doing no harm to others.
– Beneficence – the principle of doing good for others.
– Distributive justice – the benefits should be equally distributed and
equally shared in pursuit of the following three types of equality:
• Equality of moral worth
• Equality of opportunity
• Equality of outcome
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Ethics: Principles – Part 2
Other principles important to occupational and
environmental health nursing practice include the
following:
– Confidentiality – the implicit promise that information
divulged to another will be respected and not released or
repeated. (See Case Study)
– Veracity – truthfulness
– Honesty – freedom from deceit
– Promise-keeping – the act of following through on a
pledge
– Integrity – refers to unimpaired moral principles
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Ethical Conflicts – Your Responsibility
Assuring workers’ and others’ confidentiality is an
important ethical responsibility.
– Employers are charged with the responsibility for maintaining the
occupational health and safety records of their workers.
– The occupational and environmental health nurse, who is an agent of the
employer, is charged with providing occupational health service to workers
and maintaining health records; the occupational and environmental health
nurse has a duty to accomplish the following:
• Document care and services provided to a client.
• Maintain the confidentiality of the client’s health records.
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Ethical Conflicts – What To Do
When In Doubt
– If asked to divulge information contained in a worker’s health
record or to provide health records, the occupational and
environmental health nurse should consider the following
issues:
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For what purpose is the information being sought?
Is the requested information work related?
Who is requesting the information?
Is the requested information aggregate data or individual data?
Why was the information gathered?
Is the information being sought pursuant to an authorization for
release of health records signed by the worker?
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457
Ethical Conflicts – What You Might
See In The Workplace
Conflicts of interest and other ethical dilemmas may arise
in workplaces.
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The occupational and environmental health nurse has multiple roles in the
workplace, including worker, health care provider, client advocate, and
coworker; these multiple roles can result in ethical dilemmas that require
choosing between two or more compelling ethical or moral values.
The occupational and environmental health nurse may be asked to provide
the employer with information about the health needs of workers for use in
developing benefit plans, planning health education programs and services,
and identifying work site health issues.
The occupational and environmental health nurse may provide non-workrelated health care, such as periodic health assessments and screening
programs and services.
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Please Note:
The Release of non-work-related health
records requires an authorization for
release of health records BY THE CLIENT
whose records are being released!
Copyright 2012 American Association of Occupational Health Nurses
459
Case Study #1 – Confidentiality
N.O. Moore, an occupational and environmental health nurse at E.Z. Con, Ltd., performed spirometry testing
and respirator fit testing for Joe Cool. This was Mr. Cool’s pre-placement evaluation at E.Z. Con. During the
initial evaluation, Ms. Moore noted that Mr. Cool had smoked two packs of cigarettes daily for the past 25
years, and that he was an HVAC (heating, ventilation, and air conditioning) specialist. Mr. Cool admitted that
he used to smoke 2-6 joints of marijuana per day, but stopped 10 years earlier. Ms. Moore talked with Mr. Cool
about his smoking, risk factors for disease, and environmental hazards at E.Z. Con.
• Two years later, Ms. Moore received several letters in the mail and several phone calls about Mr. Cool. The
first letter, from an attorney who said he represented Mr. Cool, requested medical records from E.Z.Con.
An authorization signed by the attorney was enclosed.
• The second letter, from Mr. Risk at ABC Company, requested a copy of Mr. Cool’s medical records at
E.Z.Con. An authorization signed by Mr. Cool, and dated 2 days before Ms. Moore received the letter was
enclosed.
• The third letter from Mrs. Cool, stated that Mr. Cool had died of a mesothelioma 3 months earlier and
requested his medical records from E.Z.Con. An authorization signed by Mrs. Cool was enclosed.
• Ms. Snoopy from personnel called Ms. Moore and instructed Ms. Moore to make a copy of Mr. Cool’s
medical records for the vice president. Snoopy said that she would be down to get the records in 15
minutes.
• An attorney from H.E.L.P., E.Z.Con’s corporate counsel, called and demanded a copy of Mr. Cool’s medical
records.
Copyright 2012 American Association of Occupational Health Nurses
460
Case Study #2 – Ethics
Nancy Cohn is an occupational and environmental health nurse for a large
manufacturing company. The company is self-insured for worker short-term disability
(STD) benefits. It is Ms. Cohn’s responsibility to obtain medical information and
approve/deny STD. The medical information is provided by the worker’s attending
physicians. The form used to obtain the medical information is signed by the worker
and includes a specific consent to release pertinent information to his employer. On a
regular basis Ms. Cohn provides company management with a list of workers who are
off work on STD and estimated return to work dates
Ms. Cohn’s recently hired environmental health and safety (EHS) manager, Steve
Manager, requests that Ms. Cohn forward all completed STD medical information
forms to him so that he can verify how Ms. Cohn is managing the program. Ms. Cohn
refuses the request, citing legal and ethical issues. The company attorney is consulted
who opines that there is nothing legally preventing release of the information since
the worker has signed a consent for release of the information to the company.
Copyright 2012 American Association of Occupational Health Nurses
461
Questions??
Break
Copyright 2012 American Association of Occupational Health Nurses
AAOHN Certificate
Process
Barb Maxwell RN, MHA, COHN-S, CCM, CWCP, QRP,
FAAOHN
Copyright 2012 American Association of Occupational Health Nurses
Objectives
List other requirements for the AAOHN
certificate 30 minutes
Copyright 2012 American Association of Occupational Health Nurses
Opening Statement
• The Occupational Health Nurse specialty has depth and
breadth and requires a variety of skills that are seldom
attained in an associate or bachelor’s education.
• The value of the AAOHN Certificate:
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Gives prestige and legitimacy to the occupational health specialty.
Allows satisfaction of employer and regulatory requirements.
Promotes the recruitment and retention of certificants.
Certification is a voluntary process that involves the formal recognition
of specialized knowledge, skills, and experience demonstrated by
achievement of standards.
– Periodic renewal of the certificate will require continuing education.
Copyright 2012 American Association of Occupational Health Nurses
Obtaining an AAOHN certificate
• To obtain an AAOHN certificate, the OHN must
also show successful completion of:
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Pulmonary Function, including fit testing
Audiometry
Ergonomics
Health coaching
Copyright 2012 American Association of Occupational Health Nurses
Pulmonary Function
• The National Institute for Occupational Safety
and Health (NIOSH) has the responsibility to
approve courses in spirometry for instruction
of those individuals who will be administering
screening pulmonary function testing to
employees.
• Pulmonary Function Training must be a NIOSH
approved course.
Copyright 2012 American Association of Occupational Health Nurses
Pulmonary Function
• The course design must include at least 16 hours of
instruction with the following components:
• At least four hours of formal lectures and/or audio
visual material.
• At least eight hours of small group practical
instruction.
• At least two hours per student devoted to evaluation
and testing of the student's spirometry testing skills.
Evaluation consists of a written and a practical
examination.
Copyright 2012 American Association of Occupational Health Nurses
Pulmonary Function
The course content should include:
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Basic physiology of the forced vital capacity maneuver and the determinants of
airflow limitation with emphasis on the relation to repeatability of results.
Instrumentation requirements including calibration check procedures and sources
of error and their correction.
Performance of testing including subject coaching, recognition of improperly
performed maneuvers, and corrective actions.
Data quality with emphasis on repeatability.
Actual use of the equipment under supervised conditions.
Measurement of tracings and calculation of results.
Though all NIOSH-approved courses must have the minimal required content in
common, the courses vary somewhat in the additional topics that are covered, and
some courses are more than 16 hours in length.
Copyright 2012 American Association of Occupational Health Nurses
Audiometry
• The Council for Accreditation in Occupational
Hearing Conservation's (CAOHC) main
objective is to provide education, information
and guidance to industry and those serving
industry regarding the successful
implementation of an occupational hearing
conservation program.
• It seeks to prevent occupational hearing loss.
Copyright 2012 American Association of Occupational Health Nurses
Audiometry
Course Objectives: To prepare students to be eligible for certification through
the Council for Accreditation in Occupational Hearing Conservation (CAOHC).
Students will gain background knowledge as well as a basic and fundamental
understanding of the following:
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Responsibilities and limitations of an Occupational Hearing Conservationist, (OHC).
Responsibilities of other members of the OHC Program Team, with particular attention to the professional supervisor
Basic anatomy and physiology as they relate to hearing evaluation
Types and causes of hearing loss
Parameters of sound as they relate to hearing conservation
Hearing Conservation Regulations: Federal (OSHA) (and, as applicable: State, MSHA, and Department of Defense)
Types of audiometric instrumentation
Performance check and calibration of audiometric instrumentation
Care and troubleshooting of instrumentation
Pure-tone threshold testing and otoscopic screening techniques
Appropriate feedback to employees concerning test results and criteria for employee referral.
Basic concepts and principles of noise measurement and control
Personal hearing protection devices
Employee hearing conservation education, training, and motivation
Basics concepts and principles of hearing conservation program evaluation
Recordkeeping
Copyright 2012 American Association of Occupational Health Nurses
ERGONOMICS
• Ergonomics “is the science of designing and
arranging the physical environment,
equipment and organization of work to most
safely and effectively fit the human body of
the worker” (AAOHN, n.d.).
• The goal of this practice is to prevent workrelated musculoskeletal disorders.
Copyright 2012 American Association of Occupational Health Nurses
ERGONOMICS
• Ergonomic certification certifies that you are
able to perform a basic office and
industrial/manufacturing/healthcare
ergonomics analysis using OSHA ergonomics
assessment tools.
Copyright 2012 American Association of Occupational Health Nurses
HEALTH COACHING
Health Coaching
• The means of generating responsibility, self-motivation and awareness to
enhance performance leading to improved health.
Health Coach Certification
• Training focuses on evidence-based health coaching for healthcare
providers.
• Techniques used engage the patient/client and guide them (not direct
them) toward goals.
• By empowering them, it taps into his or her personal motivation to change
unhealthy behavior.
• National Society of Health Coaches provides a certification course which is
endorsed by AAOHN.
Copyright 2012 American Association of Occupational Health Nurses
Bibligraphy
• American Association of Occupational Health
Nurses (AAOHN), (n.d.) Ergoresources
Retrieved. November 14, 2004
• www.occupational .com
• www.cdc.gov
• www.caohc.org
Copyright 2012 American Association of Occupational Health Nurses
QUESTIONS??
Thank you all for
attending
Copyright 2012 American Association of Occupational Health Nurses
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