Occupational Health Nursing Education for the 21st Century

Occupational Health Nursing Education for the 21st Century by Marjorie C. McCullagh, PhD, RN, PHCNS-BC, COHN-S

Abstract Occupational health nurses are the largest group of occupational health professionals, and are critical to the delivery of quality health care services to the nation’s work force. Educational preparation of occupational health nurses has advanced in recent years, and the need for occupational health nurses with advanced degrees is expected to increase. Occupational health nurses use licensure, continuing education, certification, supervisor and peer assessment of job performance, formal education, and practice to maintain their professional competence and protect the public’s health. New strategies must be developed to prepare nurses to promote a safe and healthful work force. Funding for programs to prepare occupational health nurses will be essential for meeting this demand. Continuing education programs for occupational health nurses must be developed that demonstrate effectiveness in developing occupational health nurses’ skills while minimizing their time away from the workplace.

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ccupational health nurses promote the health of the nation’s work force by preventing injury and illness and promoting safe and healthful behaviors. They are the largest group of occupational health professionals (American Association of Occupational Health Nurses, Inc. [AAOHN], 2009). The roles of occupational health nurses are numerous and diverse, including management, assessment, direct care, prevention, and research. According to a 2006 Health Resources and

ABOUT THE AUTHOR

Dr. McCullagh is Assistant Professor, Occupational Health Nursing Program, University of Michigan School of Nursing, Ann Arbor, MI. The author received an honorarium from the American Association of Occupational Health Nurses, Inc., to write this article. Address correspondence to Marjorie C. McCullagh, PhD, RN, PHCNS-BC, COHN-S, Assistant Professor, Occupational Health Nursing Program, University of Michigan School of Nursing, 400 N. Ingalls Street, Suite 3182, Ann Arbor, MI 48109. E-mail: [email protected]. Received: December 13, 2011; Accepted: January 17, 2012. doi:10.3928/21650799-20120328-21

WORKPLACE HEALTH & SAFETY • Vol. 60, No. 4, 2012

Services Administration (HRSA) survey, 22,447 nurses reported they were occupational health nurses (Thompson, 2010). The work of occupational health nurses takes place in a variety of settings, including manufacturing, mining, construction, agriculture, health care, and government (e.g., local, state, and federal agencies). Historical Context of Nursing Education Although nursing education has been primarily collegiate based in recent years, prior to the 1960s, hospitals were the most common sites for nursing education. In this model, student nurses typically worked long hours caring for hospitalized patients under the supervision of graduate nurses. However, these apprentice-type programs, typically lasting 2 or 3 years, were criticized for their expense to hospitals and inferior education for students (Kalisch & Kalisch, 1978). Today, about 13% of registered nurses claim the hospital-based “diploma”

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program as their highest level of education in nursing (HRSA, 2010), although few diploma programs remain in the United States. Most newly licensed registered nurses today completed their initial nursing education through an associate or bachelor’s degree program in nursing. The associate degree in nursing is most commonly awarded following a 2-year program of study in a technical or community college, and became popular in the 1950s as a program designed for the education of nurse technicians (American Nurses Association, 1965). Today, 37% of nurses report an associate degree as their highest level of nursing education (HRSA, 2010). The bachelor’s degree in nursing is usually awarded following a 4-year program of study in a university setting. Nearly half (47%) of registered nurses today have a bachelor’s or higher degree in nursing (HRSA, 2010). The master’s degree and specialization in nursing emerged after World War II. Today, the number of nurses with a master’s or higher degree is greater than ever, at 13% (HRSA, 2010). This number includes nurses with advanced degrees in nursing and other areas. Contemporary Educational Pathways for Nurses For decades, nursing leaders have called for the baccalaureate degree to be the minimal educational level for entry into nursing practice (American Association of Colleges of Nursing, 2000; American Nurses Association, 1965; American Society for Nursing Service Administrators, 1982; Benner, Sutphen, Leonard, & Day, 2010; Institute of Medicine [IOM], 2010), but associate degrees continue to be the most commonly reported type of initial education in nursing, representing 45% of registered nurses (HRSA, 2010). However, the current nursing education model allows nurses to build on their initial education and progress from associate to terminal degree. This model is contrasted with those used in other health disciplines (e.g., pharmacy, dentistry, medicine); a clinical doctorate is the degree required for entry into practice. Curricula and Programs of Study

The undergraduate nursing curriculum typically includes courses in science (e.g., biology, microbiology, chemistry, psychology, sociology, pharmacology), mathematics, English language, nursing skills (e.g., medication administration, health assessment, health care procedures), and application of nursing process in various clinical specialty areas (e.g., adult health nursing, maternal-child nursing, mental health nursing). Baccalaureate programs also include courses in nursing research, management, and public/community health nursing. Nurses who graduate with a bachelor’s degree in nursing are prepared to function in a wide variety of clinical practice settings (e.g., acute care, home care, and ambulatory care) and are considered generalists in nursing practice (American Association of Colleges of Nursing, 2008). Although occupational health nursing is ideally a component of the public/community health nursing curriculum, few recent studies have examined how this topic

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is addressed in baccalaureate curricula. Many contemporary faculty report a persistent lack of awareness among students, employers, and the public of the role of occupational health nurses and their contributions to maintaining a safe and healthy work force (Occupational Health Nursing Task Force, 2010). It is somewhat ironic that, although the subspecialty of occupational health nursing may be virtually invisible within the discipline of nursing, 22,447 nurses’ principal role is occupational health and they are in daily contact with workers (Thompson, 2010). Nursing education programs have been criticized for their weak science and liberal arts foundation, and some have called for improved teaching methods to assist students in applying nursing knowledge to client care (Benner et al., 2010). In the 2010 Carnegie report, Benner et al. (2010) point to the power of clinical learning experiences. In a model program at the University of Georgia, undergraduate nursing students have an opportunity to learn about occupational health nursing in the classroom, and to engage with practicing occupational health nurses in supervised clinical practice (Adrienne Holland, Occupational Health Manager, UPS, personal communication, October 13, 2011). Graduate Education Programs for Advanced Practice Occupational Health Nursing

A variety of graduate study options are available to nurses, both within and outside nursing. Although the following section addresses degree options in nursing, nurses are well represented in graduate degree programs outside of nursing (e.g., education, public health, and psychology). At the master’s level, nurses often specialize in a narrow clinical practice area (e.g., adult primary care nursing, mental health nursing, or occupational health nursing) and are considered specialists. Specialist education includes the study of nursing theory and research, a variety of topics specific to the nursing specialty, and courses in non-nursing disciplines related to the nursing specialty. For example, a student in adult primary care nursing will complete courses in nursing theory and research, as well as primary care nursing, health assessment, pathophysiology, and pharmacology. The academic program will also include prescribed hours of clinical practice under the supervision of a qualified clinical supervisor. Completion of the academic nursing program at the specialist level is the first step in becoming a specialist in nursing practice. After completion of the master’s program of study, the degree of master of science is conferred by the college or university where the student was enrolled. Typically, several years (average, 8 years) lapse between completion of the bachelor’s degree in nursing and the master’s degree (HRSA, 2010); nurses often pursue experience in clinical practice during this period. Based on the 2004 National Sample Survey of Registered Nurses (Thompson, 2010), 9% of occupational health nurses report advanced practice status; this compares favorably with the proportion of the entire sample of registered nurses (8%). Further, 21% of occupational

Copyright © American Association of Occupational Health Nurses, Inc.

health nurses reported certification by one or more national nursing credentialing organizations. Specialist education in occupational health nursing is offered at most National Institute for Occupational Safety and Health (NIOSH)-funded Education and Research Centers (ERCs) nationally, and a limited number of additional academic programs. Specialist education prepares nurses to practice a diversity of occupational health nursing roles, including clinician, case manager, service coordinator, health promotion specialist, manager, and consultant. Some programs may prepare nurses in additional roles, such as nurse practitioner, researcher, and educator. The composition and balance of roles varies widely with employer, setting, and position requirements (AAOHN, 2007). In addition, two common terminal degrees in nursing, doctor of philosophy (PhD) and doctor of nursing practice (DNP), are now offered by many universities across the country. The PhD degree in nursing focuses on theory and research methods relevant to the specialty, and prepares students to function as educators and researchers. Graduates of these programs are often employed in academic or government (e.g., Centers for Disease Control and Prevention [CDC], NIOSH) settings. Some PhD graduates continue their education in post-doctoral study, focusing on further development of their research skills. In response to the increasing complexities of health care delivery, rapid scientific developments, and societal demands, a relatively new practice degree in nursing has emerged, the DNP. This clinical doctorate is similar to that of other health disciplines (e.g., medicine, dentistry, podiatry, pharmacy, psychology, physical therapy). This degree is recommended by the American Association of Colleges of Nursing as the entry-level degree for nurses in advanced practice (e.g., nurse practitioners, clinical nurse specialists, nurse midwives, and nurse anesthetists). The curriculum in the DNP program of study typically includes relevant science, advanced nursing practice, leadership, quality improvement, health policy, and application of clinical research (American Association of Colleges of Nursing, 2004). The DNP degree is currently being implemented in occupational health nursing education programs in select NIOSH ERCs (Occupational Health Nursing Task Force, 2010). The diversity of degree offerings in nursing serves the public by providing education for professional nurses who care for clients and populations to the full extent of their legal scopes of practice. It is common for nurses to continue their education beyond their initial program. Today, many education programs are designed for nurses with specific educational backgrounds and goals (e.g., associate to bachelor’s degree, second career bachelor’s degree, bachelor’s to DNP degree). Availability of diverse educational programs in nursing and nursing-related disciplines provides opportunities for nurses to expand their skills and advance their careers, to the benefit of nurses, clients, and society. The NIOSH ERCs

With an increased awareness of challenges to worker health and safety, the Occupational Safety and Health


Administration (OSHA) and NIOSH were established in 1970 (MacLaurey, 1984; NIOSH, 2011). A work force assessment conducted soon thereafter by NIOSH revealed a shortage of qualified industrial health and safety specialists. Although some educational programs for “industrial nurses,” as they were known, existed prior to the Act, this study led to the establishment of 12 centers to provide the initial and ongoing education of a qualified occupational safety and health work force (Midwest Center for Occupational Safety and Health, n.d.; Parker-Conrad, 2002). Since the mid-1970s, NIOSH has fulfilled its mission to provide training programs for occupational health and safety professionals through its support of ERCs at selected universities across the country. The 21st century ERCs, operated in collaboration with universities, provide health and safety education programs in occupational health nursing as well as industrial hygiene, occupational medicine, and occupational safety (University of Minnesota, n.d.). Currently, the NIOSH ERCs are threatened with elimination through governmental budget reductions. Owing to their critical role in preparing occupational and environmental health nurses and other occupational and safety professionals, elimination of the ERCs would rapidly result in a shortage of these professionals and negatively impact the safety of workplaces and the competitiveness of businesses. The ERCs not only represent an investment in the health of the work force, they also support the growth needed in this period of slow economic recovery. The quality of educational programs offered by the ERCs was recently affirmed by the results of an employer survey. Employers of occupational safety and health professionals indicated their overall satisfaction with the job performance of program graduates in core competency areas (McAdams, Kerwin, Olivo, & Goksel, 2011). Ten of the 17 ERCs located throughout the country offer specialist programs in occupational health nursing. Nurses interested in occupational health and safety can pursue a variety of degree options at these ERCs, including master’s degrees, the DNP degree, and the PhD degree. At the master’s level, program options include occupational health nurse manager and nurse practitioner; however, not all degree programs or program options are offered at each site. The nursing programs combine public health and occupational health nursing content and practice. Nurses study in a collaborative learning environment with students from other occupational health disciplines. Program faculty are well qualified, both academically and clinically, in occupational health nursing, and clinical practica are offered in a variety of work settings (e.g., worksite health programs, freestanding occupational health clinics, hospital-based occupational health clinics, and public health departments). NIOSH funding provides tuition assistance and stipends to qualified students. Programs prepare students to take the American Board for Occupational Health Nurses, Inc. (ABOHN) Certified Occupational Health Nurse-Specialist (COHN-S) examination. In addition to degree-granting educational programs,

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ERCs offer interdisciplinary continuing education of interest to nurses, and most offer nursing continuing education contact hours. Programs are offered in both the university setting and other locations convenient to occupational health nurses (e.g., at the worksite, in metropolitan areas, and at AAOHN meetings) and are generally open to all interested nurses. Some offerings may be available online through webinar or asynchronous formats, and qualify for meeting state licensure renewal or recertification requirements. Most programs maintain an e-mail listserv, so nurses are notified of upcoming occupational health nursing continuing education opportunities in their geographic and interest areas. Each ERC occupational health nursing program is led by a nurse educator with the title of Director. These directors are licensed professional nurses as well as accomplished educators. Each one has a program of research and record of publications that focus on one or more aspects of worker health and safety. More information about the ERCs, including contact information, is available at an associated website (University of Minnesota, n.d.). ERCs are located in Alabama, California (having two ERCs), Colorado, Florida, Illinois, Iowa, Maine, Maryland, Michigan, Minnesota, New Jersey, North Carolina, Ohio, Texas, Utah, and Washington. Monitoring and Control of Nursing Education In addition to external reviews of their host institutions, and internal reviews of their programs by their host college or university, most nursing programs voluntarily submit to external review of their baccalaureate and higher degree programs by an accrediting body in nursing. This external review ensures the quality of programs preparing nurses, and is conducted through either of two associations recognized by the U.S. Secretary of Education: the Commission on Collegiate Nursing Education (CCNE) or the National League for Nursing (NLN). Accreditation review is comprehensive, encompassing the mission, governance, program resources, curriculum, teaching-learning practices and outcomes, student performance, and faculty accomplishments. As well as monitoring program quality, the process encourages program self-assessment and a process of continuing improvement. Programs seeking accreditation complete a self-assessment and companion written report and undergo a visit to their university and clinical facilities by a team of specially prepared nurse educators and clinicians and a review by the accrediting body review board. Accreditation approval is granted for a period of 10 years, or an increment thereof (CCNE, 2008). Accreditation by CCNE or NLN provides students and others assurance of program quality. Information about individual program accreditation status is commonly found on the collegiate nursing program website. In addition to the reviews discussed above, NIOSHsponsored ERCs undergo periodic (i.e., usually every 5 years) review by a NIOSH review panel. The review process includes an examination of the ERC’s application for competing renewal and a virtual visit by conference call

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of an interdisciplinary team of reviewers. The site visitors observe facilities and interview faculty, students, alumni, and staff, verifying information included in the ERC funding application. The site visitors submit a written report of their findings to a NIOSH review panel, which then makes the funding determination (NIOSH, 2010). Occupational Health Nurse Credentialing Nurses undergo a variety of credentialing processes: graduation, licensure, and certification. These credentialing processes may be confusing, particularly to individuals outside of professional nursing practice. Generally, following satisfactory completion of an academic degree program with supervised clinical practice (and for some specialties, years of professional practice), graduates are eligible to seek certification in the clinical area(s) in which they focused their studies. Certification is recognition by a professional association for individuals who have “specialized knowledge, skills, and experience demonstrated by achievement of standards identified by a nursing specialty to promote optimal health outcomes” (American Board of Nursing Specialties, 2009). Certification assures the public that an individual has mastered a body of knowledge and skills in a particular specialty. Although certification may be mandated for entry into practice (e.g., for nurse practitioners, nurse midwives, and nurse anesthetists), voluntary certification may be used as validation of competence or recognition of excellence. Currently, certification for practice as an occupational health nurse is voluntary. In addition to licensure and certification, in some settings nurses may also be required to meet criteria for authorization to practice, or privileges. Although multiple bodies provide nursing certifications, ABOHN has been the certifying body for occupational health nursing for the past 40 years and is certified by the National Commission for Certifying Agencies. Like other certifying bodies, ABOHN “uses predetermined standards of nursing practice to validate an individual registered nurse’s qualifications, knowledge and practice in specific areas of occupational health nursing” (ABOHN, 2008). Occupational health nursing certification requires a written examination and clinical experience. Certification examinations are offered by appointment at testing centers in 150 cities throughout the United States. The examination is based on scientifically valid surveys of occupational health nurses’ knowledge, skills, and abilities, as reflected by the tasks they perform (Strasser, Maher, Knuth, & Fabrey, 2006). ABOHN offers certifications in a variety of areas, including occupational health nursing, case management, and safety management. Certification in occupational health nursing is offered at two levels, basic (certified occupational health nurse, or COHN, for nurses with associate degrees and diplomas in nursing) and specialist (certified occupational health nurse-specialist, or COHN-S, for nurses with bachelor’s degrees or higher). Renewal of certification is required every 5 years through continued practice and education requirements related to occupational health (e.g., 3,000 practice hours and 50 continuing education hours


for both COHN-S and COHN). The ABOHN directory includes the names of more than 5,195 nurses with active credentials; 1,295 are certified at the level of COHN, and 3,900 are certified as COHN-S. Of ABOHN-certified nurses, 2,148 hold bachelor’s degrees, and another 1,344 hold master’s or higher degrees (Molly Taylor, ABOHN, personal communication, November 1, 2011). Nurses, workers, and employers benefit when nurses become certified in occupational health nursing. For employers and workers, certification assures the public that the holder has met predetermined standards in the specialty of occupational health nursing. For the nurse, certification may lead to employment opportunities, professional advancement, greater earning potential, job satisfaction, personal achievement, and professionalism. Furthermore, employers, peers, and consumers associate certification with accountability, accomplishment, growth, specialized knowledge, and recognition (Niebuhr & Biel, 2007). Occupational Health Nurse Continuing Education Continuing education is a tenant of professional practice. Many State Boards of Nursing and certification agencies in the United States require a specified number of continuing education contact hours, which vary, for professional nursing license renewal and recertification. Occupational health nursing continuing education is available to nurses through a variety of formats and providers. Some academic institutions offer continuing education programs in occupational health nursing leading to a certificate in the specialty. These certificate programs do not lead to a formal degree, but provide practicing occupational health nurses opportunities to strengthen their knowledge and expertise in occupational health nursing in a structured format. For example, the University of North Carolina at Chapel Hill offers an occupational health nursing certificate that includes 11 to 12 academic credits of study in occupational health nursing and related areas (e.g., toxicology, safety, and epidemiology) (University of North Carolina, Gillings School of Global Public Health, 2011). Individual state licensing boards and national nursing certification programs have their own unique requirements for continuing education. Most requirements focus on the number of hours of programming and content. For example, nurses seeking registered license renewal in the state of Florida must complete 25 hours of continuing education every 2 years. In addition, applicants for license renewal must complete at least 3 hours of continuing education in specially named topic areas (e.g., HIV/ AIDS and prevention of health care errors). Nurses seeking recertification as COHN or COHN-S are required to have 50 hours of continuing education related to occupational health nursing every 5 years. Topic areas accepted as related to occupational health nursing are identified in the Test Content Outline and Core Content List in the Blueprint for the COHN and COHN-S examinations. More information about test content is available at the organization website (ABOHN, 2008).


One of the missions of AAOHN is to provide educational opportunities for nurses. The annual meeting provides a convenient, economical mechanism for occupational health nurses to acquire current knowledge and skills. AAOHN generally attracts several hundred members to its annual convention. The meeting includes business and plenary sessions and an extensive array of continuing education offerings of interest to occupational health nurses. Continuing education faculty and proposed content are carefully selected by AAOHN peer reviewers prior to the conference. Sessions lasting up to 3 days are attended by hundreds of members annually. AAOHN also offers online synchronous learning through its webinar series. Webinars are offered on a variety of topics related to occupational health nursing, and are available to members as well as non-members for purchase. Webinars are recorded, and are available for asynchronous viewing online subsequent to their original broadcast. AAOHN also publishes a continuing education article in each issue of its official publication, Workplace Health & Safety, for continuing education contact hours. AAOHN is an approved provider of continuing education by the American Nurses Credentialing Center, and annually approves hundreds of hours of continuing education programs from occupational health nursing organizations across the country. Trends in Occupational Health Nursing Education Data regarding the educational preparation of occupational health nurses are available from the National Sample Survey of Registered Nurses (HRSA, 2004, 2010). This survey is the most authoritative source of information regarding U.S. registered nurses. Sampling 30,000 to 35,000 registered nurses in each study year, the survey has had a response rate of 70% or higher in each year since 2004. Recent surveys were conducted in 1992, 1996, 2000, 2004, and 2008. Using public use files supplied by the National Sample Survey of Registered Nurses, Thompson (2010) identified the demographic and employment characteristics of nurses employed in an occupational health setting at the time of the survey. A total of 277 nurses in the 2004 sample met this criterion. Results of the analysis of the 2004 National Sample Survey of Registered Nurses showed advancement of the educational preparation of occupational health nurses over time. As of 2004, 38% of occupational health nurses reported the baccalaureate as their highest level of education. This finding compares favorably to that of all employed registered nurses (34%). Among occupational health nurses, another 14% had master’s or doctoral degrees; among all registered nurses, this was 13%. These findings represent advancement of occupational health nurses from education levels reported in the 1992 study, which showed 22% had bachelor’s degrees and 8% had master’s or doctoral degrees. A 2008 survey has been completed, but analysis of these data for occupational health nurses is not yet available.

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In 2010, the IOM released its landmark report, The Future of Nursing: Leading Change, Advancing Health, which proposed recommendations to advance the roles, skills, and expertise of nurses in the reform of the nation’s health care delivery system. Several recommendations had direct implications for occupational health nursing. Specifically, the IOM (2010) recommended that, “Nurses should achieve higher levels of education and training in an improved education system that promotes seamless academic progression” (p. 29). This recommendation is consistent with a 2010 joint consensus statement by the American Nurses Association, the American Organization of Nurse Executives, the NLN, and the American Association of Colleges of Nursing (American Association of Colleges of Nursing, 2010). At a current level of 38%, the distribution of occupational health nurses holding bachelor’s degrees will need to increase sharply if the IOM goal of 80% is to be achieved by 2020. This goal is not likely to be achieved without the development of partnerships between employers of occupational health nurses and nursing education programs. Improved access to alternative learning formats (e.g., executive-style and distance education programs) may assist the large number of associate degree nurses who aspire to complete a bachelor’s degree. Other measures that may support nurses in their quest for higher education suggested by the IOM may include employer-sponsored tuition reimbursement programs, and salary differentials and promotions for educational achievement. The report also called for the development of transition-to-practice programs (i.e., nurse residencies); these programs are currently rare in occupational health nursing, but may represent one way to assist new graduates with the transition from education to practice and to prepare experienced nurses who are new to occupational health nursing. Although nurse residency programs are promising, research into the efficacy and cost-effectiveness of these programs is needed. The report also called on nursing education and nursing associations to support programs that assist nurses in entrepreneurial efforts to improve health care through the establishment of new programs and businesses. Occupational health nurses, with their broad understanding of occupational health and safety services, are well positioned to accept this entrepreneurial challenge and create new programs and services to improve the occupational health care system. A survey of employers of occupational health and safety professionals was recently released (McAdams et al., 2011). The results showed that the estimated number of occupational health nurses employers expect to hire during the next 5 years is substantially higher than the number estimated to graduate. About one third of the expected hires (n = 1,373) are needed at the master’s and doctoral level. Further exacerbating this shortage will be the anticipated retirement of a substantial number of the current occupational health nursing work force. Together, these trends point to an anticipated shortage of occupational health nurses, and a need for increased capacity among occupational health nursing education programs. This report also outlined employers’ expectations of oc-

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cupational health nurses’ competencies. In this survey, employers expressed particular interest in nurses with expertise in health and wellness services as well as leadership and communication. A review of the demographic profile of the occupational health work force demonstrates that men and minorities are underrepresented in this specialty, although more males are part of the occupational health nursing work force (8%) than the registered nurse work force in general (6%). In recent years, modest gains in the recruitment of non-White and Hispanic nurses to occupational health nursing have been realized, as the non-White, nonHispanic work force has declined in general from 94% in 1992 to 90% in 2004 (Thompson, 2010). Despite these recent gains, these figures show a need to increase recruitment of non-White and Hispanic nurses to occupational health programs. Although survey data do not clearly indicate the career paths of occupational health nurses, familiarity with this population indicates that nurses do not commonly enter the specialty directly from their initial education program. Rather, nurses usually find the specialty after years of practice in other areas. Data about the age of occupational health nurses confirm this observation, as occupational health nurses had the oldest average age (i.e., 50.8 years) among all nursing practice specialties included in the National Sample Survey of Registered Nurses, and few occupational health nurses reported their age as 29 or younger (Thompson, 2010). Anecdotally, many occupational health nurses report that they were not aware of the specialty until they were well into their nursing careers. THE Future of Nursing Education Nurse practitioners provide a wide range of preventive and acute care services to individuals (American College of Nurse Practitioners, n.d.). Although the nurse practitioner role is not new, the presence of nurse practitioners in occupational health settings has increased dramatically in recent years. The scope of nurses’ practice, including nurse practitioners, is determined by state legislation, and individual State Boards of Nursing are responsible for the regulation of nursing practice in their respective states. Although some variation exists between states in nurses’ authorization to prescribe and practice without a collaborative relationship with a physician, nurse practitioners are skilled in many facets of primary care, including physical examination, diagnosis and treatment of common acute and chronic problems, interpretation of laboratory results and x-rays, prescription of medications and other therapies, and client teaching, counseling, and referral. The emphasis of nurse practitioner services is on illness prevention and health maintenance (American Academy of Nurse Practitioners, 2010). The skills of the nurse practitioner are well suited to the occupational health setting. The nurse practitioner provides health assessment, diagnosis, and preventionoriented treatment to workers, often at the worksite (Pohl, Hanson, & Newland, 2010). These services facilitate early recognition of illness and injury and treatment, re-


duced absenteeism, and continuity of care. The quality of care delivered by nurse practitioners has been affirmed by numerous government and private studies (Barkauskas, Pohl, Benkert, & Wells, 2005; Horrocks, Anderson, & Sallisbury, 2002; Laurant et al., 2009; Lenz, Mundinger, Hoplins, Lin, & Smolowitz, 2002; Mundinger et al., 2000; Pohl, Vonderheid, Barkauskas, & Nagelkerk, 2004). This approach is attractive not only to employees, but also to management, due to its favorable return on investment (Griffith & Strasser, 2010). Similarly, occupational health nurse managers contribute their knowledge and skills to safe and healthful work environments through a variety of roles. Examples of occupational health nurse manager tasks include assessing, planning, delivering, and evaluating clinical services; case management; risk reduction and health surveillance; compliance with and development of workplace and professional practice laws and regulations; design and management of health, safety, and environmental services; planning and evaluating health promotion and disease prevention programs and services; developing and evaluating occupational and environmental health and safety programs and services; and applying research findings to promote the health of workers (AAOHN, 2007). These activities impact worker and community health and safety, thus contributing positively to the company’s profitability (AAOHN, 2009). The expertise of the occupational health nurse, whether manager or nurse practitioner, is complementary to that of other occupational health team members: industrial hygienist, safety engineer, toxicologist, and occupational physician. Each member of the team shares expertise in the basic sciences of these disciplines as well as a common philosophy. This common philosophy includes a value for human dignity and self-worth, the primacy of worker health and safety, and a commitment to the human and economic benefits of occupational health services aimed at health promotion and protection, prevention of disease and disability, and treatment of illness and injury (Rogers, 1994). The occupational health nurse collaborates to deliver health services to workers and their families, acknowledging that, to a significant degree, provision of a safe and healthful work environment is too complex for any one discipline to address alone. The role of the occupational health nurse is multifaceted and described in the AAOHN competencies, which are periodically reviewed and updated (AAOHN, 2007). The competencies are the result of a Delphi study, incorporating the expertise of member experts in all competency areas. The document identifies nine categories of competencies: clinical practice; case management; work force, workplace, and the environment; regulatory and legislative; management, business, and leadership; health promotion and disease prevention; health and safety education and training; research; and professionalism. Each competency includes three practice levels: competent, proficient, and expert. The AAOHN Competency Task Force developed the levels of practice consistent with Benner’s (1984) levels of nursing expertise, acknowledg-


ing that occupational health nurses are at different levels within each competency based on education, experience, and job position. For example, the competent occupational health nurse will monitor the work environment (e.g., for noise or other toxins) to protect the health and safety of workers. The proficient nurse will analyze risks associated with worksite hazards (e.g., evaluate the results of worksite monitoring to permissible exposure limits). The expert nurse will influence policy relating to occupational and environmental health risk reduction (e.g., select, supervise, and evaluate vendors of health services and products, such as audiology and hearing protection). Although risk and hazard analyses are common responsibilities of the occupational health nurse, published reports regarding these are less common. A cursory review of articles published in a recent 12-month period in the AAOHN Journal identified 16 articles focusing on studies of worker risk and hazard analysis. Additional publications of risk and hazard analyses can be found in other nursing and related journals. Individual professional nurses are responsible for maintaining their nursing competencies (AAOHN, 2007; Neuman & Dixon, 2010). At the most basic level, professional nursing program graduates are required to pass a standardized examination (i.e., National Council Licensure Examination for Registered Nurses [NCLEX-RN]) before securing a license to practice. Licensure assures the public that nurses have achieved a minimum level of competence to practice safely. As practicing professionals and lifelong learners, nurses are encouraged to conduct self-assessments based on professional practice standards, use the results of self-assessments to identify strengths and weaknesses, and seek appropriate professional development. Continuing education, certification, supervisor and peer assessment of job performance, formal education, and practice support efforts to maintain nurses’ professional competency and protect the public’s health (Pew Health Professions Commission, 1995). However, this system has been criticized for lacking learning programs based on assessed learner needs, scientific evidence supporting continuing education methodologies, and interprofessional team focus (Committee on Planning a Continuing Health Professional Education Institute & IOM, 2009). Research is needed to develop an understanding of the relationship among certification, education, and competency, and to inform the development of new programs for maintaining competencies among nurses (IOM, 2003). Collectively, nurses monitor and control their profession through the regulatory and disciplinary functions of their respective State Boards of Nursing. Nurses are professionally obligated to report suspected cases of professional malpractice to their Boards of Nursing for subsequent investigation. In a more enlightened approach, contemporary nursing education programs assist emerging professionals to constructively critique their own nursing care as well as that of their peers and work collaboratively to develop knowledge and skills (Committee on Planning a Continuing Health Professional Education Institute & IOM, 2009).

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I N S U MM A R Y

Occupational Health Nursing Education for the 21st Century McCullagh, M. C. Workplace Health & Safety, 2012; 60(4), 167-176.

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Occupational health nurses have more formal education now than in the past. The number of occupational health nurses holding bachelor’s degrees will need to increase sharply to meet the Institute of Medicine goal of 80% by 2020.

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Specialist education in occupational health nursing is offered at most National Institute for Occupational Safety and Health-funded Education and Research Centers, as well as other academic programs. The American Board for Occupational Health Nurses, Inc., offers voluntary certification of occupational health nurses, assuring the public that an individual has mastered a body of knowledge and skills in the specialty.

To deliver quality health care services and enhance the public’s health in a rapidly changing health care environment, individual professional nurses are responsible for maintaining their nursing competencies.

Challenges and Opportunities In 2000, the IOM published a report commissioned by NIOSH on the occupational health and safety work force. Specifically, this report examined occupational safety and health work force supply and demand, roles, and education for the future. Workplace trends cited in the report included an older, more diverse work force working under increasing productivity demands while trying to maintain work-life balance. Although the report did not assess supply and demand of the occupational health work force, needs and opportunities for occupational health nurses and other occupational safety and health professionals can be inferred from data in this report. With the pace of change in society, the economy, and the workplace accelerating, the need for current information about the supply of and demand for occupational safety and health professionals and their educational needs is even more acute. Future Directions Occupational and environmental health nurses are the largest group of occupational health personnel in the United States and, as such, are critical to the delivery of quality health care services to the nation’s work force. Occupational health nurses contribute to profitable busi-

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nesses and society by reducing employee health costs, disability claims, and injuries, improving absentee rates, and maximizing employee productivity (AAOHN, 2009). Quality education is critical for occupational health nurses’ success in these roles. The NIOSH-sponsored ERCs, AAOHN, and ABOHN have been key in supporting the continuing competence of occupational health nurses for decades. Continued federal support for the NIOSH-funded ERCs is critical to meeting the occupational health and safety needs of workers, particularly with an anticipated dwindling supply of and increased demand for occupational health nurses. The current health care system in general and occupational health nursing in particular are experiencing change in the workplace. Some of these changes include an aging and more diverse work force, mandated technology, economic and legal pressures, and globalization of the economy. These changes create pressing needs for the development of nurses’ knowledge and skills. For 40 years, the NIOSH-funded ERCs have supported occupational and environmental health nursing practice through the provision of quality formal and continuing education programs. Due to severe federal budget constraints, continued funding for this program is threatened. Funding of the ERCs to meet the anticipated shortage of occupational and environmental health nurses is essential to maintain a supply of qualified health and safety professionals to protect the nation’s work force. The demand for occupational health nurses is expected to increase, and the supply of occupational health nurses is not anticipated to keep pace. Consequently, new strategies must be developed to prepare nurses to promote safe and healthful work environments. These strategies should include students in prelicensure programs as well as nurses currently in professional practice. Funding for programs designed to prepare occupational health nurses will be essential to meeting this demand. In addition, continuing education programs for occupational health nurses must demonstrate effectiveness in developing occupational health nursing skills and minimize nurses’ time away from the workplace. Baccalaureate nursing education programs should routinely include didactic and clinical learning experiences in occupational health nursing. This strategy can be expected to increase nurses’ skills in relating clients’ health conditions to their work and also to increase nurses’ awareness of the specialty. Formal graduate educational preparation of occupational health nurses is needed to meet the challenges of a changing health care system. Graduate programs in occupational health nursing must develop strategies to deliver education to students who may not be able to relocate to a residential program, and for whom full-time study is not possible. New undergraduate and graduate curricula including didactic and clinical practica should include occupational health nursing, recruiting new occupational health nurses to the workplace. Typically, nurses enter the specialty practice of occupational health nursing after they have practiced for several years. As experienced clinicians, these nurses need


knowledge and skills unique to occupational health nursing. Consequently, formal and continuing education programs should be developed to address the unique learning needs of this population. These programs must be based on assessment of learner needs and be accessible to the learner population, members of which are commonly employed full-time and have personal and family responsibilities. The number of male and minority occupational health nurses is low. Prelicensure, advanced occupational health nursing, and continuing education programs should be compelled to develop new, more effective strategies to attract minority nurses to the specialty. The relationship between nurses’ certification status and worker outcomes has been identified as an area of high priority for future research (U.S. Oncology Nursing Certification Corporation Research Committee and Executive Staff, 1999). In a rapidly changing health care environment, initial education of nurses is inadequate for maintaining or developing new competencies over the course of nurses’ careers. For this reason, a new vision of lifelong learning aimed at continued competence is emerging. Occupational health nurses can look forward to new approaches to professional development in the future (e.g., collaborative, as opposed to individual, and interprofessional learning). These methods are anticipated to strengthen nurses’ abilities to deliver quality health care services and enhance the public’s health (IOM, 2010). References

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