Occupational Health Nurses and Respiratory Protection Improving Education and Training: Letter Report (2011) / Chapter Skim
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Letter Report
Letter Report
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appointed the ad hoc Committee on the Respiratory Protection Curriculum for Occupational Health Nursing Programs under the auspices of the IOM's Standing Committee on Personal Protective Equipment for Workplace Safety and Health. The overarching charge to the ad hoc committee was to examine existing respiratory protection curricula in occupational health nursing programs and to develop recommendations to improve education and training on the selection (including situation assessment)
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The committee found that respiratory protection content taught in occupational health nursing programs receives varying amounts of dedicated time and resources and is taught using a variety of didactic and practical approaches. To improve the respiratory protection curricula for OHNs, the committee makes seven recommendations that are detailed in this report.
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Recommendation 4: Ensure Essential Respiratory Protection Content in Oc cupational Health Nursing Graduate Curricula, and Adapt and Apply It to Con tinuing Education Programs and to the Education and Training of All Nurses Occupational health nursing educators -- in collaboration with staff from other disciplines (e.g., industrial hygiene, occupational medicine, engineering) , NIOSH, AAOHN, and other expert sources -- should ensure that essential respi ratory protection content is included in graduate occupational health nursing programs and integrated into continuing education courses for OHNs.
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Recommendation 5: Develop, Expand, and Evaluate Innovative Teaching Methods and Resources to Establish Best Practices Occupational health nursing education programs and respiratory protection programs should do the following: • Integrate essential content on respiratory protection into their core curricula and continuing education programs through a variety of in novative approaches, taking into consideration the needs of the stu dents. These methods could include o online courses (including webinars)
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• Collaborate with NPPTL to evaluate innovative teaching methods used for respiratory protection education and training, including con tinuing education, in order to establish best practices in the field. Recommendation 6: Expand Online Resources, Particularly Case Studies NPPTL should develop and maintain online resources for respiratory protec tion that are relevant to educating and training OHNs, specifically by • developing template modules that could be used in the core curricu lum for occupational health nursing programs and that would draw on best practices of the NIOSH ERCs (sections of these modules could also be used for nursing students at all levels)
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To respond to NPPTL's request, the IOM convened the nine-member ad hoc Committee on Respiratory Protection Curriculum for Occupational Health Nursing Programs. The committee included members with expertise in occupational health nursing and medicine, PPE design and training, industrial hygiene and occupational health, clinical medicine, and nursing education (see Appendix D for committee biographies)
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Presentations from and discussions with experts provided the committee with insights about occupational health and safety, respiratory protection, and occupational health nursing. Workshop presenters discussed respiratory protection curricula currently used across the country, continuing education opportunities for OHNs, the role of professional boards or organizations in shaping occupational health nursing curricula, the on-the-ground perspectives of OHNs working in indus
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To inform its deliberations and gain a better understanding of respiratory protection curricula, the committee received and reviewed the results of an NPPTL-led survey of respiratory protection curricula from six NIOSH ERC occupational health nursing programs1 and from the North Carolina Division of Public Health.2 The committee also reviewed the core curriculum and competencies of the American Association of Occupational Health Nurses (AAOHN)
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Overview of Occupational Health Nursing OHNs are nurses who work to prevent injury and illness and promote the health and safety of workers across a wide range of employment settings (IOM, 2000)
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In assessment and direct health care services to workers, OHNs may • assess and monitor the health status of employees relevant to their work responsibilities and work environments; • help interpret medical diagnoses for employees and their employers; • evaluate workers' medical and occupational history, health con cerns, physical exams, laboratory results, and other health related factors; • document and treat occupational and non-occupational illnesses and injuries; and • refer employees to employee assistance programs and other re sources as needed. In prevention and research, they may • conduct assessments of employee health and workplace hazards; • work to prevent occupational illness, injury, and death due to ha zardous exposures; • educate and counsel employees about occupational hazards and safety, healthy lifestyles and behaviors, and overall health and well-being; and • conduct research to advance occupational health nursing and, more broadly, the field of occupational health and safety.
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. Graduate-level education may include programs of study as an occupational health nurse–specialist, an adult health nurse practitioner with a concentration in occupational health nursing, or a family health nurse practitioner with a concentration in occupational health nursing, such as the programs that are offered through the University of Michigan's Occupational Health Nursing Program (McCullagh,
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Further, professional organizations (e.g., ABOHN) that offer certifications set continuing education requirements for the specific occupational health nursing certifications that are available.
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. In addition to the occupational health nursing graduate programs, the ERCs also offer a number of continuing education courses for occupational health and safety professionals, including OHNs.
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. TABLE 1 ABOHN Certification Requirements Requirements COHN COHN–S SM CM Active License RN RN RN RN Education diploma or bachelor's diploma or diploma or Minimum associate degree associate associate degree degree degree Active ABOHN N/A N/A COHN or COHN or Certification COHN-S COHN-S Exam 150 150 200 100 multiple- multiple- multiple- multiple choice choice choice choice questions questions questions questions Professional 3,000 hours in 3,000 hours in • 25% of Occupational occupational occupational current Health health in the health in the position Experience previous 5 previous 5 devoted to years or years or com- safety completion of pletion of an activities an academic academic • 1,000 hours certificate of certificate of of safety occupational occupational experience in health nursing health nursing the previous or a graduate 5 years degree with a concentration in occupational health Occupational none none 50 contact hours 10 contact Health related to SM in hours related Continuing the previous 5 to CM in the Education years previous 5 years SOURCES: ABOHN, 2004, 2008a, 2008b, 2009.
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In other workplaces, OHNs do not perform fit testing at all because that responsibility belongs to another member of the occupational health and safety team. In some settings, OHNs are involved in respirator maintenance; elsewhere, this is the responsibility of an industrial hygienist.
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These types of surveys are used to measure broadly the evolving nature of occupational health nursing work environments and the practice of occupational health nursing. The surveys are also used to inform the development and revision of competencies, to compare OHNs' actual tasks with the content of certification exams, and to ensure that OHNs and ap
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Therefore, a survey of OHNs that asks questions specific to respiratory protection would be beneficial to workers and occupational health nursing if it was conducted across a representative sample 3 Spirometry is a test used to measure lung function. In the context of respiratory protection programs, spirometry is used for a variety of purposes that may include assessing workers' fitness for duty and assessing underlying pulmonary conditions (e.g., asthma)
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Additional questions could focus on education and training needs in respiratory protection and could include questions about challenges and barriers to achieving additional education and training, the preferred mechanism for receiving information on respiratory protection, and the preferred duration of respiratory protection courses that are offered. The results of this survey could be used to hone the content of respiratory curricula and to tailor teaching approaches to meet the needs of OHNs.
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Regardless of improvements that are made to respiratory protection curricula and teaching approaches for OHNs, overall advancements in respiratory protection cannot be made unless OHNs take responsibility for pursuing the necessary education and training. OHNs should have the knowledge and skills required to feel confident in using respiratory protection and teaching others to use it.
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The committee heard at the workshop that there is limited content on respiratory protection and, more broadly, on PPE and occupational health in basic nursing education curricula. As discussed above, all nurses have a responsibility to ensure safety.
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Recommendation 3: Expand Respiratory Protection Education Across All Levels of Nursing Education and Training Nursing education programs across all levels, including licensed practical or vocational, diploma, associate, baccalaureate, and graduate levels, should • introduce the basic concepts of respiratory risk and pro tection early in the education and training programs and throughout the curriculum; • reinforce this knowledge when the students begin their clinical education and are fit tested for respirators; • require that their graduates have a working knowledge of key elements of respiratory protection at the appro priate level for their scope of practice; and • look to core curricula offered by occupational health nursing graduate and continuing education programs, including the NIOSH ERCs, for guidance on required knowledge and skills to educate nurses at appropriate le vels for their scope of practice. Graduate-Level Curricula and Training Across graduate-level education programs for OHNs, the content, duration, and level of specificity of courses that focus directly, and indirectly, on respiratory protection vary greatly.
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University of Alabama at Birmingham School of Nursing occupational health nursing students are encouraged and funded to take the continuing education program on respiratory protection programs and fit testing that provides 5 The NPPTL survey results are available by request through the National Academies' Public Access Records Office. 6 Slides from the workshop presentations are available online: http://www.iom.edu/ nursesandrespirators.
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The 100-hour practicum in occupational health nursing required at the University of South Florida is precepted by a certified occupational health nurse practitioner or board-certified occupational medicine physician and includes worker teaching or counseling about PPE, which may include respiratory protection. Students are asked to consider whether the worker was wearing or using the PPE appropriately for the job when he or she was injured (Burns, 2011)
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Students are given lectures on OSHA standards, hazard assessment, respirators, and worker protection programs. These courses are taught by occupational health nursing faculty with guest lectures by IH faculty.
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: Respiratory protection content is first pre sented in the occupational and environmental health course with content including respirator basics, fit testing, equipment demonstration, and medical screening. In occupational health nursing courses, there are modules on PPE, respiratory questionnaires, and occupational spirome try.
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Continuing education courses are typically short in length, ranging from a few hours to a few days, and are designed to improve and expand the knowledge, skills, and levels of expertise of OHNs. All NIOSH ERCs offer continuing education courses and programs for occupational health and safety professionals (NIOSH, 2011c)
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. • University of Alabama at Birmingham School of Nursing: The University of Alabama at Birmingham School of Nursing's Deep South Center for Occupational Health and Safety offers two continuing education courses that are specific to respiratory protection: a 2-day respiratory protection course, which was previously offered as a 4-day course, and a 4– to 6-hour fit testing workshop.
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Curricula at schools with occupational health nursing programs are already content rich and must cover a wide range of topics, including content on multiple types of PPE, such as hearing and eye protection, in addition to respiratory pro
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Further, it is challenging to fund specialized faculty for small numbers of occupational health nursing graduate students. Another challenge is that education and training programs must appropriately tailor their courses to the needs of OHNs.
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Return-on-investment information and materials should be made available to nurses and their employers to clearly demonstrate the value of education and training in respiratory protection. Essential Content of Respiratory Protection Education and Training for OHNs Currently, respiratory protection content is taught in occupational health nursing graduate and continuing education programs using a variety of didactic and practicum approaches with varying amounts of dedicated time and resources.
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Occupational health nursing programs need to be sure that students have a basic understanding of and familiarity with all aspects of developing, implementing, and evaluating a respiratory protection program. Essential content of the occupational health nursing curriculum includes education and training on hazard assessment; selection, use, care, and maintenance of respirators; medical evaluation and monitoring; and fit testing.
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Faculty in occupational health nursing programs should ensure that students are aware of specialty courses in respiratory protection that are available and should promote additional respiratory protection education and training through continuing education. Additionally, faculty should teach OHNs to recognize the limits of their education, training, experience, and scope of practice.
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regulations and standards; • use hands-on education and training experiences to pro vide an understanding of the types of respirators and their uses; • require students to demonstrate knowledge and skills in developing a respiratory protection program that in cludes training and evaluation components; • emphasize the leadership role of OHNs in establishing a culture of safety, influencing behavior change and deci sions related to respiratory and overall health, and pro moting proper use of respirators in the workplace; • examine research and best practices relevant to respira tory protection, behavioral change and leadership, and establishing a culture of safety in the workplace; • consider including spirometry certification as a require ment for graduation; and • specify elements that could be adapted and applied to continuing education programs and to the education and training of all nurses.
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Disadvantages include limited interaction with faculty and other students and the need to arrange for in-person activities, such as hands-on exercises and preceptorships. Students enrolled in an online course at schools such as the University of Iowa, where 50 percent of occupational health nursing students are out of state, are required to attend some courses in person (Rupe, 2011)
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Further efforts are needed to implement and evaluate a range of teaching methods to better meet the needs of occupational health nursing students. Recommendation 5: Develop, Expand, and Evaluate Innovative Teaching Methods and Resources to Establish Best Practices Occupational health nursing education programs and respirato ry protection programs should do the following: • Integrate essential content on respiratory protection into their core curricula and continuing education programs through a variety of innovative approaches, taking into consideration the needs of the students.
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If these modules were available and accessible on the NIOSH website, occupational health nursing programs could use them as a template or foundation for their curricula, and undergraduate nursing programs could use them to augment their curricula with respiratory protection content. Additionally, these content modules would allow OHNs who work in diverse settings to find information and tailor their learning experience to their specific work functions.
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INCENTIVES FOR RESPIRATORY PROTECTION EDUCATION AND TRAINING Making changes to graduate-level curricula or continuing education programs can be a significant endeavor requiring careful consideration of the justifications for change and the potential impact on cost, time, and educational resources. Improving respiratory protection curricula to ensure that OHNs are knowledgeable and feel confident in their skills will require a multifaceted approach and collaboration among a variety of professional organizations, educators, employers, government agencies, and OHNs.
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. The competencies highlight safety but do not focus on respiratory protection or other types of PPE; they are written broadly to cover the range of occupational health nursing practices that are integral to the work of OHNs.
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In addition to OSHA regulations requiring respiratory protection programs for workplaces with potential respiratory hazards, other worksite inspection and accreditation criteria influence the culture of workplace safety and the degree of emphasis placed on respiratory protection. For hospitals and other health care settings, Joint Commission standards are a key driver of quality improvement.
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2004. Occupational health nursing safety management examination handbook.
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2011. Respiratory protection -- continuing education for registered nurses: PowerPoint presented at the IOM Workshop on Respiratory Protection Curriculum for Occupational Health Nursing Programs in Pittsburgh, PA.
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2011. Deep South Center for Occupational Health and Safety: Po werPoint presented at the IOM Workshop on Respiratory Protection Curri culum for Occupational Health Nursing Programs in Pittsburgh, PA.
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2011. Respiratory protection curriculum -- University of Iowa College of Nursing: PowerPoint presented at the IOM Workshop on Respiratory Pro tection Curriculum for Occupational Health Nursing Programs in Pittsburgh, PA.
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2011b. Respiratory protection training for OHNs -- developing a one day fit-testing workshop: PowerPoint presented at the IOM Workshop on Respiratory Protection Curriculum for Occupational Health Nursing Programs in Pittsburgh, PA.
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