Presentation is loading. Please wait.

Presentation is loading. Please wait.

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,

Similar presentations


Presentation on theme: "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,"— Presentation transcript:

1 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

2 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

3 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: –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

4 Obtaining an AAOHN certificate To obtain an AAOHN certificate, the OHN must also show successful completion of: –Pulmonary Function, including fit testing –Audiometry –Ergonomics –Health coaching Copyright 2012 American Association of Occupational Health Nurses

5 QUESTIONS?? Copyright 2012 American Association of Occupational Health Nurses

6 Debbie Bush, RN, COHN-S/CM Occupational and Environmental Nursing – an Overview

7 Objectives Discuss the evolution of occupational health and its basic concepts List common terms and definitions Copyright 2012 American Association of Occupational Health Nurses

8 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

9 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

10 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

11 Essential Elements of Occupational Health Workplace Hazards 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

12 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

13 Our History 19 th 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

14 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

15 IT IS A FOREIGN LANGUAGE OSHA STS Medical/Health Surveillance MSDS BBP STD/LTD FMLA HCP NIOSH WC Reserves OSHA Recordkeeping IH PEL TLV Copyright 2012 American Association of Occupational Health Nurses

16 Learning a New Language: OSHA 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

17 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

18 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

19 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

20 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

21 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

22 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

23 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

24 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

25 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

26 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

27 Material Safety Data Sheet (MSDS) 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

28 Bloodborne Pathogens (BBP) 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

29 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

30 Family Medical Leave Act (FMLA) Is the federal law of 1993 that provides unpaid, job- protected 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

31 Questions?? Copyright 2012 American Association of Occupational Health Nurses

32 Tonya F. Grayson, LPN Worker Population - Who's on First?

33 Introduction Icebreaker Copyright 2012 American Association of Occupational Health Nurses

34 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

35 The 5-W’s Who? What? When? Where? Why? Copyright 2012 American Association of Occupational Health Nurses

36 WHO? Who is worker population? Minority Ethnicity Pregnant International workers Multiple Job Holders Copyright 2012 American Association of Occupational Health Nurses

37 WHY? Why are they important to you? Copyright 2012 American Association of Occupational Health Nurses

38 Changes that Affect our Worker Population Fertility rate Job demands Technology Gender rate Minority rate Aging Workforce Contingent workers Union Workers Disabled Workers: World Health Copyright 2012 American Association of Occupational Health Nurses

39 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

40 WHERE? Where are you located and what concerns should you have for that location? Natural Disasters: Perhaps the most unpredictable of all environmental factors. –Hurricane Zone –Tornado Alley –Flood Zone –Forest Fire –Snow Copyright 2012 American Association of Occupational Health Nurses

41 Other Groups the OHN has to Consider Military Installation/High Security Area Virtual Office Ethnic Groups Union Workers Agricultural Workers Biological Hazards Copyright 2012 American Association of Occupational Health Nurses

42 WHAT? What is the OHN role related to worker population? Copyright 2012 American Association of Occupational Health Nurses

43 SUMMARY We are VITAL to the success of our companies!

44 Bibliography Salazar, M. (2011) Core Curriculum for Occupational & Environmental Health Nursing, 3 rd edition. Pensacola, FL: AAOHN Department of Labor Futurework-Trends and Challenges for Work in the 21 st 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 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 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.pdfhttp://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-20637524http://www.bbc.co.uk/news/business-20637524 Copyright 2012 American Association of Occupational Health Nurses

45 Debbie Bush, RN, COHN-S/CM Prevention and Work-Related Injuries and Illnesses

46 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

47 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

48 Levels of Prevention Primary prevention: –Immunizations –Pre-placement physical Copyright 2012 American Association of Occupational Health Nurses

49 Levels of Prevention Secondary prevention: –Screening –Early diagnosis and treatment of injury and illness –Surveillance Copyright 2012 American Association of Occupational Health Nurses

50 Levels of Prevention Tertiary prevention relates to disability & case management Copyright 2012 American Association of Occupational Health Nurses

51 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

52 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

53 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

54 Types of Hazards Physical Chemical Biological Mechanical Psychological Copyright 2012 American Association of Occupational Health Nurses

55 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

56 Chemical Chemical Inventories – look for full lists MSDS – location? PPE – where located, condition, training Copyright 2012 American Association of Occupational Health Nurses

57 Biological Exposure Control Plan OSHA 300 Log/ Sharp Injury Log Accident Investigation Hep B Program Copyright 2012 American Association of Occupational Health Nurses

58 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

59 Psychological Stress – competition, personality issues Fatigue – shift work, overtime Workplace violence – harassments, threats, physical assaults Copyright 2012 American Association of Occupational Health Nurses

60 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

61 Questions?? Break Copyright 2012 American Association of Occupational Health Nurses

62 Information Management in Occupational Health Kerri L. Rupe ARNP, FNP-C, COHN-S, DNP, FAANP Copyright 2012 American Association of Occupational Health Nurses

63 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

64 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

65 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

66 Why is confidentiality important? Morality Professional Ethics It is the law Copyright 2012 American Association of Occupational Health Nurses

67 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 ⁻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

68 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

69 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

70 Electronic Medical Record (EMR) in Occupational Health Wide range of health information is collected, organized, processed and managed by the OHN 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

71 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

72 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

73 Social Media in Occupational Health Immediate sharing and access of information worldwide Individuals and groups can communicate in real time wirelessly Utilization of hand-held devices to access up-to- date clinical references Utilization of this technology to upload or download PHI from anywhere Confidentiality Issues Copyright 2012 American Association of Occupational Health Nurses

74 References 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), 417- 421. Rogers, B. (2003). Occupational and Environmental Health Nursing: Concepts and Practice. 2 nd edition. Philadelphia: Pa. Elsevier Science. Salazar, M. (2011). Core Curriculum for Occupational & Environmental Health Nursing, 3 rd 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

75 Questions?? Lunch on Your Own Copyright 2012 American Association of Occupational Health Nurses

76 Direct Care and Clinical Decision Making Debbie Bush, RN, COHN-S/CM Copyright 2012 American Association of Occupational Health Nurses

77 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

78 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

79 Direct Care Professional Practice Concepts 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

80 Overview of Direct Care Care for Occupational and/or non- occupational 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

81 Overview of Direct Care Offered to all workers: –full time employees –Contractors –Retirees –volunteers Who may deliver the care: –LPNs, RNs, ARNPs, Physicians Copyright 2012 American Association of Occupational Health Nurses

82 Reasons For On-Site Care 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

83 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

84 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

85 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

86 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

87 Operational Requirements 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

88 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

89 Components of Comprehensive Health History 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

90 Components of Comprehensive Health History Occupational/Environmental history Review of Systems (ROS) Past Medical History Medications & allergies Copyright 2012 American Association of Occupational Health Nurses

91 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

92 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

93 Comprehensive Exposure History Exposure survey Work history Environmental history Copyright 2012 American Association of Occupational Health Nurses

94 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

95 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

96 Techniques for Physical Exam Inspection Palpation Percussion Auscultation Copyright 2012 American Association of Occupational Health Nurses

97 Clinical Decision Making Identify the abnormal findings Cluster findings into logical groups Localize the findings anatomically Copyright 2012 American Association of Occupational Health Nurses

98 Clinical Decision Making Recordable/reportable conditions OSHA 300 Log Copyright 2012 American Association of Occupational Health Nurses

99 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

100 Continuous Quality Improvement 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

101 Questions?? Copyright 2012 American Association of Occupational Health Nurses

102 Tonya Grayson, LPN Safety & Environmental Health Programs

103 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

104 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

105 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

106 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

107 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

108 Safety & Environmental Risk Analysis 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

109 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

110 The OHN Role Competencies: –Understand –Access and refer: i.e., –Advocate Copyright 2012 American Association of Occupational Health Nurses

111 Recommendations Support Participate Communication Advocacy Research Generate Data Conduct studies Visibility Education Copyright 2012 American Association of Occupational Health Nurses

112 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

113 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

114 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

115 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

116 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

117 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

118 Components of the Health History Demographic Work History Home Exposure Community Exposure Occupational Exposure Environmental Exposure Physical Assessment Copyright 2012 American Association of Occupational Health Nurses

119 Why is Environmental Health Relevant? Environmental health impacts the clinical health of all the working population Copyright 2012 American Association of Occupational Health Nurses

120 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

121 Examples Metals Respirable Dust Solvents Pesticides Asphyxiants Copyright 2012 American Association of Occupational Health Nurses

122 Metals Arsenic Beryllium Cadmium Chromium Lead Mercury Maganese Copyright 2012 American Association of Occupational Health Nurses

123 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

124 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

125 Examples of Solvents Benzene Carbon disulfide Ethylene oxide Formaldehyde n-Hexane Methylene Chloride Toluene Tricholoroethylene Metabolite Dichloracetylene Tricholoroethylene Copyright 2012 American Association of Occupational Health Nurses

126 Pesticides Pesticides made to destroy pests but may have potentially harmful effects on humans Copyright 2012 American Association of Occupational Health Nurses

127 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

128 Regulatory Agencies EPA DOT USDA FDA DOE DOD OSHA NIOSH DHHS CDC National Center for Environmental Health, Agency for Toxic Substance and Disease Registry Copyright 2012 American Association of Occupational Health Nurses

129 Bibliography http://en.wikipedia.org/wiki/Environmental_health December 17,2012http://en.wikipedia.org/wiki/Environmental_health 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, 4 th Edition, Beverly Farms, Massachusetts. OEM Press Salazar, M. (2011). Core Curriculum for Occupational & Environmental Health Nursing, 3 rd 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

130 Emergency Preparedness for the OHN Kerri L. Rupe ARNP, FNP-C, COHN-S, DNP, FAANP Copyright 2012 American Association of Occupational Health Nurses

131 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

132 Content Outline 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

133 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

134 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

135 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

136 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

137 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

138 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

139 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 all- hazards 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

140 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. 2 nd edition. Philadelphia: Pa. Elsevier Science. Salazar, M. (2011). Core Curriculum for Occupational & Environmental Health Nursing, 3 rd edition. Pensacola, Fl:AAOHN. Copyright 2012 American Association of Occupational Health Nurses

141 Questions?? Break Copyright 2012 American Association of Occupational Health Nurses

142 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

143 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

144 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

145 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

146 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 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

147 Competencies in Occupational Health and Environmental Health Nursing (AAOHN, 2007) Category 8: Research Competent Proficient Expert Copyright 2012 American Association of Occupational Health Nurses

148 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

149 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

150 AAOHN Nursing Research Priorities AAOHN funded a study to establish nursing research priorities within the profession 12 priorities emerged: –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

151 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

152 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

153 NORA - Work Environment and Workforce Emerging Technologies Indoor Environment Mixed Exposures Organization of Work Special Populations at Risk Copyright 2012 American Association of Occupational Health Nurses

154 NORA - Research Tools and Approaches 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

155 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

156 Evidenced-Based Practice Five steps of EBP 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

157 References 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. 2 nd edition. Philadelphia: Pa. Elsevier Science. Salazar, M. (2011). Core Curriculum for Occupational & Environmental Health Nursing, 3 rd edition. Pensacola, Fl:AAOHN. Copyright 2012 American Association of Occupational Health Nurses

158 Questions?? Adjourn Copyright 2012 American Association of Occupational Health Nurses

159 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

160 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

161 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

162 Health and Safety Programs Include Programs that Affect Worker Health and Productivity Health Promotion Screening Programs Copyright 2012 American Association of Occupational Health Nurses

163 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

164 Health Models Health Belief Health Promotion Health Promotion Planning Health Promotion Behavior Harm Reduction Copyright 2012 American Association of Occupational Health Nurses

165 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

166 Health Promotion Increasing the level of well-being and self- actualization. Must be an integral part of the individual’s llifestyle. Copyright 2012 American Association of Occupational Health Nurses

167 Health Promotion Planning Help plan and evaluate health promotion activities. –Example: Behavior lifestyle and environmental Copyright 2012 American Association of Occupational Health Nurses

168 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

169 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

170 Levels of Prevention Primary Secondary Tertiary Copyright 2012 American Association of Occupational Health Nurses

171 Components of Prevention/Wellness Physical Mental Emotional Psycho-Social Copyright 2012 American Association of Occupational Health Nurses

172 Prevention Programs Levels Basic –Educational Moderate –Education & Monitoring Complex –Education, Monitoring, & Intervention Copyright 2012 American Association of Occupational Health Nurses

173 Basic Level Program Education –Group Instruction –Individual Counseling –Health & Safety Alerts –Newsletters –Fliers/Pamphlets Copyright 2012 American Association of Occupational Health Nurses

174 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

175 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

176 Identify Needs Needs of all involved must be addresses –Management –Employees –Labor Unions Copyright 2012 American Association of Occupational Health Nurses

177 Program Task Force 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

178 Benefits Management –Safety –Decreased lost work days/overtime costs –Decreased medical expenses –Improved morale –Cost Containment –Increased productivity Copyright 2012 American Association of Occupational Health Nurses

179 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

180 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

181 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

182 Healthy People 2020 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

183 Why is Healthy People 2020 important? Directly related to health promotion activities and the goals associated with: –increasing physical exercise –obesity and weight loss –tobacco use –substance use –mental health –injury –violence –immunizations Copyright 2012 American Association of Occupational Health Nurses

184 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

185 Health Models On site OHN On site Clinics Near site Clinics Out sourcing to independent providers Copyright 2012 American Association of Occupational Health Nurses

186 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

187 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

188 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

189 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

190 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

191 “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

192 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

193 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

194 Strategic Planning and How to Implement Assessment data –Worker population and Environmental Assessment tools to be used –Questionnaires –HRA –Walk-through reports –WC –Case Management reports –OSHA records/logs Copyright 2012 American Association of Occupational Health Nurses

195 Program Planning Personnel Financial resources Equipment Supplies Facilities and Space Copyright 2012 American Association of Occupational Health Nurses

196 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

197 Program Implementation Monitor activities Personnel Educational Processes Management Support Timetables Progress to be monitored Copyright 2012 American Association of Occupational Health Nurses

198 Program Evaluation Identify and improve services, processes, and personnel Chart audits Concurrent reviews Interviews Copyright 2012 American Association of Occupational Health Nurses

199 Beneficial Effects of the OHN Marketable Leadership skill set Communication Recognize success ROI Copyright 2012 American Association of Occupational Health Nurses

200 Beneficial Effects of the OHN 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

201 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

202 Future Options Continued Marketing Business Building Financial Knowledge Copyright 2012 American Association of Occupational Health Nurses

203 Marketing Credibility Communication Time saving Big picture First impression Copyright 2012 American Association of Occupational Health Nurses

204 Business Building 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

205 Financial Knowledge 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

206 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

207 Understanding Service Volumes Analysis of Service Delivery Volumes: –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

208 How Service Volumes are Measured 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

209 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

210 Understanding Expenses & Costs Fixed costs Variable costs Semi-variable Combined – variable and semi-variable Copyright 2012 American Association of Occupational Health Nurses

211 Labor Expense (SWB) 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

212 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

213 The Budget Cycle Present strategic initiatives Project the balance of the year DOR Analysis Copyright 2012 American Association of Occupational Health Nurses

214 Global Measures of Success 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

215 Accounting Policy Guides APG Review Accounting Policy Guides Company Policies for accounting standards Heightened integrity for financial information Contains: –Fixed assets (capital $$’s) –Leases –Inventory –Inter-company Copyright 2012 American Association of Occupational Health Nurses

216 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

217 “Tips and Tricks” Success Cards – Score Cards Teamwork Communication Integrity Innovation Customer Service Copyright 2012 American Association of Occupational Health Nurses

218 Teamwork 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

219 Communication #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

220 Integrity Honest Ethical/Moral Credentialed Unimpaired/Soundness Whole/Undivided Completeness Copyright 2012 American Association of Occupational Health Nurses

221 Innovation “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

222 Customer Service 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

223 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

224 Alleviate Fears People in change experience the following fears: Failure Invisibility Chaos Losing power Support failure Going unrewarded Copyright 2012 American Association of Occupational Health Nurses

225 Greater Benefits for Lesser Costs 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

226 Bibliography 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

227 Questions?? Break Copyright 2012 American Association of Occupational Health Nurses

228 Essentials of Exceptional Leadership Skills Barb Maxwell RN, MHA, COHN-S, CCM, CWCP, QRP, FAAOHN Copyright 2012 American Association of Occupational Health Nurses

229 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

230 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

231 A Perspective of Leadership Traditional definition: –“Leadership is creating, and influencing others to contribute to a shared set of goals.” 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

232 Leadership Approaches Various Leadership approaches are used in business and industry: Tactical Transactional Collaborative Transformational Servant Copyright 2012 American Association of Occupational Health Nurses

233 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

234 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

235 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

236 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

237 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

238 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

239 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

240 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

241 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

242 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

243 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

244 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: –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

245 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

246 Leadership Styles Coercive Authoritative Affiliative Democratic Pacesetting Coaching Copyright 2012 American Association of Occupational Health Nurses

247 Coercive 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

248 Authoritative 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

249 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

250 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

251 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

252 Coaching Develops people for the future Style in a phrase: “Try this” EI – Developing others, empathy, self- awareness 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

253 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

254 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

255 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

256 Task Cycles and what is involved 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

257 Making Clear and Importance Goals SMART PURE CLEAR Copyright 2012 American Association of Occupational Health Nurses

258 Planning and Problem Solving Many people will have an initial reaction and ask themselves “How do I do it?” Steps to follow: –Project Management –Budget –Budget Process –Decision making and ethical considerations Copyright 2012 American Association of Occupational Health Nurses

259 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

260 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

261 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

262 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

263 Bibliography 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. 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. 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

264 Questions?? Lunch on Your Own Copyright 2012 American Association of Occupational Health Nurses

265 Scientific Foundations of Occupational and Environmental Health Nursing Practice Epidemiology Chad Rittle DNP, MPH, RN Copyright 2012 American Association of Occupational Health Nurses 265

266 Objectives Introduction to Epidemiology Distinguish between incidence rate and prevalence. Copyright 2012 American Association of Occupational Health Nurses 266

267 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 Copyright 2012 American Association of Occupational Health Nurses 267

268 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, 3 rd edition. Pensacola, Fl:AAOHN. Copyright 2012 American Association of Occupational Health Nurses 268

269 Reference Sources Additional detail for this presentation may be found at: Gordis, L. (2000). Epidemiology, 2 nd edition. Philadelphia: Saunders. Salazar, M. (2011). Core Curriculum for Occupational & Environmental Health Nursing, 3 rd edition. Pensacola, Fl:AAOHN. Copyright 2012 American Association of Occupational Health Nurses 269

270 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). Copyright 2012 American Association of Occupational Health Nurses 270

271 Wheel of Public Health Interventions Copyright 2012 American Association of Occupational Health Nurses 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 271

272 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. Copyright 2012 American Association of Occupational Health Nurses Wheel of Public Health Interventions 272

273 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. Copyright 2012 American Association of Occupational Health Nurses 273

274 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 Copyright 2012 American Association of Occupational Health Nurses 274

275 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

276 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 276

277 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 Copyright 2012 American Association of Occupational Health Nurses 277

278 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. Copyright 2012 American Association of Occupational Health Nurses 278

279 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 Copyright 2012 American Association of Occupational Health Nurses 279

280 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 Copyright 2012 American Association of Occupational Health Nurses 280

281 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 Copyright 2012 American Association of Occupational Health Nurses 281

282 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. Copyright 2012 American Association of Occupational Health Nurses 282

283 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 Copyright 2012 American Association of Occupational Health Nurses 283

284 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, 2 nd edition. Philadelphia: Saunders. Copyright 2012 American Association of Occupational Health Nurses 284

285 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., age- specific 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., age- adjusted rates) Copyright 2012 American Association of Occupational Health Nurses 285

286 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. Copyright 2012 American Association of Occupational Health Nurses 286

287 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.phphttp://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 Copyright 2012 American Association of Occupational Health Nurses 287

288 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 Copyright 2012 American Association of Occupational Health Nurses 288

289 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 Copyright 2012 American Association of Occupational Health Nurses 289

290 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 Copyright 2012 American Association of Occupational Health Nurses 290

291 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 Copyright 2012 American Association of Occupational Health Nurses 291

292 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 Copyright 2012 American Association of Occupational Health Nurses 292

293 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 Copyright 2012 American Association of Occupational Health Nurses 293

294 Types of Bias Type of BiasDescription Information Exposure and outcome data are ascertained differently from study groups Recall Individuals with negative outcomes are more likely to remember and report exposure Interviewer Interviewers' prior knowledge of outcome status affects ascertainment of exposure information in the interview Lost to Follow-up Prospectively, those with negative outcomes may be lost to follow-up at a greater rate than controls Misclassifica tion Ascertainment of either exposure or outcome status is incorrect form some subjects Selection Entry into the study or control group is affected by factors related to exposure (case-control) or outcome (cohort) Self- selection Individuals' participation is affected by their knowledge of disease or exposure status Copyright 2012 American Association of Occupational Health Nurses 294

295 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 Copyright 2012 American Association of Occupational Health Nurses 295

296 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 Copyright 2012 American Association of Occupational Health Nurses 296

297 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) Copyright 2012 American Association of Occupational Health Nurses 297

298 References Gordis, L. (2000). Epidemiology, 2 nd edition. Philadelphia: Saunders. Salazar, M. (2011). Core Curriculum for Occupational & Environmental Health Nursing, 3 rd edition. Pensacola, Fl:AAOHN. Copyright 2012 American Association of Occupational Health Nurses 298

299 Scientific Foundations of Occupational and Environmental Health Nursing Practice Injury Epidemiology Chad Rittle DNP, MPH, RN Copyright 2012 American Association of Occupational Health Nurses c 299

300 Objectives Injury Epidemiology Name three (3) examples of source injury Copyright 2012 American Association of Occupational Health Nurses 300

301 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, 3 rd edition. Pensacola, Fl:AAOHN. Copyright 2012 American Association of Occupational Health Nurses 301

302 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. Copyright 2012 American Association of Occupational Health Nurses 302

303 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 Copyright 2012 American Association of Occupational Health Nurses 303

304 Example of Risk Factor Analysis for Injury Occurrence: A Fracture HostInjuryAgentVector Exposure EventPhysical EnvironmentSociocultural Environment IndividualFracture Kinetic Energy Cement Floor Slip and fall oil, grease, dirt and water on the floorattitude 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 Copyright 2012 American Association of Occupational Health Nurses Source: Salazar, M. (2011). Core Curriculum for Occupational & Environmental Health Nursing, 3 rd edition. Pensacola, Fl:AAOHN. 304

305 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. Copyright 2012 American Association of Occupational Health Nurses 305

306 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, 3 rd edition. Pensacola, Fl:AAOHN. PhaseHuman factors Environmental and engineering factorsSocial, legal and political 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 Copyright 2012 American Association of Occupational Health Nurses 306

307 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. Copyright 2012 American Association of Occupational Health Nurses 307

308 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 Copyright 2012 American Association of Occupational Health Nurses 308

309 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 Copyright 2012 American Association of Occupational Health Nurses 309

310 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 Copyright 2012 American Association of Occupational Health Nurses 310

311 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 Copyright 2012 American Association of Occupational Health Nurses 311

312 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 Copyright 2012 American Association of Occupational Health Nurses 312

313 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 Copyright 2012 American Association of Occupational Health Nurses 313

314 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 ⁻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. 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 ⁻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 Copyright 2012 American Association of Occupational Health Nurses 314

315 Scientific Foundations of Occupational and Environmental Health Nursing Practice Toxicology Chad Rittle DNP, MPH, RN Copyright 2012 American Association of Occupational Health Nurses 315

316 Objectives Describe three (3) toxic agents by their classification on the biological system Copyright 2012 American Association of Occupational Health Nurses 316

317 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, 3 rd edition. Pensacola, Fl:AAOHN. Copyright 2012 American Association of Occupational Health Nurses 317

318 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) Copyright 2012 American Association of Occupational Health Nurses 318

319 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 Copyright 2012 American Association of Occupational Health Nurses 319

320 Potential toxic effects by system, with examples of toxins SystemEffectsSources of Exposure RespiratoryIrritationHydrogen chloride, ammonia SensitizationIsocyanates FibrosisSilica, asbestos, beryllium CarcinogensAsbestos, arsenic, chromium VI DermatologicIrritationAcetone, carbon disulfide Corrosive burnsAlkali, hydrogen flouride SensitizationChromate, nickel CarcinogenesisUltraviolet light, arsenic Nervous SystemDepressed/altered consciousnessCarbon monoxide, solvents, lead, mercury, manganese Behavior and mood disturbanceLead, solvents, toluene, mercury Cognitive disturbance, cerebellar impairmentCarbon monoxide, manganese, pesticides Peripheral neuropathyAcrylamide, n-hexane, methyl n-butyl ketone Hearing and VisionAcid burns of eyesHydrochloric and tannic acid Alkali burns of eyesSodium hydroxide, calcium oxide BlindnessMethanol DeafnessNoise HematopoieticBone marrow supressionIonizing radiation, benzene Red cell lysisArsine, trinitrotoluene (TNT), naphthalene HepaticNecrosisCarbon tetrachloride, chloroform, tetrachloroethane CirrhosisCarbon tetrachloride MalignancyVinyl chloride monomer Renal and BladderNephrotoxicityHeavy metals, carbon tetrachloride, chloroform Renal cancerCoke oven emissions Bladder cancerBenzidine, B-naphthylamine ReproductiveDecreased sperm productionIonizing radiation, heat Decreased female fertilityIonizing radiation, carbon disulfide Spontaneous abortionsEthylene oxide Congenital defectsRubella, varicella Copyright 2012 American Association of Occupational Health Nurses 320

321 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 Copyright 2012 American Association of Occupational Health Nurses 321

322 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/m 3 ) Higher concentrations are generally absorbed in greater amounts Longer or more-frequent periods of exposure also lead to greater absorbed doses Copyright 2012 American Association of Occupational Health Nurses 322

323 Exposure Acute exposure occurs when exposure is short- term 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 Copyright 2012 American Association of Occupational Health Nurses 323

324 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 Copyright 2012 American Association of Occupational Health Nurses 324

325 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 Copyright 2012 American Association of Occupational Health Nurses 325

326 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 Copyright 2012 American Association of Occupational Health Nurses 326

327 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 Copyright 2012 American Association of Occupational Health Nurses 327

328 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 Copyright 2012 American Association of Occupational Health Nurses 328

329 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 Copyright 2012 American Association of Occupational Health Nurses 329

330 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 Copyright 2012 American Association of Occupational Health Nurses 330

331 Three Major Exposure Routes –Cutaneous –Inhalation –Ingestion Copyright 2012 American Association of Occupational Health Nurses 331

332 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! Copyright 2012 American Association of Occupational Health Nurses 332

333 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 Copyright 2012 American Association of Occupational Health Nurses 333

334 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 Copyright 2012 American Association of Occupational Health Nurses 334

335 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 LD 50 (lethal-dose, 50%) – produces death in 50 of a group of experimental animals (Also known as LC 50 (lethal concentration, 50%) Example – LD 50 of acetone is 5,340 mg/kg, while the LD 50 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 Copyright 2012 American Association of Occupational Health Nurses 335

336 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 Copyright 2012 American Association of Occupational Health Nurses 336

337 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 25- 30 days in the blood Copyright 2012 American Association of Occupational Health Nurses 337

338 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 Copyright 2012 American Association of Occupational Health Nurses 338

339 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 Copyright 2012 American Association of Occupational Health Nurses 339

340 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 Copyright 2012 American Association of Occupational Health Nurses 340

341 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 Copyright 2012 American Association of Occupational Health Nurses 341

342 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

343 Other Common Risks Vibration – power tools or other equipment Whole body vibration – truck drivers, jack- hammer operators Cold environments- can affect manual dexterity and muscle strength Copyright 2012 American Association of Occupational Health Nurses 343

344 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

345 Evaluating Risk Factors Interviews or questionnaires – ask workers about their work ⁻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. Observation and use of a checklist – observe workers noting any risk factors ⁻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

346 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

347 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

348 Questions?? Break Copyright 2012 American Association of Occupational Health Nurses

349 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

350 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

351 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

352 Disability Case Management Definition Disability Case Management is: the coordination and management of work- related 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 long- term disability benefits. Copyright 2012 American Association of Occupational Health Nurses

353 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

354 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 non- occupational injury or illness. Copyright 2012 American Association of Occupational Health Nurses

355 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

356 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

357 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

358 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

359 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

360 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

361 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

362 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

363 INDEMNITY In worker’s compensation language, generally refers to payments made for lost wages. Money = Indemnity Copyright 2012 American Association of Occupational Health Nurses

364 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

365 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

366 THIRD-PARTY ADMINISTRATOR (TPA) A company that handles all the administrative tasks involved in managing claims for self- insured employers who fund their own benefit plans. Copyright 2012 American Association of Occupational Health Nurses

367 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

368 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

369 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

370 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

371 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

372 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

373 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

374 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

375 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

376 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

377 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

378 COACHING Coaching is the means of generating responsibility, self motivation and awareness to enhance performance. Copyright 2012 American Association of Occupational Health Nurses

379 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

380 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

381 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

382 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

383 QUESTIONS ?? Copyright 2012 American Association of Occupational Health Nurses

384 Debbie Bush, RN, COHN-S/CM Professionalism – What Does it Take?

385 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

386 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

387 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

388 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

389 Your Development Where are you? Copyright 2012 American Association of Occupational Health Nurses

390 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

391 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

392 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

393 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

394 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

395 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

396 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

397 Communicating Results Reports –Monthly –Quarterly –Annually –Trip Reports* –Special Reports –Memorandums/Letters Copyright 2012 American Association of Occupational Health Nurses

398 Questions?? Adjourn Copyright 2012 American Association of Occupational Health Nurses

399 The Legal Aspects of AAOHN Practice Part 1 Chad Rittle DNP, MPH, RN Copyright 2012 American Association of Occupational Health Nurses 399

400 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

401 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, 3 rd edition. Pensacola, Fl:AAOHN. Copyright 2012 American Association of Occupational Health Nurses 401

402 Sources of Law –Common Law –Statutes –Federal Law –State Law Civil law Criminal law Copyright 2012 American Association of Occupational Health Nurses 402

403 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

404 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

405 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

406 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

407 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

408 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

409 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 Legal Responsibilities 409

410 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 Legal Responsibilities 410

411 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

412 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