COMPETITIVE
EDGE

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References 

Salazar, Mary K. AAOHN Core Curriculum for Occupational Health Nursing, American Association of Occupational Health Nurses. Philadelphia: W.B. Saunders Company, 1997. 

In the current nursing shortage, experienced occupational health nurses are in great demand. Therefore occupational health administrators must often recruit registered nurses and orient them to practice in this complex and highly regulated field. This shortage is likely to become more acute: the nursing workforce in this country is aging. The average registered nurse in the United States is reported to be 45 years old and the majority of nurses over 40 only work part time. With growing job opportunities and a schedule that allows most weekends off, occupational health nursing can be an attractive option for nurses with many years of nursing experience and a desire for more reasonable hours. How can programs recruit and train nurses for these demanding and significantly different roles, while ensuring safe, competent care at the clinic and employer worksite? The following guidelines, which have emerged from 15 years of management experience and teaching nurses in a college degree program, may assist clinics in successfully recruiting and training registered nurses for clinic and on-site services.

The Challenge
Occupational health nursing requires a broad knowledge base not only in assessment and treatment of injured workers but also in public health issues and regulatory requirements of the workers in the workplace. The occupational health nurse must be knowledgeable in work-place hazards as well as injury and illness prevention, often for multiple industries. Instead of caring for patients, he/she will develop a trusting relationship with the injured worker to facilitate the healing and safe return to full duty. All of this is done while communicating with the employer and the insurer and maintaining confidentiality according to state and federal regulations and practice standards.

The occupational health nurse must also become knowledgeable in the management of infectious and toxic exposures and the management of pre-placement screening and drug testing, again adhering to the regulations that govern this practice. If the clinic provides on-site services, the nurse must learn the specific types of services provided and the policies and procedures that govern their delivery for the company (or companies) where she is placed. This nurse should also possess good teaching skills for both one-on-one and group instruction on safety, wellness and prevention.

Perhaps most importantly, she will need the ability to think and act independently and have good interpersonal skills to navigate company politics. At times, these politics may place the RN in direct opposition to the program’s medical director or she may be the ombudsman between an injured worker and his or her supervisor. In these instances, federal or state regulations and the program’s policies and procedures must be communicated tactfully and followed, unless the medical director determines there is a substantially compelling reason to make an exception. Depending on her placement, she may be isolated from a direct organizational support network, so she must be able to navigate turbulent waters independently but know when to appropriately involve or inform others.

Recruitment
Many nurses will apply for a posted position in the occupational health program because the hours of work are desirable. Most are daylight hours with rare weekend work. This is not a position for a new graduate but should require a minimum of three years’ experience. The most desirable experience for an RN to make the transition to occupational health nursing is five years of experience including:

• Emergency/Urgent Care

• Physician Office Practice

• Case Management

Experience in any of these areas will readily transfer to the occupational health setting. These nurses are familiar with assessing patients for episodic care, referring them for ancillary services and following up on the outcome as recommended. They are nurses who are flexible and have experience handling multiple tasks concurrently. They seem to adapt more quickly to the procedures, critical thinking, and independence necessary for occupational health nursing.

Often, current nurses who have transitioned into your department can make effective recruiters of other nurses with whom they have previously worked. Encourage staff to consider former co-workers who might be ready for a change from hospital-based nursing, utilizing and rewarding their professional relationships to fill critical positions in your department.

Stages of Orientation
Because occupational health nursing is a specialty, it requires more extensive orientation to become proficient in its practice. The American Association of Occupational Health Nurses, the professional association for occupational health nurses, has adopted standards for this practice of nursing. The Standards of Occupational Health Nursing Practice include Standards of Clinical Nursing Practice and Professional Practice Standards. There are criteria related to each standard. The introduction of occupational health to the registered nurse should include a review of these standards as well as the educational opportunities to achieve a working knowledge of the standards. In addition, assigning a mentor to the new occupational health nurse to assist in orientation will ease the process. This is not to imply that a technician certified in hearing conservation or pulmonary function testing cannot orient the nurse to audiometry or PFT testing. A manager must use all available resources to assist in the orientation of new personnel.

The initial orientation will take place over approximately three weeks, with the nurse assigned a preceptor or mentor who will document the education and return competency of the nurse’s practice before assigning the procedures involved. A sample orientation schedule follows:

Week One

Introduction to the staff and key company representatives

Introduction to the top account list and services provided

Facilities, including security and emergency procedures

Human Resources policies and procedures, including review of job description and orientation schedule

Clinic/On-Site policies and procedures including mission, vision, values, and relationship to the larger organization, if appropriate

Information System including medical record policies

Appointment schedule and flow of patient care

Customer service

Job shadowing to include registration, injury care, and screening services. (We recommend this occur the last two-three days of the first week.)

Weeks Two & Three: Establishing Proficiencies

Testing/screenings

Medications

Laboratory procedures

General patient care

Shadowing physician or other provider

Set-up for clinic procedures

Referrals

Case Management

Managing blood-borne pathogen exposures

Any regulations with which the company must comply

Telephone triage (if applicable)

Managing walk-in patients (if applicable)

Performance Improvement Program

During the orientation period the preceptor meets with the orienting nurse every day, if possible. If not, every other day is the minimum to ensure competency and open communication. The schedule may have to be altered if the information appears too extensive. Competency is documented and maintained for review at later dates and to adhere to JCAHO standards.

First Six-Twelve Months

Following the initial orientation, a continuing education program can be conducted that includes a more developed in-house training, assigned reading of professional journal articles, as well as Internet access to education programs such as those found on www.systoc.com.

In the early months, as often as possible, the nurse should accompany other nurses or physicians to on-site visits to see firsthand the work performed by the workers in the client companies. Through this process he/she will become familiar with the hazards of the local workplaces and participate in the corrective and/or preventive methods that are recommended by the more experienced professional.

Throughout this orientation, the use of the information system to track injuries and illnesses should be stressed. Outcome data should be available to provide customers’ outcomes reporting and significant trends, noting all opportunities for improvement. Referral to rehab services and other specialists, along with the resulting communication and case management, should be tracked in the information system.

Participation in the hospital’s Performance Improvement Program will also begin during this time. With this approach, the nurse soon becomes aware of the main focus of occupational health nursing, which is to promote, protect, and restore workers’ health within the context of a safe and healthy work environment.

As the schedule allows, a visit to other on-site clinics for a partial day of observation will allow for networking and an opportunity to see other clinic practices firsthand. As funds are available, continuing education programs toward certification in hearing conservation and spirometry, as well as ergonomic and other specialized training, will enable the nurse to move toward the certification goals by achieving continuing education credits in occupational health.

Retention
As the occupational health nurse becomes more experienced she will become more valuable to her current contracted companies, and other employers may try to recruit her. This is why it is important to have tightly written contracts that prohibit this practice or have a significant buy-out option. Furthermore, your retention program should provide assistance in continuing education, particularly toward becoming a certified occupational health nurse. Additionally, if she is spending the majority of her time on-site at companies, good management and on-going communication are absolutely essential to counter the sense of isolation from the parent organization that inevitably arises.

Assigning the staff nurse the opportunity to develop educational programs for other employees and employer groups as well as write for a professional journal may also increase job satisfaction and position the nurse as an "internal" expert. Naturally, the pay rate for occupational health nurses must be consistent with your organization’s salary structure, local market rates, and recognition of her growing experience. Finally, any flexibility in scheduling or other personal accommodations that an administrator can provide will go far toward retention of these nurses.

Summary
As with most challenges faced by occupational health professionals, developing a plan, carrying it out, and evaluating it over time will lead to successful outcomes. The recruitment and retention of occupational health nurses are much the same. Good Luck!

Editor’s Note: Recruitment and retention of staff at all levels within the occupational health program have always been difficult, since relatively few staff are hired with all of the skill-sets required for proficiency in the occupational health setting. With today’s tight labor market, recruitment and retention of staff have never been more difficult. Many of the strategies and training components in the following article should also be employed by administrators for all of their staff positions, since most staff will have little or no work experience in the occupational health field. Typically, RNs are utilized in the occupational health setting to fill key leadership roles and on-site contracts, keeping in mind that some states require RNs in outpatient clinics. Nurses who are being trained for positions with more authority, responsibility, and independent thinking should naturally have more extensive occupational training. - KS