Reflections on Certification Edna May Klutas, R.N., M.P.H., C.O.H.N.
Miss Klutas is Consulting Nurse, Occupational & Environmental Medicine Division, U.S. Army Environmental Hygiene Agency, Aberdeen Proving Ground, Maryland.
n April 23, 1977, the fourth examination for O certification of occupational health nurses was given by the American Board for Occupational Health Nurses (ABOHN). The 118 who passed the examination join 449 other nurses who have, in the past three years, successfully completed the examination together with the 938 occupational health nurses who were certified as Founders during the period of March 1972 to March 1973. To those pioneer nurses, who for years have envisioned the establishment of a certification program to recognize qualified occupational health nurses, this steadily increasing body of Certified Occupational Health Nurses (C.O.H.N.s) represents a dream that has become a reality. Although the primary function of ABOHN is to establish standards and examinations to certify professional nurses in the field of occupational health nursing, this was only a means to an end for the early dreamers. Their major goals were stated in the secondary functions of ABOHN. They were seeking a way to "elevate and maintain the quality of occupational health nursing service; (to) stimulate the development of improved educational standards and programs in ... occupational health nursing; (to) encourage occupational health nurses to continue their professional education; (and to) provide a means to identify'" or recognize those nurses who did make the effort to become qualified and competent in occupational health nursing. One of the major concerns of the early exploratory discussions was the need for organized educational programs which would upgrade occupational health The opinions or assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the Army or Department of Defense.
nursing practice and be recognized and accepted as preparing nurses to function competently in occupational health. Many of the occupational health nurses who had learned their specialty through "trial and error" on the job were approaching retirement. It did not make sense, professionally or economically, for all new nurses entering the field of occupational health to continue to learn the specialty in the same slow, difficult way. During the mid 1940s and early 1950s, several universities had offered comprehensive baccalaureate degree programs in industrial nursing (as it was called then). These were discontinued when specialization on the baccalaureate level was discontinued by nurse educators. Later, the closest substitute to the degree programs was the coordinated series of short courses in occupational health nursing that was offered by the Division of Occupational Health, US Public Health Service (PHS) in the 1960s. A nurse who completed all the PHS courses, theoretically, would be able to function effectively in occupational health. But the availability of these courses was limited and could take a nurse several years to complete the sequence. In addition to these offerings were a wide variety of short courses sponsored by national and local occupational health nursing organizations or by colleges. However, these did not provide the essential coordinated sequence offundamental occupational health nursing knowledge and skills based on overall objectives. Clearly, other more coordinated educational programs were needed. Although efforts were being made to stimulate colleges and universities to integrate occupational health into the baccalaureate curriculum, reactivation of in-depth specialty preparation at the undergraduate degree level was
out of the question. Nursing education philosophy and policy placed those programs at the graduate level. So, would a non-credit program be a feasible solution? Could a certificate educational program be established, similar to the New York Medical College non-credit programs in nurse-midwifery and in rehabilitation, or the six-month occupational health nursing certificate course provided by the Royal College of Nursing in London? A small task group of concerned occupational health nurses, each of whom belonged to all three nursing organizations but none representing anyone organization, met informally in January 1965 to explore these questions. This task group of nurses confirmed the need for an educational program that would provide the nurse with a foundation of knowledge of the principles and practices of occupational health nursing essential for effective performance in the specialty. In addition, the group felt such a program could also provide a sound foundation for formal certification of qualified occupational health nurses. Various problems inherent to establishing the desired educational programs were reviewed but not considered insurmountable. However, since both the American Association of Industrial Nurses' and American Nurses' Association (ANA) were concurrently involved in projects related to certification, the group delayed proposing specific action to any organization, pending completion of those projects." The members of the group did continue to discuss with various other people (nurses, management, physicians) the need and feasibility of an organized fundamental educational program in occupational health nursing. These nurses did not meet again or take further action as a group. However, almost all were subsequently involved in the development of the existing ABOHN program for certification of occupational health nurses. In April 1966, the AAOHN Board of Directors appointed an Ad Hoc Committee to study certification of occupational health nurses similar to the specialty certification boards in occupational medicine and industrial hygiene. Representatives from the National League for Nursing (NLN), and ANA were invited to serve on the committee. However, since ANA was reorganizing its own internal structure, this invitation was declined. After much deliberation, including various discussions of the necessity to establish high standards of educational preparation and nursing performance, the Ad Hoc Committee recommended the establishment of an interorganizational action committee to develop a certification program. This committee was appointed and included representatives from AAOHN, ANA, NLN, AAOHN's Education, Management, and Medical Advisory Councils; the American Board of Industrial Hygiene; the American Academy of Occupational Medicine; and the Industrial Medical Association. The Interorganizatonal Committee first met in July 1968 and developed a protocol for an occupational health nurse certification program. They recommended that the pro-
gram should be implemented by an autonomous American Board of Occupational Health Nursing and endorsed by the three nursing organizations. However, since ANA was beginning to develop its own certification program for all areas of nursing, ANA and NLN withdrew, after the first meeting, from active participation in the development of the occupational health nurse certification program. In May 1971 the Organizing Board for Certification of Occupational Health Nurses was established." This later (1972) was incorporated as the American Board for Occupational Health Nurses which administers the certification program. During the early stages of setting up the program, practical guidance was given to the OrganiZing Board by the American Society of Safety Engineers (ASSE). This group had established its certification program shortly before the organizing Board was formed. On the basis of their recent experience, the ASSE members stressed the need for clear, specific policies and procedures for each aspect of the program, from applications through examinations and renewals. This guidance was followed by the Board. Since there was no defined fundamental education program in occupational health nursing that could be used as a basic requirement for certification, the Organizing Board felt it was imperative to have a valid, objective way to measure each candidate's knowledge in occupational health. This evaluation measure is the certification examination, developed in coordination with the Professional Examination Service (PES). PES, recognized as one of the leading organizations in the field of examination development and administration, proved to be an invaluable aid to ABOHN. The Board is convinced that the quality and integrity of the resultant examination (one of the costliest items in the ABOHN budget) has been worth the cost and effort. The scope of the examination is shown in Appendix 1. Occupational health nurses planning to take the examination are encouraged to review thescopeofthe examination carefully. Then, identify those areas where knowledge is weakest and establish a plan of study to eliminate those weaknesses. ABOHN provides a study gUide of pertinent reading references. In addition, AAOHN and other resources are offering courses useful in preparing forthe examination. Also, brushing up on skills in taking examinations, to include reading skills, may help the individual who has been out of school for a period of time. Reading of current journals is also important since examination test items are being continuously updated to keep the examination pertinent to current practices in occupational health. Nurses who have become certified and who have suggestions for new test items are encouraged to contact the ABOHN Executive Secretary' for instructions on how to prepare and submit their suggestions. To further assure that the certification program was
"Now known as the American Association of Occupational Health Nurses (AAOHN).
"Mrs. Mayrose Snyder, R.N., C. O.H.N., P. O. Box 638, Thousand Palms, California 92276.
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REFLECTIONS ON CERTIFICATION
founded on sound principles of nursing and occupational health practice,the ABOHN Board of Directors defined Standards and Criteria for Occupational Health Nurse Candidates for Certification by Examination (Appendix 2). These standards and criteria provide the basis for determining the scope and content of the examination and other requirements for applicaton for and/or renewal of certification, as well as for evaluating each applicant's eligibility. Throughout this developmental period, communications were maintained with the ANA. As the certification programs of ABOHN and ANA progressed, it became apparent that steps should be taken to avoid conflict and dupl ication if both certification prog rams were to succeed. To that end, the three nursing organizations most involved (ABOHN, ANA, AAOHN) met together and developed and published a statement of mutual interest and support.' Recognizing the common goal of promoting high quality of nursing practice, thethree organizations endorsed both certification programs: ANA's certification for the generalist in community health nursing and ABOHN's certification for the specialist in occupational health nursing. . While most occupational health nurses may choose only one route to certification (ABOHN's C.O.H.N. or ANA's broader certification in community health nursing), there will be those who will seek certification in both categories.' For example, the recently appointed ABOHN Executive Secretary has been certified by both ABOHN and ANA. So, have the goals of the early dreamers been met? As a somewhat biased observer, my answer is "Yes - in part." In some areas the progress has been greater than in others. Other areas are more difficult to [udqe. In regard to the first goal, no really valid, objective, generally accepted means have been developed to measure the "quality of the occupational health nursing service" provided by the nurse. Some efforts are being made in that direction, but there is still a long way to go. Even so, if any of the teaching from the multitude of courses now being offered has increased the knowledge of the occupational health nurses, surely there must be some improvement in the quality of services they are providing. Achievement of the second and third goals is easier to measure. There has been a significant increase in the availability and quality of continuing education courses in occupational health nursing. The need for such programs was emphasized by the pretest of the ABOHN examination. Analysis of the pretest results indicated that having taken continuing education courses was more important than years of experience for the nurses who did well in the pretest. While there have been questions about ABOHN's requirement that continuing education courses must be a minimum of five contact hours in length, the minimum was established as a means of assuring the quality of continuing education. Shorter courses can, and do, provide useful information, but the depth and scope of
"However, for calendar year 1977, the ANA Community Health Nursing Practice Certification Examination will not be offered, due to funding restrictions.
content is necessarily of lesser value. Further, this standard, along with the other ABOHN standards and guides, has resulted in more careful planning of objectives and content of the courses being developed. Since there is such widespread interest in continuing education, ABOHN cannot take full credit for the rapid increase in the availability of courses. However, ABOHN's requirements have been an added stimulus both to the development and the utilization of courses by the occupational health nurse. This does represent significant progress. But the need still exists for a well-defined comprehensive basic educational program in occupational health nursing that would be widely accepted and available. This would also provide a sound foundation for the graduate degree programs that are becoming available in occupational health nursing. Some efforts have been initiated in this direction by the National I nstitute of Occupational Safety and Health and other groups, but much work remains to be done before this goal can be met. The final goal of providing a means to identify and recognize those nurses who become qualified and competent in occupational health nursing has certainly been met, as evidenced by the numbers of nurses who add C.O.H.N. after their signatures. More important, though, is the recognition of the meaning of C.O.H.N. by employers as seen in advertisements, "C.O.H.N. preferred"; or in a company policy requiring C.O.H.N., or evidence that the nurse is working to become qualified as a C.O.H.N., as a basis for promotion; or in the Occupational Health and Safety Program Accreditation Commission standards that call for the supervising nurses to be certlfled.> Thus, in looking back over the almost fifteen years of dreaming, struggling, selling, and long, tedious hours in and out of meetings, was it worth it? The evidence indicates that it was. Further, as ABOHN grows in experience, certifica.ron of occupational health nurses will have greater acceptability and influence on the improvement of nursing care of the health of the workerthe ultimate goal of the occupational health nurse.
REFERENCES 1. Bulletin. American Board for Occupational Health Nurses, Inc., New Jersey, 1972. 2. Minutes, Meeting of Task Force on Certificate Courses in Occupational Health Nursing, January 27, 1965, New York, NY, unpublished. 3. Ahern MS: The American board for certification of occupational health nurses. Occup Health Nurs January 1972. 4. Ahern MS: AAIN, ABOHN, ANA statement on certification of occupational health nurses. Occup Health Nurs November 1975. 5. Standards, Interpretations, and Audit Criteria for Performance of Occupational Health Programs. Occupational Health and Safety Program Accreditation Commission, Occupational Health Institute, 1975, unpublished.
Appendix 1 AMERICAN BOARD FOR OCCUPATIONAL HEALTH NURSES, INC.
SCOPE OCCUPATIONAL HEALTH NURSE CERTIFICATION EXAMINATION Since applicants will bring a wide variety of preparation and experience to the certification examination, the examination is planned to be broad in scope, emphasizing basic concepts and principles rather than specific technical details. The examination is divided into five major categories: Administration, Nursing Care, Illness and Injury, Physical Examination Programs, and Disease Prevention and Control. Following is a more definitive breakdown of the subject categories of the examination.
I. ADMINISTRATION A. Program Planning and Evaluation 1. Policies, Directives, and Procedure - Company & Medical 2. Budget 3. Programs B. Staffing - Nursing and Auxiliary Staff 1. Patterns and Organization 2. Functions 3. Growth & Development (a) Education - inservice, formal, other (b) Training 4. Personnel Policies C. Records & Reports 1. Individual Health Records 2. Health Service Records 3. Company Reports 4. Legal Reports D. Facility, Equipment, and Maintenance E. Working Relationships 1. Interdepartmental (a) Management (b) Labor (c) Supervision 2. Professional 3. Community (a) Use of Resources - what, why, how, when (b) Health Care Delivery Systems F. Health & Safety Legislation 1. Health (a) Food Service (b) Plant Sanitation (c) Communicable Disease (d) Other 2. Welfare (inclUding EEO) 3. Safety (a) Workmen's Compensation (b) OSHA (c) Other Occupational Health Nursing, October 1977
REFLECTIONS ON CERTIFICATION
Appendix 1 (continued)
4. Professional (a) Licensure (b) Nurse Practice Acts 5. Environmental (a) Air (b) Water Pollution (c) Other II. NURSING CARE A. Develop Plans For Patient Care 1. Assess Worker's Needs (collect, record, and evaluate data) 2. Identify Capabilities and Resources for Meeting Needs 3. Set Goals for Health Care (short & long term) B. Implement Plans for Health Care 1. Emergency Care (nursing skills & performance) 2. Supportive Care (nursing skills & performance) 3. Referrals (including transportation, handling) 4. Follow-up & Continuity of Care 5. Rehabilitation (medical/surgical aspects, chronic disability surveillance, employment of handicapped) 6. Counseling 7. Evaluate & Report Results of Care III. ILLNESS & INJURY A. Occupational Illness 1. Caused by Physical Agents (a) Temperature (b) Vibration and Motion (c) Radiation (d). Noise (e) Other 2. Caused by Chemical Agents (a) Dermatitis (b) Lung Diseases (c) Cancer (d) Other 3. Caused by Biological Agents (a) Infectious Diseases (b) Parasitic Diseases 4. Caused by Work Environment Stresses (a) Coronary Disease (b) Alcoholism (c) Other B. Occupational Injury 1. Skeletal 2. Muscular 3. Dermal 4. Vital Organs 5. Sensor Organs 6. Neuroskeletal C. Non-Occupational Illness 1. Upper Respiratory 2. Gastrointestinal 30
3. Cardiovascular, Renal 4. Psychiatric (neurotic to psychotic, acute emotional problems, addiction) 5. Metabolic Disturbances 6. Nutritional Diseases 7. Neurosensory (epilepsy, glaucoma, etc.) 8. Skeletal 9. Communicable D. Epidemiology (occupational and non-occupational health problems) IV. PHYSICAL EXAMINATION PROGRAMS A. Placement, (preemployment, return after illness, transfer) B. Periodic 1. Job Related (hazardous exposure, physical requirements, etc.) 2. Non Job Related (medical or nursing health evaluations, single disease screening, multiphasic screening) C. Termination (exit, disability, retirement) D. Components of Physical Examinations 1. History (health, occupational) 2. Tests & Measurements (audiometer, vision, electrocardiograph, tonometry-what, why) 3. Evaluation and Interpretation of Findings 4. Referral 5. Counseling 6. Follow-up 7. Coordination (supervisor, personnel office, physicians, etc.) V. DISEASE PREVENTION AND CONTROL A. Surveillance and Monitoring of Environment 1. Hazard Identification (physical, chemical, toxicological, biological) 2. Control Measures (personal protection; tests & measurements; environmental, medical, engineering controls, education) B. Immunization 1. Basic Principles (active, passive, precautions, anaphylaxis) 2. Job Related 3. Non Job Related C. Health & Safety Education 1. Individual & Group 2. Personal Health & Safety 3. Methods 4. Resources D. Mental Health E. Sickness Absence
Appendix 2 AMERICAN BOARD FOR OCCUPATIONAL HEALTH NURSES, INC.
STANDARDS OF PRACTICE FOR CANDIDATES APPLYING FOR CERTIFICATION BY EXAMINATION STANDARD I -
OCCUPA TlONAL HEAL TH NURSE (OHN)
AN OHN IS ONE WHO APPLIES NURSING PRINCIPLES IN GONSERVING THE HEALTH OF WORKERS IN ALL OCCUPATIONS. Criteria:
1. Is familiar with the work environment of persons served.
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REFLECTIONS ON CERTIFICATION
Appendix 2 (continued)
2. Knows the job requirements. 3. Is employed to conserve the health of workers. 4. Works as a member of the health team to protect and improve the health, safety, and wellbeing of those served. Currently Employed
An OHN is one who devotes fifty percent of her employment time as an occupational health nurse. Criteria:
1. A professional nurse employed regularly on a full- or part-time basis (at least 20 hours per week) in commerce or industry in conserving, protecting, or restoring the health and safety of employed workers.
THE NURSE HAS PROFESSIONAL PREPARATION COMMENSURATE WITH RESPONSI BIL1TIES. Criteria:
1. (See "Specific Requirements" as listed in ABOHN Bulletin, page 3.) 2. Continues educational efforts for professional development through: a. Courses in occupational health nursing, public health nursing, or related fields. b. Attendance at institutes, seminars, and inservice training. c. Home study courses. d. Attendance at organizational meetings and conferences. 3. Meets specifications defined by professional organizations and licensure boards for continuing education. 4. Participates in certified or approved courses in special technical procedures and programs.
THE NURSE HAS A PHILOSOPHY AND OBJECTIVES WHICH REFLECT THE PURPOSES OF AND GIVES DIRECTION TO THE NURSING CARE PROGRAM. In collaboration with management, physician, legal counsel and others: Criteria: 1. Participates in formulation of objectives for the employee health service program. 2. Recommends nursing functions consistent with company objectives and with pertinent standards established by the nursing profession. 3. Recognizes the place of the employee health service in the total company organization. 4. Interprets nursing implications, independent and dependent functions, within the context of company administrative policies. 5. Assists in determining use of information about sick absentee cases, new industrial processes, changes in job requirements, and changes in company matters. 6. Collaborates in establishing plans for orienting employees and interpreting company policies concerning the employee health service program. 7. Assures provision of adequate supplies. STANDARD IV
THE NURSE PROVIDES SAFE, EFFICIENT AND THERAPEUTICALLY EFFECTIVE NURSING CARE THROUGH APPROPRIATE PLANNING OF EACH WORKER'S CARE AND THE EFFECTIVE IMPLEMENTATION OF THE PLAN. Criteria:
1. Evaluates as required the nursing needs of the patient. 2. Develops and implements the nursing care plan for the patient. 3. Provides nursing services, treatments, and diagnostic and preventive procedures requiring specialized skill.
4. Initiates preventive and rehabilitative nursing procedures as appropriate for the patient's care and safety. 5. Observes signs and symptoms and reports to the physician reactions to treatments, including drugs, and changes in the patient's physical or emotional condition. 6. Provides for continuity of care and effective return to work. 7. Supervises and trains other nursing service personnel. STANDARD V
AN ADEQUATE SYSTEM OF RECORDS AND REPORTS IS MAINTAINED FOR EFFECTIVE NURSING CARE OF THE EMPLOYEE. Criteria:
1. 2. 3. 4. 5.
Records are complete, accurate, concise and meet needs of nursing service. Records are maintained for continuity of nursing care and legal protection. Records are kept confidential and stored in the health service. Records are reviewed periodically and goals of nursing care adjusted. Records are complete enough to provide adequate information for job placement, health maintenance, workmen's compensation, and to keep management accurately informed. 6. Data is entered in such a way that epidemiologic studies can be conducted. 7. Reports are submitted periodically to management.
THE NURSE PARTICIPATES IN PROMOTING ENVIRONMENTAL HEALTH AND SAFETY. Criteria:
1. Identifies safety and health needs through observation, interview, and analyses of records and reports. 2. Identifies patterns of accidents and illnesses in relation to environment. 3. Exchanges information and cooperates with other health and safety personnel. 4. Participates in employee education related to health and safety hazards and protection. 5. Participates in medical monitoring of health hazards. 6. Assists in the selection, training, and supervision of first aid workers.
THE NURSE HELPS PROMOTE HEALTH MAINTENANCE OF THE WORKER. Criteria:
1. Participates in health evaluation program, interprets findings, and conducts follow-up. 2. Encourages the employee to recognize and assume responsibility for emotional and physical health of himself and family and guides him toward this end through counseling, teaching, and demonstration. 3. Interprets health related information to employees. 4. Identifies patterns of employee's health needs from analysis of records and reports and utilization of health care services. 5. Develops control programs for special health needs.
THE NURSE COORDINATES THE NURSING ACTIVITIES WITH THOSE OF THE COMPANY'S BENEFIT PLANS AND WITH COMMUNITY HEALTH PROGRAMS. Criteria:
1. Helps to keep employees informed of current community health programs and services provided by community agencies. 2. Helps to establish and to maintain cooperative relationships with all community health and welfare agencies and local physicians. 3. Participates in community health programs. 4. Interprets company benefit and welfare programs to employees. 5. Analyzes relationships of nursing to other health team members both in plant and community.
Occupational Health Nursing, October 1977