The Nurse Practitioner in Industry Colleen K. Bartel, R.N.

Mrs. Bartel is Head Nurse and Adult Health Nurse Practitioner, Keebler Companyl Denver Bakery, Denver, Colorado.

When I was asked to be a speaker on the Nurse Practitioner in I ndustry at this Conference I began to try to organize my thoughts on the entire scope of the Nurse Practitioner Movement My first thoughts were, maybe I shou Id acquaint you as to the context in which I will be speaking. I am reminded, for instance, of all the recent articles in our nursing journals which have described the various activities of Nurse Practitioners, and the varied educational and experience backgrounds of these nurses. For example: A nurse who has worked in a clinical specialty for a number of years can become highly specialized, knowledgeable and proficient in her field. Some of these nurses are calling themselves Nurse Practitioners of that specialty area. To compare this to each of you in the audience who has been in Occupational Health Nursing for a number of years, I am sure you will agree, you have become a specialist and expert, but this is not the type of a Practitioner that I am referring to today. I am also sure you will agree that with the addition of OSHA and the necessary health hazard monitoring, our roles have certainly expanded and out of self-preservation we have become knowledgeable. I have read articles where the term "Nurse Practitioner" is used in its broadest sense to describe any nurse involved in the practice of nursing which then makes us all Nurse Practitioners. Then I began to wonder if the title "Nurse Practitioner," alone with Presented at the Thirty- Third Annual Meeting of the American Association of Industrial Nurses, Inc., San Francisco, California, April 15-17, 1975 Occupatronal Health Nursing, August 1975

all the other terms and titles, to name a few, "Nurse Clinician," "Physician Assistant," "Physician Extender," "Nurse Assistant," "Para-Medic," etc., is as confusing to you as it has been to me. Then I thought of the patient who must be totally overwhelmed as to the qualifications of all these fairly new additions to the health team. For clarification, while speaking to you today, the term "Nurse Practitioner" will be a Registered Nurse who has completed a structured program of study which prepares the nurse to function in an expanded role. I am speaking to this one segment and it is based entirely on my experience with it Whi Ie reflecting back over the last decade, which is the approximate age of the practitioner movement, I recall the Pediatric Nurse Practitioner Program as being the first on the horizon. As I read of their learning and working experiences I was extremely interested in the concept of a nurse establishing a case load of patients within the scope of her ability, learning to do physical examinations and physical assessments, forming a nursing diagnosis and discussing the findings with the physician, and being so totally involved in the care and treatment plans. These nurses were responsible for the care of patients with health needs that cou Id be met by the Registered Nurse in an expanded role with the physician available as a consultant when needed. I was fortu nate to be accepted to attend the Adu It Health Practitioner Course, where the practitioner movement originated, at the Colorado University School of Nursing and Medicine. This course was designed to prepare nurses in an independent role 7

THE NURSE PRACTITIONER IN INDUSTRY

in health maintenance. and to broaden and improve their capacity to provide emergent. chronic. and preventive care for the adu It patient. It was developed in cooperation with the Colorado-Wyoming Regional Medical Program in an effort to meet regional health manpower shortages. The medical team; namely. Marcus Bond, M.D. and Virginia Anderson. R.N. of Mountain Bell Telephone Company, was instrumental in convincing coordinators of the program to accept occupational health nurses in the Adult Health Practitioner Program which was limited to 12 participants. The Bell System in other areas of the cou ntry had already successfu Ily used the occupational health nurse in an expanded role. QUALIFICATIONS FOR ACCEPTANCE The qualifications for acceptance were:

1. Written commitment from my employing agency, Keebler Company, to allow me to function in the nurse practitioner role and to receive supervised clinical learning experiences needed to gain the necessary expertise for the Practitioner role. Written commitment from the Company or the boss is often viewed by the nurse as a difficult assignment The question has always been this - How am I going to convince my management that this will benefit the Company? This is a non-ending involvement of your management in your professional goals. evidence of your awareness of the Company needs and goals, and by your performance in meeting those needs in trying to organize a health program that will benefit the Company. It is a difficult sell job for the occupational health nurse to convince management that an already over-worked health program can provide more, and to gain their attention which is usually directed towards business and production goals. In selling a re-evaluation of your role in serving the employee and providing management with a healthy productive employee this can be done in terms of improvement of health and accident care programs. safety programs, pre-employment physical examinations, early detection of disease resulting in reduction of absenteeism. facilitation of entry into other health care systems. health teaching. less time spent in gathering medical data and a concise medical history and a systematic approach to a health problem. Management has always been remotely involved in its employees health. This concept is changing ... management is finding itself directly concerned and involved with health care issues. with providing increased insurance benefit programs, union demands, Workmen's Compensation laws that are more stringent. OSHA laws, and now, even the employee is turning to his company in many cases for health care. This is a way management can supply the demand in a better way. A more knowledgeable employee has always been to the benefit of the 8

employer and the Nu rse Practitioner is no exception to this idea. Who knows where we will be and what the role will be if National Health Care coverage becomes our way of life? What type of health care will the company be obliged to provide its employees? To personalize this I will tell you of my apprehension~ when my company was purchased by an English firm. Will they see a need for continuing the medical program? Do the English firms have occupational health programs with their system of Socialized Medicine? Much to my surprise. when they visited the Denver Bakery and its medical facility I found they financed a more comprehensive type of health coverage than what presently exists in my department 2. Written commitment from a physician who agrees to serve as a preceptor. This. of course. was my company physician. James D. Gibson. M.D.. who seemingly has assumed a non-ending task of being my preceptor. Ordinarily this commitment is for approximately six months to one year for practice of skills and gaining in clinical experience. This commitment is certainly not to be taken lightly. The physician is put in the position of saying ... this nurse has performed in the past to the degree he feels she is capable and ready to assume the broadened responsibilities and he puts himself on the line to accept the responsibility of seeing. to a larger extent. that she gains the expertise to function in that capacity. I will never forget the day my preceptor turned over to me his best stethoscope and said. "Here take this and use it, if you are going to be listening to hearts and it is my responsibility, I don't want you to miss a sound." The nurse also has to take into account the seriousness of this commitment and not over extend a sense of well-being. This is especially true in occupational health with all the legal implications involved. I know of instances where the nurse and physician had not reached the plateau of mutual respect of the other's role and they did not have much past knowledge of the other's expectations and needs. and this was a difficult situation. This professional relationship should not be a fleeting and temporary arrangement merely for the convenience of meeting the qualifications of the course. We were an established team prior to my acceptance into the cou rse and the cou rse served to strengthen this nu rsephysician collaboration. Personally, I am not prepared to accept total independence at this stage of the game and feel total team effort is the most effective in my setting. I rely on my preceptor's input for continued growth into the role. The occupational health setting is ideal in cultivating a climate for this type of program - the agency or company. the physician and the nurse are an established and well-functioning team involved in total team effort of the occupational health program. 3. Completion of application form with past personal history. employment background, educational

background and a statement of my professional goals followed by an interview. My goals were simple - to gain in knowledge and skills, to better serve the employees of Keebler Company, be more valuable to Keebler Company in being able to function more effectively, and to gain better job satisfaction in being more proficient in performing in an area such as my work involves. The interview was one of my more tense moments of this experience. I was afraid I might not qualify. The interview was going smoothly until we arrived at what seemingly was to be a verbal test of the extent of my medical knowledge. The first question was to state the significance and implications of the third heart sound. Not being a cardiac specialist I didn't have a notion as to how to answer the question. After mustering all the courage I had in knowing I was possibly tossing out all chances of entrance into the course, I stated, " I just don't know." Quickly the interview continued until I replied, "Wait a minute before we go on, what is the significance and implications of the third heart sound?" I figured I would at least gain that bit of knowledge! I was advised at that po int they were only concerned of evaluating how I would respond . . .If I was willing and able to say, "I don't know, what is i t show me or whatever." This I learned was to be my way of life in the near future. WHAT WAS IT LIKE BACK AT SCHOOL? The first day was one of the most "nerve-racking" days of my life. I cou ldn't even find a place to park my car in the busy Medical Center area. Prior to arrival I had been given a bibliography for reference, advised that a comprehensive review of anatomy and physiology was in order, and told to read and be familiar with Weed's Problem Oriented System of Medical Records. I n preparation for my absence at work and on the home setting, I felt I had not given my assignment as much time as I should and was apprehensive about the fact only to learn that the eleven other classmates were in the same boat Then I was faced with an all morning long pretest - I've never felt so inadequate in all my life. That afternoon classes started immediately and continued for five weeks. The material was presented in examination of a system or a part and followed by clinical experience at the hospital examining abnormalities of what we had covered in class. These clinical visits were usually three or four nurses with one physician visiting the patient Then this was followed up by examination of a classmate hopefu lIy negative for pathology, then homework was to corner as many family members for examination and writing up the exam that night Nurses with limited family members were soon at a disadvantage as even five-year-olds that normally love attention were soon found hiding from fear of being Occupational Health Nursing, August 1975

poked and peered at, at great length by the new and inexperienced Nurse Practitioner. Friends were even hard to find at times. This brings me to one of the days we had heart rounds. We had been studying murmurs, and were, of course, on our detection of heart murmur rounds. We arr ived at the room of one gentlemen who possessed a murmur which was very easy to detect and the physician was trying to relate this to us. Some murmurs are so loud you don't need the stethoscope on the skin to hear and some are so intense you can feel the rumble. This one was supposedly easy to feel and each student was given an opportunity to feel it after listening to it I was last to examine the man; therefore, last to meet the others out in the hall where I was asked, "Did you hear it?" "Yes." "Did you feel It?" "No." Again, an explanation and return visit to the man. After what seemed to be an eternity I returned to my group. My questioning was to continue. "No I didn't feel it" Again, an explanation from the understanding physician and a return visit with the man in the room who possessed the uniquely loud murmur. This time I was told to stay there until I was sure I felt that murmur. I was almost ready to give in to the fact that the man and I were going to be roommates when I finally was able to feel what the physician had described. This was only one of my painfu lIy trying experiences with the practitioner program, and rounds continued. The first five weeks went by so quickly I couldn't believe it was over. The classes were all extremely interesting, homework kept us busy, and soon we were to return to our home agency for an interim period to practice our skills. One of which was a new way of charting - the Problem Oriented Medical Records System (POMR). What I had not realized was what was happening and had happened to me. I n looking back I can see I was changing but I had not realized it then. I had left my Company sure of my role as a registered nurse , I knew what I was doing and was sure of myself and my abilities to perform. When I returned to my familiar setting I didn't fit and I couldn't understand why. I had been so busy learning the skills I did not realize the changes that were occurring. The nurse role was still there, but I was different and felt I hadn't even filled the role very well in the past I would function, or at least try, as I used to, then feel gUilty for not doing it as I had been taught recently. However, I was not sure of my new capabilities and I didn't feel comfortable in the use of my skills. Charting was confusing, I was using some POMR with myoid system of charting . I was discouraged as I didn't have as much time as I wanted in which to practice my examinations. The physician worked with me and we were slowly making progress, but time passed quickly. Our interchange was a confusing one to me - just when I felt sure of myself in one area I would feel inadequate 9

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in others. Sometimes I felt my preceptor expected more than he should. The employees responded in the same way and management didn't appear to notice any change. Time was limited and the workload stacked up with my absence and in preparing for another absence it soon was time to return to class. I returned to the second five weeks of the course feeling defeated and with a lot of goals unmet. We discussed these problems back at school. Determined to make this work and convinced that it would be beneficial to all of us if I made it work, I surged on. Experience in use of skills was gained by sending us to a number of health facilities in the Denver area so we could see how different areas were handling our same type of problems. I attended sick call at Lowry Air Force Base, but my more permanent area of practice was at a large private clinic called "The Denver Clinic" where Dr. Hayes, a cardiologist was my main class preceptor and much information and practice was gained from him and other'physicians. I visited other outpatient clinics such as the VD Clinic, Adult Walk-in Clinic, Chest Clinic and Arthritic Clinic at the Medical Center. I n each of these settings we were free to examine the patient, and discuss and enter in on the care of the patient. In some of the areas we were sent we felt uncomfortable, in others we cou Id sense the discomfort of physicians. One physician. after questioning me at length on my work responsibi lities, stated, "You cou Id probably do just as good of a job here as I am doing." It was sick call at Lowry, he pointed out his boredom and lack of interest in minor health problems and how he longed to be in the acute illness setting where his interests and talents could be used, and where he felt a challenge. This is part of the purpose of training the R.N. to assume these roles to free the physician for the type of work that requires top level of expertise. We were given the opportunity to perform on closed circuit TV, and actually see and hear ourselves perform. These sessions were shown to our peers who gave their criticism. This was a painfu I part of our growth ... blatent evidence of how we came across, our lack of confidence was easily seen. Polish was added with determination, and we tried again and again. Class lectures were usually done by physicians who were specialists in their particular field. We were fortunate to receive instruction on cardiac auscultation from the well-known Abe Ravin, M.D., who developed the Heart Sound Simulator which is an instrument for teaching cardiac auscu ltation. We were also allowed and encouraged to use this machine. as well as other equipment aids when we wished for after class practice. Management was invited to an afternoon session called "Agency Day." One of the assignments of that day was to outline what our goals and expectations were, hopefully, to meet on some common ground 10

prior to return to work. Management- the boss -was to do the same. One of my expectations was for a patient, understanding boss. I knew, for instance. I could not give as much as I had hoped for in the beginning, as I was slow at performing all my new skills including a total examination. I needed growing room. I knew I would need my preceptor to confirm my physical findings and I needed to express this to my boss. My boss had some clear-cut expectations of rapidly expanding our program. performance of physicals - a good portion of them - a greater involvement in the management and planning programs with an emphasis on Safety. The session ended with each of us understanding what was reasonable for them to expect and what was possible for me to give. RETURN TO JOB Upon completion of the second five weeks it was back to the job for all of us. The course ended, as it started, with a final test, the resu Its of which were to be compared with the scores of the pretest. My course coordinators must have sensed my apprehension as my first return had been described in my own words as a "flop." How was I going to return and use my role? I didn't know how the employee was going to know I was expanded in my new role and able to do more for him. He would expect no more or no less. Would I be caught in the old grind and not be allowed to use the new skills that I had learned? I knew something had to be done to make everyone, including myself, realize that a change had occurred. After discussing this with my instructors we decided the best way to insure this idea was to effect a visual change - something you could see. Obviously, it was my appearance, I always dressed in traditional nurse uniform, and in the course. I dressed in street clothes with a laboratory coat or white jacket with slacks. This was how I was advised to dress in order to facilitate a change from others. I was not sure at all that this wou Id be accepted. MEETING MANAGEMENT IN THE NEW ROLE Upon reporting to work in an entirely different "uniform" my first day it was obvious I had accomplished the effect which I set out to obtain. Management described me as appearing "more business like," "more professional," "easier to talk to," and "less rigid." Much to my surprise, my white uniform had actually intimidated some of my staff. My top management had a new nurse - definitely looking different - and the concept was a total success. It was obvious there had been a change and this return was much different than the last. The last time I fit so well that it didn't seem I had been gone at all. Meeting my physician in street clothes was a different story all together. He knew I was changing

gradually and that was okay, but this was too much. I am not su re that he has fu Ily accepted my new mode of dress even now. Meeting the employee in my new appearance was to receive a different set of reactions. "Gosh ... are you a doctor already?" What a golden opportunity this was - I could explain with ease - "No, I am still your nurse, but I can do more for you now and this is the way some nurses dress that are doing some different things that used to be done only by doctors." I might add that I work in the VD Clinic and dress in very casual clothes, jeans, shirt, etc. At first I felt uncomfortable and unprofessional dressed this way, but the patients respond better and seem more at ease. When I am performing a physical examination in the VD Clinic, the patient will often ask how long I have been a doctor even though the interview is started with "I am one of the nurses working in the clinic." The patient is always given an explanation of the new expanded role for nurses, and they are very accepting and interested in the new role and seem appreciative to have someone pay more attention to their less critical needs. They have expressed such feelings as "Physicians are always too busy to have to take time to explain," or "I feel so guilty about taking up the doctor's time." The patients are extremely gratefu I of the attention and time given to help them resolve or find a solution to their problems. I hope I do not appear to be putting the physician in jeopardy. When a problem arises that requires his attention and challenges his expertise he has always been on hand and a most eager and willing participant of the medical team. What I am trying to get across is thisShould the physician be bogged down with an overload of tasks that someone else could assume? Shou Id he have to do all of the physical assessment screening when a nurse with expanded skills could see some of these patients and lessen the physician's load and allow him the time he needs to spend with the patients with an abnormality? I think it wou Id be to everyone's advantage to use his knowledge and time where it is needed the most. The registered nurse in an expanded role and her previous broad base of medical knowledge makes this possible as she assumes some of the load which does not require the physician's expertise. After having established a climate of change and realizing it was up to me to facilitate change by my performance and actions, progress was much easier. Also, in realizing the changes that had gradually occurred in my role and my performance, I was able to gain the confidence that kept me moving toward my goal. I began using the POMR method of charting as much as I cou Id. This new way of charting is a systematic and well-organized approach to gathering and recording the medical history, physical examination and laboratory data, and listing of the health problems, developing a plan of treatment, and Occupational Health Nursing, August 1975

ensures a more thorough follow-up of an established health problem. Physical examinations were done on as many of the pre-employment applicants as 1 could handle and still keep up with the rest of my work. My preceptor wou Id then redo the examination to confirm my findings. Presently, I am now able to perform the preemployment physicals, and if the examination is normal, the applicant is put to work. This allows prompt placement of the applicant in the job setting and helps the Company respond more quickly to fluctuating production requ irements. I n discussing performance of physicals comes the question of the female checking for hernias on male patients as well as female patients. I have found that in general it has been the medical profession that has clung to this outdated sense of propriety. For example - the male employee who reports to the nurse with a pain in the groin, and he is certain he has a hernia and is really quite frightened. I wonder how consoling it has been to be instructed not to lift anything heavy, to report any increase of discomfort or pain, and wait until the physician can examine him. I have had occasions where I was confronted with this situation. A 20-year-old single black male called me one afternoon stating frantically that he had been trying to be seen in several clinics in the Denver metro area and had been unsuccessful. He was supposed to work that afternoon and didn't want to jeopardize his job, but he felt unable to work and frankly was quite frightened. I n questioning him over the telephone he said he had noticed the swelling in the groin area while bathing. He could recall no occasion of injury; thus, it was considered a nonoccupational problem. He stated it had nothing to do with his work. I told him I could arrange for him to see the Company physician as a private patient, but the next day was the doctor's day off so it wou Id be a two-day wait. He asked if there wasn't any way I could find someone who could check him, hinting that he probably knew I had had the recent training in performance of this type of examination. I reverted to my past training and old role, and handled it wrong. I expressed my concern then said I could examine him, but if he didn't want me to I would understand. What an unprofessional way to handle a problem. This man should have been handled no differently than if his complaint was chest pain or back pain - I would examine him and relay my assessment to the physician, we would discuss it and take the necessary medical steps. I was the medical person this man turned to, he was asking for help. Thankfully, he must not have picked up on my statement negatively he was grateful to find someone with the abi lity and a few minutes of time just for him. Examination revealed an easily reducable right inguinal hernia. I reported my findings to the company physician who confirmed my findings two days later. Since this was not an emergency situation, 11

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and I did not anticipate him to have any trouble, I gave the man detailed instructions, one of which was, if he did have any questions, how he cou Id reach me through the plant Surgery was required and the man had been through such a difficu It experience he was happy to find the plant physician wi lIing to perform the surgery. Incidently, this man had full insurance benefits so that was not the reason he had so much difficu Ity in being seen. What at first was handled quite poorly and must have been a real ordeal for the patient ended well. ... 1 was actually able to detect a hernia, the man was given instructions and encouragement and was no longer frightened, the surgeon had gained a surgical case, and the patient was extremely grateful. Another similar case was another young male patient who thought he had a work-related hernia. He was working on another shift when he reported his symptoms to the R.N.; thus, he was not examined. I became aware of the situation the next day when he called to report he was having too much pain to work. I requested that he report for examination. My examination revealed a small tender swelling in the spermatic cord and he did not have a hernia. The company physician later confirmed my findings and diagnosed the swelling as an enlargement of a vein which was not due to the occupation and the employee was referred to his own physician. His physician advised him he "tore something" and after some communication with the employee's doctor and a further examination on his part, a workmen's compensation case with time loss involved was avoided. While performing all these new duties the nurse must realize that this will more than likely be in addition to all the other job duties as varied as they might be. I used to dream of the day I would be free to do all nursing duties after the practitioner course .... 1 dreamed of freeing myself to do just those duties Reality finally struck! Maybe some of you are fortunate enough to be in positions that it is all nurse and medical work, but I want to point out that maybe you have a rare setting. Quite frankly I consider myself fortunate to have received my extended education which was backed by the Company, but I wonder how the management wou Id feel if suddenly after receiving this backing I demanded to use it to the fu lIest advantage - I have no question in my mind as to the Company benefit that wou Id be experienced. What it wou Id mean is to provide one with: (1) a secretary, (2) ,new equipment for the department, (3) other medical help, and (4) of course, a larger salary, etc. Someday these things will happen and I don't mean to imply I have not benefited personally for accepting the new responsibilities. I do mean to impress - change is gradual. I involve my management in my professional goals daily as to how I would like to see the department function and how my abilities could best 12

be used. Industry has its problems today ... take a look at the economic situation faced by big industries. We have the largest number in history of businesses closing their doors, a staggering figure of unemployment, high prices on raw products and high salaries being paid. Industry is in trouble and so is the common employee of which I am one. I can visualize pricing myself right out of the market before my true value is even realized and all these other tasks that I do will still need to be done by someone and that someone will be me for a while until the changes can occur. I am still involved in the "grubby" task work of answering my own telephone, typing my own correspondence, i nsu rance reports and forms, workmen's compensation reports, OSHA logs and reports, and all the other non-nursing work that occupational health nursing is all about. Gradually I see industry progressing to the point of using the medical personnel to the fu lIest advantage in an effort to gain back some of the financial drain which has been realized in hidden and often unmeasurable cost areas. Another case where my practitioner skills paid off was with a 39-year-old Spanish-American married female who had been a good employee for six years. Her chief complaint was pain and numbness in her right shou Ider and arm. Activity made it hurt worse and she was unable to do certain jobs as they involved holding her arm shoulder height and it caused her an extreme amount of pain. She couldn't set her own hair or perform normal houskeeping duties such as hanging up clothes, washing walls or painting. She was extremely fatigued by her alleged pain, she had a headache most of the time and her neck and back hurt This pain was so distressing she could not get along with anyone especially at home due to the fact she was grumpy and tired all the time. She had been treated by her local medical physician for the past year and a half with tranquilizers, and she said they didn't help at all. She had been through an expensive and unsuccessful series of chiropractic adjustments and presently didn't know which way to turn. Since I was taking this history by telephone on an absence call, I suggested that she seek the help of a specialist such as a neurologist or orthopedic physician. She did not follow my advice, but went to another doctor this time an osteopath who felt on her first visit she was suffering from anxiety and pressure definitely caused by her work. At the end of a month, and on her second visit, he released her to return to work with a note to that effect which brought her back to my office. The patient insisted these symptoms were not caused by her work, that she just was so tired and in so much pain she just could not do her work - but since she had been released she guessed she wou Id just have to try. She had been off work for one month, her insurance benefits had been denied as her latest doctor felt it was work related and I had not been

advised so a claim could be filed. Rather than allow her to return to work as advised by the doctor I took a full history of all her complaints which were suggestive of thoracic outlet syndrome. Examination revealed a possible confirmation of lack of blood to the extremity. I took the risk and contacted her latest doctor and explained I had talked with the employee and was trying to help her get back to work and straighten out her disability benefits that had been denied. I discussed with him the fact that the employee did not feel her problem was caused by her work. I was informed he felt they were and that she had been released for work. My next question was to the effect that if this was caused by her work and her symptoms had not been relieved, then did he still think she should return to the same job setting. (Back to the doctor-nurse game, a habit which is hard to break.) I challenge this point - who knows this patient better than I do? I see her on a daily basis - not always as a patient, but as a happy, healthy well-functioning adult who develops a health problem. This employee had already been evaluated by all the previously mentioned doctors. My next step was to discuss my findings and the entire problem with my preceptor who agreed the symptoms were that of a thoracic outlet syndrome, and since we had to resolve this problem, especially due to the workmen's compensation involvement, we referred her to a neurosurgeon. Since her scalenotomy to correct the thoracic outlet syndrome, she has returned to work symptom free, and again I see not a neurotic unhappy female, but a well-functioning happy healthy adu It I might add this patient confided upon return to work she had actually been ready to go to a psychiatrist, since no one seemed to be able to find a physical cause for her pain she felt it must be imagined. I finally got her insurance benefits straightened out for her, and as the neurologist felt her condition was not due to her work or accident. we were able to avoid a work-related/ lost time-i nvolved case. DISEASE DETECTION PROGRAMS Since completion of the course I have had three disease detection programs - Glaucoma, Diabetes and Hypertension. These disease detection programs are mu ttl-told, they identify the employees with the health problem known by the employee, but not by medical, and they also identify patients with the disease that were not previously aware of their illness. This allows for identification of the health problem so it can be noted on the chart, and also allows for followup on the employee's progress with his condition. The most involvement was with the hypertension detection screeni ng, and as a resu It, I have become involved in the regulating of a group of employees in cooperation with the employee's private physician. Nurses that do not have the broadened scope of practice cou Id do the same types of studies, however, since I have Occupational Health Nursing, August 1975

completed the course and this becomes known to the physicians, they seem more willing to work with me and rely more on my judgment to regulate or change dosage of a medication within a set protocol from that physician. One of my patients, a 57-year-old black married male was found to be hypertensive on the screening. He was referred to his local medical doctor with a letter stating we had found his blood pressure to be elevated. As a result, his physician placed him on medication. I n following this employee, I was not satisfied with the resu Its and asked the man for permission to telephone his doctor to advise him that his blood pressure was not responding. As a result, I was given a regime to follow in adjusting the medication. The physician and I now share a cooperative responsibi lity in the regu lation process of this man's problem. With this type of follow-up, the patient-employee gets closer medical supervision of his chronic problem. I t is beneficial for all, in that the employee remains in the health care delivery system, saves valuable time for his physician, there is less medical expense for the employee and it keeps Keebler's loss time down and production up. Another example of this cooperative responsibility was brought to light recently by a patient who is being followed for hypertension in my office. She had been off work for another health problem and was returning to work. My concern was that both physicians were aware of each other's treatment programs, and I asked if she had seen the physician who was treating her for hypertension. She told me she had been advised by him if I was following her and was satisfied with the control, it was not necessary to return to see him. I had sent her originally to the physician with notes stating my findings, but had never received any communication from him other than comments from the patient I was not really aware that the physician was relying that heavily on my assessment Physicians are becoming more aware and dependent upon the broadened capabilities of nurses and seem appreciative to have someone else tracking their patients who have chronic health problems. We have progressed to the point where patients are not resistant, as in the past, of identifying their health problems. Rather, they are coming to the office to report even short-term medications and problems "just for the record." A recent patient had been on layoff for nearly four months and was called back to work and she came to the office to say she was on an antibiotic as she had been ill with a bacterial infection, but was well enough to work. She had heard through other employees that we wanted to know of any existing health problems and medications. I carefully noted this minor bit of health information on her chart with full knowledge of its present lack of significance; however, this employee is convinced she is to report these health problems to the Medical 13

THE NURSE PRACTITIONER IN INDUSTRY

Department, and that's the way we want it, she is now a convert so to speak in the total health program, especially, important in the POMR system. ON-THE-JOB INJURIES We all face the care of the on-the-job injuries suffered by our employees. As a Nurse Practitioner I am in better position to determine the extent of the injury and can communicate my findings to the physician because I am able to perform a more valuable physical examination of the injured part These expanded assessment skills now enable me to assume a greater role in assessing the needs of the patient The employee with a chief complaint of a back pain reporting to the clinic will be examined. If muscle spasms are fou nd this wou Id be reported to the physician and appropriate treatment started immediately. This would not necessitate a trip to the doctor's office or emergency room for the physician's examination as it did in the past. ~ome nurse practitioners are even suturing minor lacerations in their clinics, there again, eliminating use of the already overburdened emergency rooms. I have found the use of Steri-Strips successful in treatment of the less severe lacerations which I would have previously sent for suturing in the emergency room. In functioning in the broadened scope of nursing, one also assumes other responsibilities such as implementation of the role, legal requirements of the

role, and the setting of professional standards. Presently, the role is so new many of the requirements of education, implementation and legal aspects are still being formulated and discussed. It therefore becomes my responsibility to be available in time, and interested enough in my profession to be involved. It means being actively involved in my professional organizations, willing to be an office holder, speaking to others on the subject when asked, keeping up medically by reading appropriate materials, attending seminars, and at times, being politically active in health issues. SUMMARY To summarize my feelings of my original goals and how I presently feel about being an I ndustrial Nurse Practitioner: What it has made me is a better nurse, definitely more valuable to my employer, and I am serving my patient/employees at a more skilled level. I have much greater job satisfaction in my expanded role. Progress is slow and painful, and in representing the new expanded role of nursing, I am still involved in the routine everyday problems. Success is not always realized at the time it is most needed or wanted and there have been days when the load seemed almost too heavy to bear; however, I have experienced some of the triumphs of when a goal is realized, and it is knowledge of this that makes it all worthwhile.

23rd Annual AAIN Presidents' Meeting The Biltmore

New York, New York

September 27 & 28, 1975 14

The nurse practitioner in industry.

To summarize my feelings of my original goals and how I presently feel about an Industrial Nurse Practitioner: What it has made me is a better nurse, ...
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