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The hospital occupational health service: Basic emergency nurse cross-training and differences from emergency services
The hospital occupational health service: Basic emergency nurse cross-training and differences from emergency services Author: Polly Gerber Zimmermann, RN, MS, MBA, CEN, Chicago, Ilhnois
c c u p a t i o n a l h e a l t h (OH) c a n p r o v i d e a n alternative w o r k e n v i r o n m e n t for a n e m e r g e n c y nurse, as well a s r e v e n u e e n h a n c e m e n t for t h e e m e r g e n c y d e p a r t m e n t . T h e t e r m occupational health (a/k/a i n d u s t r i a l m e d i c i n e ) is loosely i n t e r c h a n g e a b l e w i t h e m p l o y e e h e a l t h - - t a k i n g c a r e of t h e i n s t i t u t i o n ' s or b u s i n e s s ' s o w n e m p l o y e e s . However, in t h i s context, it is a selling of t h e h o s p i t a l ' s h e a l t h c a r e s e r v i c e s to outside b u s i n e s s e s for p r o v i d i n g l i m i t e d h e a l t h c a r e to their e m p l o y e e s . B e i n g affiliated w i t h a n e m e r g e n c y d e p a r t m e n t , r a t h e r t h a n a f r e e s t a n d i n g facility, is often a major selling p o i n t to t h e b u s i n e s s e s . In t h e b e g i n n i n g , S w e d i s h C o v e n a n t H o s p i t a l h i r e d a n o u t s i d e firm t h a t e s t a b l i s h e d its OH p r o g r a m and solicited companies within a specific geographic radius. A s t h e b u s i n e s s grew, it b e c a m e an i n d e p e n d e n t , s e p a r a t e e n t i t y w i t h i n t h e hospital, w i t h its own p h y s i c i a n , nurse, r e c e p t i o n i s t , c a s e m a n a g e r , forms, policies, a n d s a l e s p e r s o n . T h e OH t r e a t m e n t rooms, l o c a t e d a d j a c e n t to t h e e m e r g e n c y d e p a r t m e n t , a r e u s e d as t h e after-hours ED fast t r a c k area. H o s p i t a l d e p a r t m e n t s s u c h as laboratory, radiology, p h y s i c a l therapy, a n d o c c u p a t i o n a l t h e r a p y all s h a r e in t h e i n c r e a s e d profitable volume, a s well a s t h e on-call s p e c i a l t y p h y s i c i a n s (hand, o r t h o p e d i c s , eye). P o t e n t i a l c u s t o m e r s a r e n o t only in t h e t y p i c a l l y p e r c e i v e d m a n u f a c t u r i n g i n d u s t r i e s , b u t in s e r v i c e f o c u s e d o r g a n i z a t i o n s as well. S u c c e s s f u l clients h a v e i n c l u d e d e m p l o y e e s of c o l l e g e s , f a s t - f o o d r e s t a u r a n t s , d a y c a r e c e n t e r s , charities, l o n g - t e r m care facilities, governmental departments (post office, c i t y t r a n s p o r t a t i o n , p a r a m e d i c s , police), priv a t e a m b u l a n c e c o m p a n i e s , retail stores, g a r a g e s / b o d y w o r k shops, a n d g r o c e r y c h a i n s .
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Polly Gerber Zimmermann is staff nurse III, Emergency Department and Occupational Health, Swedish Covenant Hospital, and an associate nurse, American Airlines Occupational Health, Chicago, Illinois, and faculty, Truman College, Chicago. For reprints, write Polly Gerber Zimmermann, RN, MS, MBA, CEN, 4200 N. Francisco, Chicago, IL 60618. J Emerg Nurs 1996;22:591-4. 0099-1767/96 $5.00 + 0 18/9175474
Occupational health role The OH n u r s e ' s b r o a d e r role e n c o m p a s s e s a s p e c t s along t h e e n t i r e h e a l t h c a r e c o n t i n u u m . B e y o n d t h e a s s e s s m e n t a n d t r e a t m e n t of initial injuries w i t h w h i c h e m e r g e n c y n u r s e s are familiar, t h e p a t i e n t r e l a t i o n s h i p c o n t i n u e s until r e h a b i l i t a t i o n / h e a l i n g is c o m p l e t e a n d future p r e v e n t i v e m e a s u r e s are instituted. T h e n u r s e also regularly p a r t i c i p a t e s in r o u t i n e physical examinations, immunizations, prevention t e a c h i n g , a n d t e s t i n g for d r u g s . E x a m i n a t i o n skills include physical assessment, including tympanic m e m b r a n e evaluations, v i s u a l acuity, a u d i o g r a m s , t y r n p a n o g r a m s , a n d spirometry. Proficiency in precise, d e s c r i p t i v e c h a r t i n g is essential. While a d m i n i s t r a t i o n of t h e OH s e r v i c e w a s h a n dled b y t h e e m e r g e n c y d e p a r t m e n t , volunteer, crosstrained nurses between the two departments helped w i t h t h e staffing n e e d s in light of fluctuations in cens u s a n d s c h e d u l i n g . A n e m e r g e n c y n u r s e ' s core skills a n d c o m p e t e n c i e s in r a p i d a s s e s s m e n t of o u t p a t i e n t s a n d h i s t o r y t a k i n g a r e t h e b e g i n n i n g s of a role t r a n s i t i o n to OH. M y o r i e n t a t i o n to OH c o n s i s t e d of w o r k i n g a few o n - t h e - j o b shifts w i t h a n e x p e r i e n c e d OH nurse. I also j o i n e d t h e A m e r i c a n A s s o c i a t i o n of O c c u pational Health Nurses and did some independent reading. M a n y n u r s e s initially i n d i c a t e d i n t e r e s t in p a r t i c ipation. T h e o p p o r t u n i t y s e e m e d to p r o v i d e job s e c u r i t y a n d a c o m m o n m i s p e r c e p t i o n t h a t it is " e a s y work." H o w e v e r , m a n y n u r s e s d e c l i n e d furt h e r i n v o l v e m e n t . S o m e lost i n t e r e s t b e c a u s e of t h e r e g i m e n t e d , e x a c t i n g r e q u i r e m e n t s a n d t h e difficulty in m a i n t a i n i n g c u r r e n t k n o w l e d g e a n d p r a c t i c e t e c h n i q u e s w h i l e w o r k i n g only i n f r e q u e n t l y in t h e OH area. S c h e d u l i n g flexibility is limited, a n d early or late h o u r s m u s t b e a u t o m a t i c a l l y w o r k e d a c c o r d i n g to p a t i e n t s ' n e e d s b e c a u s e t h e r e is no relief staff. A s one of t h e h o s p i t a l ' s c r o s s - t r a i n e d nurses, I also soon r e a l i z e d t h a t OH w a s a v e r y different p r a c t i c e area. U n d e r s t a n d i n g t h e u n i q u e n a t u r e of OH a n d m a k i n g a d j u s t m e n t s in t h e n u r s i n g a p p r o a c h are k e y to a n effective transition.
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Differences between the occupational health and emergency departments 1. The principles of managed care are fully used. M a n y b e n e f i t s are offered to c o m p a n i e s for u s i n g a n OH p r o g r a m . S e r v i c e s sold i n c l u d e (1) d i s c o u n t e d fees for volume, (2) t i m e l y t r e a t m e n t s , a n d (3) a coord i n a t e d c o u r s e of t r e a t m e n t . C o n t r a c t i n g m a n a g e m e n t w a n t s t h e "on-the-clock" e m p l o y e e s to r e c e i v e e x p e d i t e d t r e a t m e n t a n d to e x p e r i e n c e a faster r e t u r n to full c a p a b i l i t i e s .
S u c c e s s f u l clients h a v e i n c l u d e d e m p l o y e e s of colleges, fast-food restaurants, day care centers, charities, long-term care facilities, governmental departments (post office, city transportation, paramedics, police), private a m b u l a n c e c o m p a n i e s , retail stores, g a r a g e s / b o d y work shops, and grocery chains.
E m p l o y e e s m u s t follow-up w i t h t h e OH p r o g r a m a t regular, f r e q u e n t intervals, e v e n if t h e y are off w o r k or are also s e e i n g a p r i v a t e p h y s i c i a n . A n y m i s s e d a p p o i n t m e n t s are i n v e s t i g a t e d a n d t h e e m p l o y e r is notified. P a t i e n t s w i t h injuries t h a t are not i m p r o v i n g at t h e e x p e c t e d r a t e a r e a p p r o p r i a t e l y referred for a d d i t i o n a l i n t e r v e n t i o n s , s u c h a s p h y s i c a l t h e r a p y or a s p e c i a l i s t ' s services. T r e a t m e n t focus e x t e n d s b e y o n d m e r e l y looking at t h e q u a l i t y of t h e d i r e c t c a r e g i v i n g a c t s to m o n i t o r i n g of t h e overall i m p r o v e d p e r f o r m a n c e . Unlike a p e r s o n a l illness, w h e n t h e i n d i v i d u a l e m p l o y e e c h o o s e s w h e t h e r to w o r k on a p a r t i c u l a r day, t h e e m p l o y e e w i t h a w o r k - r e l a t e d injury w h o s e c a r e is m a n a g e d b y t h e OH s e r v i c e d o e s not i n d e p e n d e n t l y control t h e t i m e a w a y from w o r k or t h e r a p e u t i c interventions. After assessing and interviewing the p a t i e n t , t h e t r e a t m e n t r e g i m e n a n d r e s t r i c t i o n s are u n d e r t h e control of t h e OH d e p a r t m e n t . P o s t i n j u r y m o n i t o r i n g of w o r k r e s t r i c t i o n s for t h e e m p l o y e e is a major r e s p o n s i b i l i t y of t h e p r o g r a m . A n impartial, s o u n d clinical j u d g m e n t is m a d e , g u i d e d b y w h a t is e s s e n t i a l for t h e condition, not p o l i c y or p a y m e n t i m p l i c a t i o n s . E m p l o y e e s c a n also s e e k c a r e
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from their o w n p h y s i c i a n s , b u t d i s c r e p a n c i e s are r e s o l v e d t h r o u g h a t h i r d - p a r t y o p i n i o n in t h e form of an independent medical examiner. E m p l o y e e s are u s u a l l y r e l e a s e d w i t h " s e d e n t a r y duty" l i m i t a t i o n s as a m i n i m u m ; t h e c o m p a n y t h e n d e c i d e s if t h e r e are t a s k s t h a t a c c o m m o d a t e t h o s e r e s t r i c t i o n s or if t h e c o m p a n y w a n t s to give t h e e m p l o y e e t i m e off. This p r o c e s s m i n i m i z e s m a l i n g e r ing. T h e reality is t h a t s o m e w o r k e r s ' g e n e r o u s b e n efits p r o v i d e little i n c e n t i v e to work. For i n s t a n c e , one u n i o n c o m p a n y p a y s i n j u r e d w o r k e r s 80% of t h e i r salary for 3 m o n t h s . S u s p i c i o n s are a r o u s e d in t h e OH d e p a r t m e n t if a w o r k e r b e c o m e s h o s t i l e w h e n a s s i g n e d to a n s w e r t h e p h o n e at a p l a c e of e m p l o y m e n t i n s t e a d of b e i n g s e n t h o m e . A t t h e other e n d of t h e s p e c t r u m , p r o b l e m s o c c u r w h e n a n e m p l o y e e p r e m a t u r e l y w a n t s full d u t y b e c a u s e of r e d u c e d p a y or b e n e f i t effects from n o t working. A s a p a t i e n t a d v o c a t e , it is i m p o r t a n t to prev e n t reinjury to t h e p a t i e n t b e c a u s e of a n early r e t u r n to work. This is e s p e c i a l l y t r u e w h e n t h e e m p l o y e e d o e s n o t u n d e r s t a n d or a g r e e w i t h t h e d e c i s i o n e v e n after a t h o r o u g h e x p l a n a t i o n . O c c u p a t i o n a l h e a l t h ' s m a n a g e d care a p p r o a c h h a s m a n y s u c c e s s stories. O n e e m p l o y e e w h o w a s i n j u r e d on t h e job h a d a p o s i t i v e result after alcohol s c r e e n i n g . After c o m p l e t i n g a n e m p l o y e e a s s i s t a n c e p r o g r a m , h e n o w h a s l o n g - s t a n d i n g sobriety. In a d d i tion, w h i l e i n v e s t i g a t i n g his d e l a y e d w o u n d healing, an u n k n o w n d i a b e t i c c o n d i t i o n w a s d i s c o v e r e d .
S c h e d u l i n g flexibility is limited, and early or late hours m u s t be automatically w o r k e d according to patients' n e e d s b e c a u s e there is no relief staff.
2. The contracting company is the employer. C o m p a n i e s p u r c h a s e OH s e r v i c e s to monitor t h e i r e m p l o y e e s ' s a f e t y a n d t h e l e g i t i m a c y of j o b - r e l a t e d h e a l t h claims. A l t h o u g h OH n u r s e s a d v o c a t e indirectly for p a t i e n t s , t h e b a s i c u n d e r s t a n d i n g is t h a t all staff m e m b e r s u l t i m a t e l y are w o r k i n g for t h e c o m p a ny, n o t t h e p a t i e n t . C o m p a n i e s a n d t h e g o v e r n m e n t h a v e regulations t h a t are s p e c i f i e d for their e m p l o y e e s at the t i m e of their hire. E m p l o y e e s h a v e t h e right to decline t h e
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company-provided free medical care or even the "for cause" drug screening with an understanding of the consequences. Once the employee consents to comply, however, the c o m p a n y ' s c o n t a c t s are k e p t informed throughout the employee's treatment course, including documentation and laboratory results.
Unlike a personal illness, w h e n t h e individual e m p l o y e e c h o o s e s w h e t h e r to w o r k o n a particular day, t h e e m p l o y e e w i t h a w o r k - r e l a t e d injury w h o s e c a r e is m a n a g e d b y the OH service does not independently control the t i m e a w a y f r o m w o r k or therapeutic interventions. There is c o n s t a n t vigilance to discern the validity of any e m p l o y m e n t - r e l a t e d complaint. This m a y s e e m in opposition to the usual ED approach where the nurses' predisposition is to believe their p a t i e n t s (provided they do not have severe pain and are allergic to everything but narcotics). Why else would they come for t r e a t m e n t with their own funds if they did not have a n e e d ? Although this difference m a y initially cause emotional conflict for the nurse, it is helpful to consider that it is also in the employees' b e s t interest to be s t o p p e d from operating a drill press w h e n inebriated or otherwise physically impaired. In one scenario, a c o m p a n y that contracted for OH services sent an employee for t r e a t m e n t of an onthe-job m a n u f a c t u r i n g injury. The nurse d e t e c t e d an alcohol smell. An e m e r g e n c y nurse would protect that p a t i e n t ' s confidentiality, b u t the OH nurse cont a c t e d the c o m p a n y to ask if they w a n t e d a blood s a m p l e taken to d e t e r m i n e that p a t i e n t ' s alcohol level. When informed that the t e s t was requested, the m a c h i n i s t angrily s h o u t e d to the nurse, "So I like beer. Is that a crime?"
3. Customer service is premium. Offering OH services is a b u s i n e s s venture, and the m a r k e t i n g "sell" is always on display. A professional a p p e a r a n c e and interactions with the contracting c o m p a n y from the initial g r e e t i n g through the final disposition is involved. To p r e v e n t a loss of business, it is essential that the nurse be p e r c e i v e d as knowl-
edgeable, approachable, credible, caring, and professional by everyone from the entry-level worker to the c o m p a n y ' s owner. Good p a t i e n t relationships prom o t e t r e a t m e n t compliance. Satisfied m a n a g e m e n t ensures continued b u s i n e s s in this increasingly competitive field. The OH nurse m u s t a d d r e s s both the cost containment and safety concerns of the company while being e m p a t h i c and u n d e r s t a n d i n g to the emotions and a d e q u a t e care concerns of the employee. A truck driver with a blood pressure of 190/110 m m Hg could have serious implications for both sides. M e e t i n g the c u s t o m e r s ' n e e d s also includes u n d e r s t a n d i n g their environmental a n d cultural perspective, rather than artificially a t t e m p t i n g to make t h e m fit into the hospital structure. For example, during one on-site flu vaccination program, it was glaringly inappropriate to have only English consent forms for the overwhelming n u m b e r of Spanishs p e a k i n g employees.
4. Treatment of work-related matters only. Only job-related concerns are t r e a t e d in OH. In an OH setting, personal m e d i c a l problems, from the flu to bunions, are not t r e a t e d b u t should be brought to the employee's personal care provider. This distinction often needs reinforcement b e c a u s e some employees e x p e c t c o m p r e h e n s i v e "free" care. For example, w h e n a p r e e m p l o y m e n t physical reveals hypertension or a n e e d for glasses, the a p p l i c a n t is encoura g e d to s e e a p r i v a t e p h y s i c i a n although a r e c o m m e n d a t i o n is always m a d e about the applic a n t ' s current ability to work.
T h e r e a l i t y is t h a t s o m e workers' generous benefits p r o v i d e little i n c e n t i v e to work.
5. Dot the i's, cross the t's. Occupational health d e m a n d s extensive knowledge of and strict adherence to governmental (Occupational Safety and Health Administration [OSHA], National Institute of Occupational Safety and Health, [NOISH], A m e r i c a n s With Disabilities Act, D e p a r t m e n t of Transportation [DOT]), union, and workers' compensation regulations, in addition to nursing care standards. By necessity, ED nursing focuses on m e e t i n g the m o s t e m e r g e n t n e e d s in w h a t e v e r w a y possible. Occupational health, on the other hand, cannot toler-
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a t e a n y i n d i v i d u a l i n c o n s i s t e n c i e s . It is t h e r e p e t i tive, t h o r o u g h , d e t a i l e d c o m p l e t i o n of p r o c e d u r e s and documentation details that protects the practice a n d t h e n u r s e in t h e e x t e n s i v e d e a l i n g s w i t h insurance companies, workers' compensation hearings,
One employee who was injured on t h e job h a d a p o s i t i v e r e s u l t after a l c o h o l s c r e e n i n g . After c o m p l e t i n g an e m p l o y e e a s s i s t a n c e program, he now has l o n g - s t a n d i n g sobriety. In addition, w h i l e i n v e s t i g a t i n g his d e l a y e d w o u n d h e a l i n g , an u n k n o w n diabetic condition was discovered. a n d u n i o n g r i e v a n c e s . This i n c l u d e s a l w a y s d e s c r i b i n g p a t i e n t s in o b j e c t i v e t e r m s and, in s o m e c a s e s , staying with the physician as a witness during an e m p l o y e e e x a m i n a t i o n a n d c a s e d i s c u s s i o n . Datab a s e d c h a r t i n g is e v e n m o r e i m p o r t a n t . For e x a m p l e , t h e OH n u r s e w o u l d n o t c h a r t t h a t t h e p a t i e n t w a s "paranoid" b u t d o c u m e n t "Patient s t a t e s , ' E v e r y o n e is out to g e t m e . ' " P r e c i s i o n is p a r t i c u l a r l y critical in t h e c h a i n of c u s t o d y d u r i n g t e s t i n g for drugs. Vigilance m u s t b e maintained because employees continually develop
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n e w w a y s to try to "beat" t h e test. For e x a m p l e , one n e w m i s g u i d e d staff m e m b e r "helpfully" let t h e e m p l o y e e t a k e a d r u g t e s t e v e n t h o u g h he "forgot" his p h o t o identification. W h e n t h e d r u g s c r e e n i n g p r o v e d positive, t h e i n c o n s i s t e n c y p r e v e n t e d its u s e in d i s c i p l i n a r y action.
6. The role of prevention A b a s i c p r e m i s e in e m e r g e n c y n u r s i n g is t r e a t i n g illness, w h e r e a s t h e a s s u m p t i o n in OH is t h a t a g i v e n p a t i e n t is g e n e r a l l y healthy. Vital s i g n s are m e a s u r e d just once, n o t every hour. P r o a c t i v e p r e v e n t i o n p l a y s a m a j o r role as it d o e s in e m e r g e n c y n u r s i n g , a l t h o u g h t h e t o p i c s differ. For i n s t a n c e , t h e OH n u r s e s t r e s s e s h e a r i n g c o n s e r v a t i o n a n d b a c k protection. P r e v e n t i o n ' s m a n y f a c e t s i n c l u d e i n - d e p t h disc h a r g e i n s t r u c t i o n s , informational literature, i m m u n i z a t i o n s , h e a l t h fairs, a n d e r g o n o m i c s . Flu a n d h e p a t i t i s v a c c i n a t i o n s , b a c k care, h e a r i n g p r e s e r v a tion, O S H A c o m p l i a n c e , AIDS a w a r e n e s s , or p r e n a t a l c l a s s e s are c o m m o n topics. Our d e p a r t m e n t e v e n h e l p e d w i t h one c o m p a n y ' s r e s e a r c h on e m p l o y e e ' s p o s t e x p o s u r e zinc levels. A n e w e r trend, particularly in t h e w h i t e - c o l l a r sector, is a confidential h e a l t h risk a s s e s s m e n t i n c l u d i n g blood t e s t s a n d a n e m p l o y e e c o m p l e t e d h e a l t h h a b i t s survey. A k e y difference in OH is t h a t only p a y i n g cust o m e r s are c o u r t e d a n d kept. T h e r e is no s u c h c a t e gory a s " b a d debt" or "charity" from n o n p a y m e n t . A s a result, our OH p r o g r a m h a s e x p e r i e n c e d a profitable n e t r e t u r n for t h e last 3 y e a r s a n d h a s h e l p e d to prov i d e a b a l a n c i n g a s s e t for our hospital. This field is a n a t u r a l o u t g r o w t h for an e m e r g e n c y d e p a r t m e n t a n d e m e r g e n c y n u r s e s p r o v i d e d t h e differences are clearly understood.
c c u p a t i o n a l h e a l t h (OH) c a n p r o v i d e a n alternative w o r k e n v i r o n m e n t for a n e m e r g e n c y nurse, as well a s r e v e n u e e n h a n c e m e n t for t h e e m e r g e n c y d e p a r t m e n t . T h e t e r m occupational health (a/k/a i n d u s t r i a l m e d i c i n e ) is loosely i n t e r c h a n g e a b l e w i t h e m p l o y e e h e a l t h - - t a k i n g c a r e of t h e i n s t i t u t i o n ' s or b u s i n e s s ' s o w n e m p l o y e e s . However, in t h i s context, it is a selling of t h e h o s p i t a l ' s h e a l t h c a r e s e r v i c e s to outside b u s i n e s s e s for p r o v i d i n g l i m i t e d h e a l t h c a r e to their e m p l o y e e s . B e i n g affiliated w i t h a n e m e r g e n c y d e p a r t m e n t , r a t h e r t h a n a f r e e s t a n d i n g facility, is often a major selling p o i n t to t h e b u s i n e s s e s . In t h e b e g i n n i n g , S w e d i s h C o v e n a n t H o s p i t a l h i r e d a n o u t s i d e firm t h a t e s t a b l i s h e d its OH p r o g r a m and solicited companies within a specific geographic radius. A s t h e b u s i n e s s grew, it b e c a m e an i n d e p e n d e n t , s e p a r a t e e n t i t y w i t h i n t h e hospital, w i t h its own p h y s i c i a n , nurse, r e c e p t i o n i s t , c a s e m a n a g e r , forms, policies, a n d s a l e s p e r s o n . T h e OH t r e a t m e n t rooms, l o c a t e d a d j a c e n t to t h e e m e r g e n c y d e p a r t m e n t , a r e u s e d as t h e after-hours ED fast t r a c k area. H o s p i t a l d e p a r t m e n t s s u c h as laboratory, radiology, p h y s i c a l therapy, a n d o c c u p a t i o n a l t h e r a p y all s h a r e in t h e i n c r e a s e d profitable volume, a s well a s t h e on-call s p e c i a l t y p h y s i c i a n s (hand, o r t h o p e d i c s , eye). P o t e n t i a l c u s t o m e r s a r e n o t only in t h e t y p i c a l l y p e r c e i v e d m a n u f a c t u r i n g i n d u s t r i e s , b u t in s e r v i c e f o c u s e d o r g a n i z a t i o n s as well. S u c c e s s f u l clients h a v e i n c l u d e d e m p l o y e e s of c o l l e g e s , f a s t - f o o d r e s t a u r a n t s , d a y c a r e c e n t e r s , charities, l o n g - t e r m care facilities, governmental departments (post office, c i t y t r a n s p o r t a t i o n , p a r a m e d i c s , police), priv a t e a m b u l a n c e c o m p a n i e s , retail stores, g a r a g e s / b o d y w o r k shops, a n d g r o c e r y c h a i n s .
O
Polly Gerber Zimmermann is staff nurse III, Emergency Department and Occupational Health, Swedish Covenant Hospital, and an associate nurse, American Airlines Occupational Health, Chicago, Illinois, and faculty, Truman College, Chicago. For reprints, write Polly Gerber Zimmermann, RN, MS, MBA, CEN, 4200 N. Francisco, Chicago, IL 60618. J Emerg Nurs 1996;22:591-4. 0099-1767/96 $5.00 + 0 18/9175474
Occupational health role The OH n u r s e ' s b r o a d e r role e n c o m p a s s e s a s p e c t s along t h e e n t i r e h e a l t h c a r e c o n t i n u u m . B e y o n d t h e a s s e s s m e n t a n d t r e a t m e n t of initial injuries w i t h w h i c h e m e r g e n c y n u r s e s are familiar, t h e p a t i e n t r e l a t i o n s h i p c o n t i n u e s until r e h a b i l i t a t i o n / h e a l i n g is c o m p l e t e a n d future p r e v e n t i v e m e a s u r e s are instituted. T h e n u r s e also regularly p a r t i c i p a t e s in r o u t i n e physical examinations, immunizations, prevention t e a c h i n g , a n d t e s t i n g for d r u g s . E x a m i n a t i o n skills include physical assessment, including tympanic m e m b r a n e evaluations, v i s u a l acuity, a u d i o g r a m s , t y r n p a n o g r a m s , a n d spirometry. Proficiency in precise, d e s c r i p t i v e c h a r t i n g is essential. While a d m i n i s t r a t i o n of t h e OH s e r v i c e w a s h a n dled b y t h e e m e r g e n c y d e p a r t m e n t , volunteer, crosstrained nurses between the two departments helped w i t h t h e staffing n e e d s in light of fluctuations in cens u s a n d s c h e d u l i n g . A n e m e r g e n c y n u r s e ' s core skills a n d c o m p e t e n c i e s in r a p i d a s s e s s m e n t of o u t p a t i e n t s a n d h i s t o r y t a k i n g a r e t h e b e g i n n i n g s of a role t r a n s i t i o n to OH. M y o r i e n t a t i o n to OH c o n s i s t e d of w o r k i n g a few o n - t h e - j o b shifts w i t h a n e x p e r i e n c e d OH nurse. I also j o i n e d t h e A m e r i c a n A s s o c i a t i o n of O c c u pational Health Nurses and did some independent reading. M a n y n u r s e s initially i n d i c a t e d i n t e r e s t in p a r t i c ipation. T h e o p p o r t u n i t y s e e m e d to p r o v i d e job s e c u r i t y a n d a c o m m o n m i s p e r c e p t i o n t h a t it is " e a s y work." H o w e v e r , m a n y n u r s e s d e c l i n e d furt h e r i n v o l v e m e n t . S o m e lost i n t e r e s t b e c a u s e of t h e r e g i m e n t e d , e x a c t i n g r e q u i r e m e n t s a n d t h e difficulty in m a i n t a i n i n g c u r r e n t k n o w l e d g e a n d p r a c t i c e t e c h n i q u e s w h i l e w o r k i n g only i n f r e q u e n t l y in t h e OH area. S c h e d u l i n g flexibility is limited, a n d early or late h o u r s m u s t b e a u t o m a t i c a l l y w o r k e d a c c o r d i n g to p a t i e n t s ' n e e d s b e c a u s e t h e r e is no relief staff. A s one of t h e h o s p i t a l ' s c r o s s - t r a i n e d nurses, I also soon r e a l i z e d t h a t OH w a s a v e r y different p r a c t i c e area. U n d e r s t a n d i n g t h e u n i q u e n a t u r e of OH a n d m a k i n g a d j u s t m e n t s in t h e n u r s i n g a p p r o a c h are k e y to a n effective transition.
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Differences between the occupational health and emergency departments 1. The principles of managed care are fully used. M a n y b e n e f i t s are offered to c o m p a n i e s for u s i n g a n OH p r o g r a m . S e r v i c e s sold i n c l u d e (1) d i s c o u n t e d fees for volume, (2) t i m e l y t r e a t m e n t s , a n d (3) a coord i n a t e d c o u r s e of t r e a t m e n t . C o n t r a c t i n g m a n a g e m e n t w a n t s t h e "on-the-clock" e m p l o y e e s to r e c e i v e e x p e d i t e d t r e a t m e n t a n d to e x p e r i e n c e a faster r e t u r n to full c a p a b i l i t i e s .
S u c c e s s f u l clients h a v e i n c l u d e d e m p l o y e e s of colleges, fast-food restaurants, day care centers, charities, long-term care facilities, governmental departments (post office, city transportation, paramedics, police), private a m b u l a n c e c o m p a n i e s , retail stores, g a r a g e s / b o d y work shops, and grocery chains.
E m p l o y e e s m u s t follow-up w i t h t h e OH p r o g r a m a t regular, f r e q u e n t intervals, e v e n if t h e y are off w o r k or are also s e e i n g a p r i v a t e p h y s i c i a n . A n y m i s s e d a p p o i n t m e n t s are i n v e s t i g a t e d a n d t h e e m p l o y e r is notified. P a t i e n t s w i t h injuries t h a t are not i m p r o v i n g at t h e e x p e c t e d r a t e a r e a p p r o p r i a t e l y referred for a d d i t i o n a l i n t e r v e n t i o n s , s u c h a s p h y s i c a l t h e r a p y or a s p e c i a l i s t ' s services. T r e a t m e n t focus e x t e n d s b e y o n d m e r e l y looking at t h e q u a l i t y of t h e d i r e c t c a r e g i v i n g a c t s to m o n i t o r i n g of t h e overall i m p r o v e d p e r f o r m a n c e . Unlike a p e r s o n a l illness, w h e n t h e i n d i v i d u a l e m p l o y e e c h o o s e s w h e t h e r to w o r k on a p a r t i c u l a r day, t h e e m p l o y e e w i t h a w o r k - r e l a t e d injury w h o s e c a r e is m a n a g e d b y t h e OH s e r v i c e d o e s not i n d e p e n d e n t l y control t h e t i m e a w a y from w o r k or t h e r a p e u t i c interventions. After assessing and interviewing the p a t i e n t , t h e t r e a t m e n t r e g i m e n a n d r e s t r i c t i o n s are u n d e r t h e control of t h e OH d e p a r t m e n t . P o s t i n j u r y m o n i t o r i n g of w o r k r e s t r i c t i o n s for t h e e m p l o y e e is a major r e s p o n s i b i l i t y of t h e p r o g r a m . A n impartial, s o u n d clinical j u d g m e n t is m a d e , g u i d e d b y w h a t is e s s e n t i a l for t h e condition, not p o l i c y or p a y m e n t i m p l i c a t i o n s . E m p l o y e e s c a n also s e e k c a r e
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from their o w n p h y s i c i a n s , b u t d i s c r e p a n c i e s are r e s o l v e d t h r o u g h a t h i r d - p a r t y o p i n i o n in t h e form of an independent medical examiner. E m p l o y e e s are u s u a l l y r e l e a s e d w i t h " s e d e n t a r y duty" l i m i t a t i o n s as a m i n i m u m ; t h e c o m p a n y t h e n d e c i d e s if t h e r e are t a s k s t h a t a c c o m m o d a t e t h o s e r e s t r i c t i o n s or if t h e c o m p a n y w a n t s to give t h e e m p l o y e e t i m e off. This p r o c e s s m i n i m i z e s m a l i n g e r ing. T h e reality is t h a t s o m e w o r k e r s ' g e n e r o u s b e n efits p r o v i d e little i n c e n t i v e to work. For i n s t a n c e , one u n i o n c o m p a n y p a y s i n j u r e d w o r k e r s 80% of t h e i r salary for 3 m o n t h s . S u s p i c i o n s are a r o u s e d in t h e OH d e p a r t m e n t if a w o r k e r b e c o m e s h o s t i l e w h e n a s s i g n e d to a n s w e r t h e p h o n e at a p l a c e of e m p l o y m e n t i n s t e a d of b e i n g s e n t h o m e . A t t h e other e n d of t h e s p e c t r u m , p r o b l e m s o c c u r w h e n a n e m p l o y e e p r e m a t u r e l y w a n t s full d u t y b e c a u s e of r e d u c e d p a y or b e n e f i t effects from n o t working. A s a p a t i e n t a d v o c a t e , it is i m p o r t a n t to prev e n t reinjury to t h e p a t i e n t b e c a u s e of a n early r e t u r n to work. This is e s p e c i a l l y t r u e w h e n t h e e m p l o y e e d o e s n o t u n d e r s t a n d or a g r e e w i t h t h e d e c i s i o n e v e n after a t h o r o u g h e x p l a n a t i o n . O c c u p a t i o n a l h e a l t h ' s m a n a g e d care a p p r o a c h h a s m a n y s u c c e s s stories. O n e e m p l o y e e w h o w a s i n j u r e d on t h e job h a d a p o s i t i v e result after alcohol s c r e e n i n g . After c o m p l e t i n g a n e m p l o y e e a s s i s t a n c e p r o g r a m , h e n o w h a s l o n g - s t a n d i n g sobriety. In a d d i tion, w h i l e i n v e s t i g a t i n g his d e l a y e d w o u n d healing, an u n k n o w n d i a b e t i c c o n d i t i o n w a s d i s c o v e r e d .
S c h e d u l i n g flexibility is limited, and early or late hours m u s t be automatically w o r k e d according to patients' n e e d s b e c a u s e there is no relief staff.
2. The contracting company is the employer. C o m p a n i e s p u r c h a s e OH s e r v i c e s to monitor t h e i r e m p l o y e e s ' s a f e t y a n d t h e l e g i t i m a c y of j o b - r e l a t e d h e a l t h claims. A l t h o u g h OH n u r s e s a d v o c a t e indirectly for p a t i e n t s , t h e b a s i c u n d e r s t a n d i n g is t h a t all staff m e m b e r s u l t i m a t e l y are w o r k i n g for t h e c o m p a ny, n o t t h e p a t i e n t . C o m p a n i e s a n d t h e g o v e r n m e n t h a v e regulations t h a t are s p e c i f i e d for their e m p l o y e e s at the t i m e of their hire. E m p l o y e e s h a v e t h e right to decline t h e
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company-provided free medical care or even the "for cause" drug screening with an understanding of the consequences. Once the employee consents to comply, however, the c o m p a n y ' s c o n t a c t s are k e p t informed throughout the employee's treatment course, including documentation and laboratory results.
Unlike a personal illness, w h e n t h e individual e m p l o y e e c h o o s e s w h e t h e r to w o r k o n a particular day, t h e e m p l o y e e w i t h a w o r k - r e l a t e d injury w h o s e c a r e is m a n a g e d b y the OH service does not independently control the t i m e a w a y f r o m w o r k or therapeutic interventions. There is c o n s t a n t vigilance to discern the validity of any e m p l o y m e n t - r e l a t e d complaint. This m a y s e e m in opposition to the usual ED approach where the nurses' predisposition is to believe their p a t i e n t s (provided they do not have severe pain and are allergic to everything but narcotics). Why else would they come for t r e a t m e n t with their own funds if they did not have a n e e d ? Although this difference m a y initially cause emotional conflict for the nurse, it is helpful to consider that it is also in the employees' b e s t interest to be s t o p p e d from operating a drill press w h e n inebriated or otherwise physically impaired. In one scenario, a c o m p a n y that contracted for OH services sent an employee for t r e a t m e n t of an onthe-job m a n u f a c t u r i n g injury. The nurse d e t e c t e d an alcohol smell. An e m e r g e n c y nurse would protect that p a t i e n t ' s confidentiality, b u t the OH nurse cont a c t e d the c o m p a n y to ask if they w a n t e d a blood s a m p l e taken to d e t e r m i n e that p a t i e n t ' s alcohol level. When informed that the t e s t was requested, the m a c h i n i s t angrily s h o u t e d to the nurse, "So I like beer. Is that a crime?"
3. Customer service is premium. Offering OH services is a b u s i n e s s venture, and the m a r k e t i n g "sell" is always on display. A professional a p p e a r a n c e and interactions with the contracting c o m p a n y from the initial g r e e t i n g through the final disposition is involved. To p r e v e n t a loss of business, it is essential that the nurse be p e r c e i v e d as knowl-
edgeable, approachable, credible, caring, and professional by everyone from the entry-level worker to the c o m p a n y ' s owner. Good p a t i e n t relationships prom o t e t r e a t m e n t compliance. Satisfied m a n a g e m e n t ensures continued b u s i n e s s in this increasingly competitive field. The OH nurse m u s t a d d r e s s both the cost containment and safety concerns of the company while being e m p a t h i c and u n d e r s t a n d i n g to the emotions and a d e q u a t e care concerns of the employee. A truck driver with a blood pressure of 190/110 m m Hg could have serious implications for both sides. M e e t i n g the c u s t o m e r s ' n e e d s also includes u n d e r s t a n d i n g their environmental a n d cultural perspective, rather than artificially a t t e m p t i n g to make t h e m fit into the hospital structure. For example, during one on-site flu vaccination program, it was glaringly inappropriate to have only English consent forms for the overwhelming n u m b e r of Spanishs p e a k i n g employees.
4. Treatment of work-related matters only. Only job-related concerns are t r e a t e d in OH. In an OH setting, personal m e d i c a l problems, from the flu to bunions, are not t r e a t e d b u t should be brought to the employee's personal care provider. This distinction often needs reinforcement b e c a u s e some employees e x p e c t c o m p r e h e n s i v e "free" care. For example, w h e n a p r e e m p l o y m e n t physical reveals hypertension or a n e e d for glasses, the a p p l i c a n t is encoura g e d to s e e a p r i v a t e p h y s i c i a n although a r e c o m m e n d a t i o n is always m a d e about the applic a n t ' s current ability to work.
T h e r e a l i t y is t h a t s o m e workers' generous benefits p r o v i d e little i n c e n t i v e to work.
5. Dot the i's, cross the t's. Occupational health d e m a n d s extensive knowledge of and strict adherence to governmental (Occupational Safety and Health Administration [OSHA], National Institute of Occupational Safety and Health, [NOISH], A m e r i c a n s With Disabilities Act, D e p a r t m e n t of Transportation [DOT]), union, and workers' compensation regulations, in addition to nursing care standards. By necessity, ED nursing focuses on m e e t i n g the m o s t e m e r g e n t n e e d s in w h a t e v e r w a y possible. Occupational health, on the other hand, cannot toler-
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a t e a n y i n d i v i d u a l i n c o n s i s t e n c i e s . It is t h e r e p e t i tive, t h o r o u g h , d e t a i l e d c o m p l e t i o n of p r o c e d u r e s and documentation details that protects the practice a n d t h e n u r s e in t h e e x t e n s i v e d e a l i n g s w i t h insurance companies, workers' compensation hearings,
One employee who was injured on t h e job h a d a p o s i t i v e r e s u l t after a l c o h o l s c r e e n i n g . After c o m p l e t i n g an e m p l o y e e a s s i s t a n c e program, he now has l o n g - s t a n d i n g sobriety. In addition, w h i l e i n v e s t i g a t i n g his d e l a y e d w o u n d h e a l i n g , an u n k n o w n diabetic condition was discovered. a n d u n i o n g r i e v a n c e s . This i n c l u d e s a l w a y s d e s c r i b i n g p a t i e n t s in o b j e c t i v e t e r m s and, in s o m e c a s e s , staying with the physician as a witness during an e m p l o y e e e x a m i n a t i o n a n d c a s e d i s c u s s i o n . Datab a s e d c h a r t i n g is e v e n m o r e i m p o r t a n t . For e x a m p l e , t h e OH n u r s e w o u l d n o t c h a r t t h a t t h e p a t i e n t w a s "paranoid" b u t d o c u m e n t "Patient s t a t e s , ' E v e r y o n e is out to g e t m e . ' " P r e c i s i o n is p a r t i c u l a r l y critical in t h e c h a i n of c u s t o d y d u r i n g t e s t i n g for drugs. Vigilance m u s t b e maintained because employees continually develop
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n e w w a y s to try to "beat" t h e test. For e x a m p l e , one n e w m i s g u i d e d staff m e m b e r "helpfully" let t h e e m p l o y e e t a k e a d r u g t e s t e v e n t h o u g h he "forgot" his p h o t o identification. W h e n t h e d r u g s c r e e n i n g p r o v e d positive, t h e i n c o n s i s t e n c y p r e v e n t e d its u s e in d i s c i p l i n a r y action.
6. The role of prevention A b a s i c p r e m i s e in e m e r g e n c y n u r s i n g is t r e a t i n g illness, w h e r e a s t h e a s s u m p t i o n in OH is t h a t a g i v e n p a t i e n t is g e n e r a l l y healthy. Vital s i g n s are m e a s u r e d just once, n o t every hour. P r o a c t i v e p r e v e n t i o n p l a y s a m a j o r role as it d o e s in e m e r g e n c y n u r s i n g , a l t h o u g h t h e t o p i c s differ. For i n s t a n c e , t h e OH n u r s e s t r e s s e s h e a r i n g c o n s e r v a t i o n a n d b a c k protection. P r e v e n t i o n ' s m a n y f a c e t s i n c l u d e i n - d e p t h disc h a r g e i n s t r u c t i o n s , informational literature, i m m u n i z a t i o n s , h e a l t h fairs, a n d e r g o n o m i c s . Flu a n d h e p a t i t i s v a c c i n a t i o n s , b a c k care, h e a r i n g p r e s e r v a tion, O S H A c o m p l i a n c e , AIDS a w a r e n e s s , or p r e n a t a l c l a s s e s are c o m m o n topics. Our d e p a r t m e n t e v e n h e l p e d w i t h one c o m p a n y ' s r e s e a r c h on e m p l o y e e ' s p o s t e x p o s u r e zinc levels. A n e w e r trend, particularly in t h e w h i t e - c o l l a r sector, is a confidential h e a l t h risk a s s e s s m e n t i n c l u d i n g blood t e s t s a n d a n e m p l o y e e c o m p l e t e d h e a l t h h a b i t s survey. A k e y difference in OH is t h a t only p a y i n g cust o m e r s are c o u r t e d a n d kept. T h e r e is no s u c h c a t e gory a s " b a d debt" or "charity" from n o n p a y m e n t . A s a result, our OH p r o g r a m h a s e x p e r i e n c e d a profitable n e t r e t u r n for t h e last 3 y e a r s a n d h a s h e l p e d to prov i d e a b a l a n c i n g a s s e t for our hospital. This field is a n a t u r a l o u t g r o w t h for an e m e r g e n c y d e p a r t m e n t a n d e m e r g e n c y n u r s e s p r o v i d e d t h e differences are clearly understood.