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OCR for page 1
Board on Health Sciences Policy
August 2, 2011
Maryann D’Alessandro
Associate Director for Science
National Personal Protective Technology Laboratory
National Institute for Occupational Safety and Health
Centers for Disease Control and Prevention
626 Cochrans Mill Road
Pittsburgh, PA 15236
Dear Dr. D’Alessandro:
At the request of the National Personal Protective Technology La-
boratory (NPPTL) of the National Institute for Occupational Safety and
Health (NIOSH), the Institute of Medicine (IOM) appointed the ad hoc
Committee on the Respiratory Protection Curriculum for Occupational
Health Nursing Programs under the auspices of the IOM’s Standing
Committee on Personal Protective Equipment for Workplace Safety and
Health. The overarching charge to the ad hoc committee was to examine
existing respiratory protection curricula in occupational health nursing
programs and to develop recommendations to improve education and
training on the selection (including situation assessment), use, care, and
maintenance of respirators. More specifically, the committee was asked
to identify the essential content that should be included in occupational
health nursing education and training programs and to recommend best
approaches for teaching that content.
The committee’s findings and recommendations for improving the
respiratory protection curricula for occupational health nursing programs
are summarized in this letter report. After gathering and reviewing the
available information and evidence, including samples of existing respi-
ratory protection curricula and content provided by NIOSH-supported
Education and Research Centers for Occupational Safety and Health
(ERCs), the committee concluded that occupational health nurses (OHNs) are
1
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2 OCCUPATIONAL HEALTH NURSES AND RESPIRATORY PROTECTION
front-line advocates for preventing illness and injury and protecting and
promoting health in the workplace. As key members of the occupational
and environmental health and safety workforce, they contribute to the
nation’s health and productivity by mobilizing the knowledge, expe-
rience, and commitment of professional nursing to serve and help protect
employees. OHNs work with employees in a wide array of settings that
are associated with a diverse range of exposures and hazards, including
agriculture, construction, health care, manufacturing, mining, services,
trade, transportation, oil and gas extraction, and public safety. The role of
OHNs is particularly important in protecting the respiratory health of
America’s workforce, and respiratory protection needs to be a consistent
component of nursing programs at all levels.
Through its work, the committee determined two types of essential
components of the occupational health nursing curriculum related to res-
piratory protection. One is technical and includes hazard assessment;
selection, use, care, and maintenance of respirators; medical evaluation
and monitoring; and fit testing. The second pertains to behavior: to best
serve the health of nurses, workers, and the public, the technically
oriented material must be paired with education on ways for nurses to
protect themselves from respiratory exposures and hazards, the potential
consequences of not using appropriate personal protective equipment
(PPE), strategies for effective behavioral change and leadership, and
strategies to build a culture of safety. The committee found that respira-
tory protection content taught in occupational health nursing programs
receives varying amounts of dedicated time and resources and is taught
using a variety of didactic and practical approaches. To improve the res-
piratory protection curricula for OHNs, the committee makes seven rec-
ommendations that are detailed in this report. Box 1 summarizes the
committee’s recommendations, which speak to the following areas: the
responsibilities of OHNs, respiratory protection education and training,
and incentives for respiratory protection education and training.
BOX 1
Recommendations
The Responsibilities of OHNs
Recommendation 1: Conduct a Survey of OHNs
The American Association of Occupational Health Nurses (AAOHN), working
in collaboration with NPPTL and other agencies and professional organizations,
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3
LETTER REPORT
BOX 1 Continued
should conduct a survey of a representative group of OHNs asking about their
current roles and responsibilities relevant to respiratory protection and asking
for their input on education and training needs in this area.
Recommendation 2: Achieve and Maintain Knowledge and Skills in Respirato-
ry Protection
OHNs should take responsibility for achieving and maintaining knowledge and
skills in respiratory protection that are appropriate to their scope of practice.
They should provide instruction and demonstrate leadership in motivating
others to use respirators appropriately.
Respiratory Protection Education and Training
Recommendation 3: Expand Respiratory Protection Education Across All Le-
vels of Nursing Education and Training
Nursing education programs across all levels, including licensed practical or
vocational, diploma, associate, baccalaureate, and graduate levels, should
• introduce the basic concepts of respiratory risk and protection early in
the education and training programs and throughout the curriculum;
• reinforce this knowledge when the students begin their clinical educa-
tion and are fit tested for respirators;
• require that their graduates have a working knowledge of key ele-
ments of respiratory protection at the appropriate level for their scope
of practice; and
• look to core curricula offered by occupational health nursing graduate
and continuing education programs, including the NIOSH ERCs, for
guidance on required knowledge and skills to educate nurses at ap-
propriate levels for their scope of practice.
Recommendation 4: Ensure Essential Respiratory Protection Content in Oc-
cupational Health Nursing Graduate Curricula, and Adapt and Apply It to Con-
tinuing Education Programs and to the Education and Training of All Nurses
Occupational health nursing educators—in collaboration with staff from other
disciplines (e.g., industrial hygiene, occupational medicine, engineering),
NIOSH, AAOHN, and other expert sources—should ensure that essential respi-
ratory protection content is included in graduate occupational health nursing
programs and integrated into continuing education courses for OHNs. The
essential respiratory protection content should
• reiterate the value of respiratory protection in reducing illness and
injury;
• reinforce respiratory protection throughout the graduate occupational
health curriculum and clinical practice;
Continued
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4 OCCUPATIONAL HEALTH NURSES AND RESPIRATORY PROTECTION
BOX 1 Continued
• include content on hazard assessment; respirator selection, use,
care, and maintenance; medical evaluation and monitoring; respirator
fit testing; employee training; and program evaluation;
• require, at a minimum, familiarity with relevant federal (e.g., 29 CFR
1910.134), state (e.g., California Division of Occupational Safety and
Health 5144), and national consensus (e.g., American National Stan-
dards Institute/American Industrial Hygiene Association Z88.10) regu-
lations and standards;
• use hands-on education and training experiences to provide an un-
derstanding of the types of respirators and their uses;
• require students to demonstrate knowledge and skills in developing a
respiratory protection program that includes training and evaluation
components;
• emphasize the leadership role of OHNs in establishing a culture of
safety, influencing behavior change and decisions related to respira-
tory and overall health, and promoting proper use of respirators in the
workplace;
• examine research and best practices relevant to respiratory protec-
tion, behavioral change and leadership, and establishing a culture of
safety in the workplace;
• consider including spirometry certification as a requirement for grad-
uation; and
• specify elements that could be adapted and applied to continuing
education programs and to the education and training of all nurses.
Recommendation 5: Develop, Expand, and Evaluate Innovative Teaching
Methods and Resources to Establish Best Practices
Occupational health nursing education programs and respiratory protection
programs should do the following:
• Integrate essential content on respiratory protection into their core
curricula and continuing education programs through a variety of in-
novative approaches, taking into consideration the needs of the stu-
dents. These methods could include
online courses (including webinars),
o
simulation techniques,
o
case studies,
o
education and training modules,
o
field observation and practice, and
o
conferences and workshops.
o
• Draw on resources available from NIOSH, the Occupational Safety
and Health Administration, state and local governments, the NIOSH
ERCs and other educational institutions, professional organizations
and unions, advocacy organizations, international health and safety
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5
LETTER REPORT
BOX 1 Continued
organizations (e.g., the Network of World Health Organization Collabo-
rating Centres in Occupational Health and the International Labour
Organization), contractors, other professional communities and insti-
tutions, and the private sector.
• Collaborate with NPPTL to evaluate innovative teaching methods
used for respiratory protection education and training, including con-
tinuing education, in order to establish best practices in the field.
Recommendation 6: Expand Online Resources, Particularly Case Studies
NPPTL should develop and maintain online resources for respiratory protec-
tion that are relevant to educating and training OHNs, specifically by
• developing template modules that could be used in the core curricu-
lum for occupational health nursing programs and that would draw on
best practices of the NIOSH ERCs (sections of these modules could
also be used for nursing students at all levels);
• compiling case studies (e.g., health hazard evaluations) that illustrate
the value of respirators in protecting the health of workers across a
range of work environments; and
• providing easily accessible links to existing resources, including the
OSHA checklists.
Incentives for Respiratory Protection Education and Training
Recommendation 7: Explore the Development of a Set of Core Competencies
in Respiratory Protection
NPPTL, in collaboration with relevant professional organizations, should ex-
plore the development of a set of interdisciplinary core competencies in respi-
ratory protection that could be used to guide the education and training of
OHNs and other occupational health and safety professionals.
We would like to thank NPPTL and its staff members for generously
supporting this study and for the guidance and information they provided
to the IOM committee in the course of its work. We are also appreciative
of the time and energy that the IOM committee and staff members dedi-
cated to planning the successful information-gathering workshop that
was held in March 2011 and to developing the report and its recommen-
dations. We hope that NPPTL will find the committee’s recommenda-
tions and this report informative as it considers ways to improve the res-
piratory protection curricula for OHNs and other occupational health and
safety professionals.
Linda Hawes Clever, Co-Chair
M. E. Bonnie Rogers, Co-Chair
Committee on the Respiratory Protection Curriculum
for Occupational Health Nursing Programs
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6 OCCUPATIONAL HEALTH NURSES AND RESPIRATORY PROTECTION
CHARGE TO THE COMMITTEE
Protecting the health of workers who are employed in workplaces
with hazardous exposures (including chemicals, biologics, noise, radia-
tion, particulates, stress, heat, and ergonomics) (NIOSH, 2011a) involves
a range of protective measures that aim to remove the hazard or, if that is
not possible, to mitigate the extent of the exposure through environmental-,
administrative-, or individual-level measures. PPE standards and practic-
es (including the use of hearing protection devices, respirators, gloves,
eye protection, and protective clothing) are the primary means of hazard
reduction and worker protection in some work situations and a key com-
ponent for many others (e.g., chemical plants, mining, health care). With
its mission to “prevent work-related injury, illness, and death, by advancing
the state of knowledge and application of personal protective technologies”
(NIOSH, 2009), NPPTL has explored the issues involved in respiratory
protection through a number of IOM studies, which have supported the
value of PPE use, including respirators, for the protection and promotion
of worker health and safety (see Appendix C). Additionally, the IOM
Standing Committee on Personal Protective Equipment for Workplace
Safety and Health has had discussions on the range of professions,
including occupational health nursing, that have an impact on improving
the use of PPE.
NPPTL requested that the IOM conduct a study to examine respira-
tory curricula in occupational health nursing programs and make recom-
mendations for essential content that should be incorporated into the cur-
ricula and approaches for teaching that content (see Box 2). This letter
report and its findings and recommendations represent a starting point in
a larger effort to improve respiratory education and training opportunities
for all occupational health and safety professionals.
To respond to NPPTL’s request, the IOM convened the nine-member
ad hoc Committee on Respiratory Protection Curriculum for Occupation-
al Health Nursing Programs. The committee included members with ex-
pertise in occupational health nursing and medicine, PPE design and
training, industrial hygiene and occupational health, clinical medicine,
and nursing education (see Appendix D for committee biographies).
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7
LETTER REPORT
BOX 2
Statement of Task
The IOM will conduct a study that examines respiratory protection curricula
in occupational health nursing programs. The IOM committee will begin by ex-
amining the current respiratory protection curricula and training approaches
used by the NIOSH ERCs and other occupational health programs. Based on
this review, the committee will develop recommendations to improve training on
the selection (including situation assessment), use, care, and maintenance of
respirators. It will aim to address the following questions:
• What essential content should be incorporated in occupational health
nursing education and training programs to produce professionals who
are fully aware and informed about respiratory protection technologies?
• What are the best approaches for teaching that content so that effec-
tive respiratory protection programs are implemented?
As part of its data-gathering activities, the committee will plan and con-
duct a public workshop with input from the ERCs and relevant professional or-
ganizations, along with input from staff of health care and other employers
where occupational health nurses are involved in training staff on respirator use.
The committee will produce a letter report with its findings and recommendations.
STUDY PROCESS
The committee used several methods to reach its conclusions and
recommendations. In addition to reviewing materials the committee held
three meetings. The first meeting designed the study plan, began to gath-
er and review available information, and started to plan a public work-
shop. The committee’s second meeting included a public workshop held
on March 30, 2011, in Pittsburgh, Pennsylvania, in conjunction with the
NIOSH Personal Protective Technology Program’s annual stakeholder
meeting (see Appendix A for the IOM workshop agenda and Appendix B
for a list of registered attendees). The workshop was an information-
gathering session. Presentations from and discussions with experts pro-
vided the committee with insights about occupational health and safety,
respiratory protection, and occupational health nursing. Workshop pre-
senters discussed respiratory protection curricula currently used across
the country, continuing education opportunities for OHNs, the role of
professional boards or organizations in shaping occupational health nurs-
ing curricula, the on-the-ground perspectives of OHNs working in indus-
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8 OCCUPATIONAL HEALTH NURSES AND RESPIRATORY PROTECTION
try and health care settings, and challenges and opportunities for improv-
ing respiratory protection education and training for OHNs. At the third
meeting the committee reviewed and edited the report draft and refined
findings and recommendations.
To inform its deliberations and gain a better understanding of respi-
ratory protection curricula, the committee received and reviewed the re-
sults of an NPPTL-led survey of respiratory protection curricula from six
NIOSH ERC occupational health nursing programs1 and from the North
Carolina Division of Public Health.2 The committee also reviewed the
core curriculum and competencies of the American Association of Occu-
pational Health Nurses (AAOHN). A literature search was conducted,
but few articles currently exist on the educational needs of OHNs both in
general and specific to respiratory protection or on effective teaching
methods for respiratory protection content. The committee reviewed a
selection of available literature on occupational health nursing and respi-
ratory protection programs.
The committee’s statement of task required that it focus on respirato-
ry protection and, more specifically, on the essential content of respirato-
ry protection curricula and the best approaches for teaching that content
to OHNs. Therefore, this letter report does not address broader questions
related to areas such as the capacity and efficacy of occupational health
nursing programs or the education pipeline for OHNs, nor does it consid-
er or evaluate the education of other occupational health and safety pro-
fessionals in respiratory protection. The committee recognizes that
OHNs are often educated and trained in interdisciplinary programs and
courses that are sometimes taught by other occupational health and safety
professionals, such as industrial hygienists. The committee also recog-
nizes that successful respiratory protection programs in the workplace
often involve the work of interdisciplinary teams of occupational health
and safety professionals that include OHNs. Although this report is fo-
cused on OHNs, the committee believes that many of its findings and
1
The six ERCs that submitted information for the survey were the University of
Alabama at Birmingham School of Nursing; University of California, Los Angeles,
School of Public Health; University of California, San Francisco; University of Iowa,
College of Public Health; University of Michigan School of Nursing; and University of
South Florida College of Public Health.
2
The North Carolina Division of Public Health developed a respiratory protection
training program that is used for training local health department staff throughout the
state. The course materials used for this program were provided, along with the ERC
materials, as part of the survey conducted by NPPTL.
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9
LETTER REPORT
recommendations could be applicable to the education and training of
other professionals involved in respiratory protection programs.
BACKGROUND
Nationwide, there are approximately 5 million employees, across 1.3
million employment settings, who are required to wear respirators as part
of their jobs (OSHA, 2011). A wide range of work environments may
present respiratory health hazards to employees, such as the use of chem-
icals in agricultural and industrial settings, the presence of infectious
agents in health care settings, and the presence of particulate matter in
mining and construction settings. If effective safety and preventive
measures are not in place, these exposures may negatively affect the
health of employees and their families and could result in debilitating
respiratory illness, disease, or death.
Collaboratively, industrial hygienists, safety engineers, OHNs, phy-
sicians, infection preventionists (called infection control officers in some
workplaces), and other occupational health and safety professionals are
responsible for monitoring workplace hazards; developing and imple-
menting safety policies, procedures, and programs; educating employers
and employees about occupational health and safety; complying with all
relevant federal, state, and local regulations and standards; conducting
workplace health assessments; and generally ensuring a safe working
environment for all employees. Respiratory protection is one of many
necessary components to ensure the overall health and safety of workers
across employment settings.
Overview of Occupational Health Nursing
OHNs are nurses who work to prevent injury and illness and promote
the health and safety of workers across a wide range of employment set-
tings (IOM, 2000). Although OHNs make up a small proportion (< 1
percent) of the more than 3 million licensed registered nurses (RNs) in
the United States (HRSA, 2010; Thompson, 2010), they represent the
largest sector of health care professionals who work to ensure the health
and safety of workers in employment settings (AAOHN, 2011).
In the course of their work, among many other tasks, OHNs act in
the areas of management and organization, assessment, direct health care
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10 OCCUPATIONAL HEALTH NURSES AND RESPIRATORY PROTECTION
services to workers, prevention, and research. In management and organ-
ization, they may
• develop and implement occupational health and safety programs
in the workplace;
• work to establish and maintain a culture of safety and health in
the workplace;
• ensure compliance with federal, state, and other occupational
health and safety regulations and standards; and
• contribute to emergency preparedness and disaster planning.
In assessment and direct health care services to workers, OHNs may
• assess and monitor the health status of employees relevant to
their work responsibilities and work environments;
• help interpret medical diagnoses for employees and their employers;
• evaluate workers’ medical and occupational history, health con-
cerns, physical exams, laboratory results, and other health-
related factors;
• document and treat occupational and non-occupational illnesses
and injuries; and
• refer employees to employee assistance programs and other re-
sources as needed.
In prevention and research, they may
• conduct assessments of employee health and workplace hazards;
• work to prevent occupational illness, injury, and death due to ha-
zardous exposures;
• educate and counsel employees about occupational hazards and
safety, healthy lifestyles and behaviors, and overall health and
well-being; and
• conduct research to advance occupational health nursing and,
more broadly, the field of occupational health and safety.
OHNs by the Numbers
The 2008 Health Resources and Services Administration (HRSA)
National Sample Survey of Registered Nurses (NSSRN) estimated that
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11
LETTER REPORT
there are 18,840 RNs whose principal nursing position is in an occupa-
tional health setting (HRSA, 2010). Since 1980, the number of OHNs in
the United States has declined by approximately 36 percent, with 2008
representing the lowest number of OHNs in the last 3 decades (HRSA,
2010; Thompson, 2010). The 2004 NSSRN noted that, with an average
age of 51 years, OHNs have the highest age among all of the settings in
which RNs work (HRSA, 2006). In 2008, approximately 47 percent of
OHNs were between the ages of 50 and 64 (HRSA, 2010).
Occupational Health Nursing Education and Training
OHNs come from a variety of educational backgrounds and have a
wide range of professional experience. AAOHN, the profession’s mem-
bership organization, conducts periodic surveys of its members. In a
2006 survey, AAOHN reported that approximately 42 percent of its
members had between 6 and 15 years of occupational health nursing ex-
perience, 43 percent had greater than 15 years of experience, and only 15
percent had fewer than 6 years of experience (AAOHN, 2006a).
Generally, OHNs are RNs who provide occupational health nursing
services; however, a small number of companies may hire licensed prac-
tical or vocational nurses to provide occupational health services. OHNs
who are RNs can hold a diploma in nursing, an associate degree in nurs-
ing (ADN), or a baccalaureate of science in nursing (BSN)—the mini-
mum levels of nursing education required to practice as an RN. Of those
OHNs who are RNs, approximately 52 percent hold either a diploma or
an ADN as their highest level of nursing education, whereas 30 percent
have a BSN (HRSA, 2010). In 2006, AAOHN reported that approx-
imately 11 percent of its members held a baccalaureate degree in another
field (i.e., a non-nursing degree) as their highest level of education
(AAOHN, 2006a).
Beyond basic nursing education, occupational health nursing special-
ty education is available at the master’s and doctoral levels. Approx-
imately 18 percent of OHNs have either a master’s degree or a doctorate
in nursing or a nursing-related field (not necessarily occupational health
nursing) (HRSA, 2010). Graduate-level education may include programs
of study as an occupational health nurse–specialist, an adult health nurse
practitioner with a concentration in occupational health nursing, or a
family health nurse practitioner with a concentration in occupational
health nursing, such as the programs that are offered through the Univer-
sity of Michigan’s Occupational Health Nursing Program (McCullagh,
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34 OCCUPATIONAL HEALTH NURSES AND RESPIRATORY PROTECTION
Teaching Methods and Resources for Respiratory Protection
Education and Training
To successfully cover the essential content for a respiratory protec-
tion curriculum, occupational health nursing programs can use a range of
approaches and resources to improve access to their courses and enhance
the students’ learning experience. Some occupational health nursing pro-
grams are already using innovative online and simulation educational
methods to teach respiratory protection (e.g., Brown, 2011; Rupe, 2011).
Online courses offer an accessible format for students who do not
have a school nearby. Of the OHNs surveyed by Mackey and colleagues
(2003), over 56 percent reported that distance from a campus was a
barrier to their obtaining a graduate degree. Online courses, including
virtual lectures and training, webinars, Internet videoconferencing, and
computer-managed instruction, are increasingly available and are being
integrated into traditionally campus-based programs. Advantages and
disadvantages of the distance learning approach were noted in the IOM’s
report Safe Work in the 21st Century (2000). Advantages include the
program’s ability to be flexible, to be reproduced, and to draw on experts
at multiple institutions. Disadvantages include limited interaction with
faculty and other students and the need to arrange for in-person activities,
such as hands-on exercises and preceptorships. Students enrolled in an
online course at schools such as the University of Iowa, where 50 percent
of occupational health nursing students are out of state, are required to
attend some courses in person (Rupe, 2011). This approach allows the
students to take advantage of the flexibility of an online course yet also
learn from applied activities.
Participants at the IOM workshop also described the value of using
nontraditional teaching methods—such as simulation techniques, case stu-
dies, field observation and practice, and team projects—in addition to
conventional classroom lectures. By using a range of teaching methods,
education and training programs can more effectively convey and rein-
force knowledge and skills in ways that target different learning styles
and needs in order to better teach the essential content for respiratory
protection. Presenters at the workshop emphasized the importance of
hands-on educational approaches for effectively teaching OHNs how to
use a respirator and how to instruct others in respirator use and mainten-
ance. Hands-on learning experiences with fit testing and using a variety
of respirators help OHNs understand the practical challenges presented
by this equipment and the pros and cons of different models. Using a
respirator while attempting to go about normal work-related tasks under
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35
LETTER REPORT
normal working conditions is valuable in understanding worker concerns
and experiences (Bayer, 2011).
Furthermore, using innovative teaching methods may help to em-
phasize the value of respirators and respiratory protection more broadly.
Carrico and colleagues (2007) found that emergency department nurses
who received a training program that involved a biosimulation of respira-
tory disease transmission, combined with standard classroom training,
had a 74 percent rate of compliance with PPE use, compared to a 53 per-
cent rate for a control group that received standard classroom training
alone. Although the goal of this study was to evaluate PPE compliance
when visual demonstration is used as a teaching approach, the study also
noted that biosimulators are being used “to assist and improve the learn-
ing of residents, medical students, nursing students, and employed
HCWs [health care workers]” and that the “visual demonstration [used in
the study was] built on the principles of adult learning” (Carrico et al.,
2007, p. 18). Comparable simulations could be useful in improving
OHNs’ abilities to teach workers about respiratory protection. Further
efforts are needed to implement and evaluate a range of teaching me-
thods to better meet the needs of occupational health nursing students.
Recommendation 5: Develop, Expand, and Evaluate Innovative
Teaching Methods and Resources to Establish Best Practices
Occupational health nursing education programs and respirato-
ry protection programs should do the following:
• Integrate essential content on respiratory protection into
their core curricula and continuing education programs
through a variety of innovative approaches, taking into
consideration the needs of the students. These methods
could include
online courses (including webinars),
o
simulation techniques,
o
case studies,
o
education and training modules,
o
field observation and practice, and
o
conferences and workshops.
o
• Draw on resources available from NIOSH, OSHA, state
and local governments, the NIOSH ERCs and other
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36 OCCUPATIONAL HEALTH NURSES AND RESPIRATORY PROTECTION
educational institutions, professional organizations and
unions, advocacy organizations, international health
and safety organizations (e.g., the Network of World
Health Organization Collaborating Centres in Occupation-
al Health and the International Labour Organization), con-
tractors, other professional communities and institutions,
and the private sector.
• Collaborate with NPPTL to evaluate innovative teaching
methods used for respiratory protection education and
training, including continuing education, in order to es-
tablish best practices in the field.
Online Resources and Modules
Online resources, available through NIOSH and OSHA (http://www.
cdc.gov/niosh and http://www.osha.gov), provide a wealth of informa-
tion for occupational health and safety professionals. These websites in-
clude information on workplace safety and occupational hazards, such as
flu preparedness and respirable dust exposure. Among other laws and
regulations, OSHA’s website includes the full text of 29 CFR 1910.134.
Both NIOSH’s and OSHA’s websites have a number of respirator-specific
resources that include information about respirators, respiratory protec-
tion, instructions and checklists for compliance with OSHA regulations,
and opportunities for training and continuing education.
The NIOSH website could play a more active role in educating and
training OHNs in respiratory protection. For example, it could highlight
continuing education opportunities in respiratory protection and could
offer additional resources for education and training purposes, such as
case studies that illustrate the importance of respiratory protection and
the value of respirators. NIOSH could also draw on the experiences of
ERCs and develop content modules based on their best practices. If these
modules were available and accessible on the NIOSH website, occupa-
tional health nursing programs could use them as a template or founda-
tion for their curricula, and undergraduate nursing programs could use
them to augment their curricula with respiratory protection content. Ad-
ditionally, these content modules would allow OHNs who work in di-
verse settings to find information and tailor their learning experience to
their specific work functions. By centralizing the resources in an easy-to-
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37
LETTER REPORT
find place and supplementing with case studies and modules, NIOSH’s
website would be a valuable resource for educating and training OHNs.
Recommendation 6: Expand Online Resources, Particularly
Case Studies
NPPTL should develop and maintain online resources for respi-
ratory protection that are relevant to educating and training
OHNs, specifically by
• developing template modules that could be used in the
core curriculum for occupational health nursing pro-
grams and that would draw on best practices of the
NIOSH ERCs (sections of these modules could also be
used for nursing students at all levels);
• compiling case studies (e.g., health hazard evaluations)
that illustrate the value of respirators in protecting the
health of workers across a range of work environments;
and
• providing easily accessible links to existing resources, in-
cluding the OSHA checklists.
INCENTIVES FOR RESPIRATORY PROTECTION
EDUCATION AND TRAINING
Making changes to graduate-level curricula or continuing education
programs can be a significant endeavor requiring careful consideration of
the justifications for change and the potential impact on cost, time, and
educational resources. Improving respiratory protection curricula to en-
sure that OHNs are knowledgeable and feel confident in their skills will
require a multifaceted approach and collaboration among a variety of
professional organizations, educators, employers, government agencies,
and OHNs. Incentives to improve and promote respiratory protection
education and training can help drive change at the individual, educa-
tional, and employer levels. For example, the value and importance of
respiratory protection could be further promoted through conferences,
materials, and webinars that are hosted by professional associations,
NIOSH, OSHA, and other organizations. Specific steps toward develop-
ing incentives and increasing awareness could include
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38 OCCUPATIONAL HEALTH NURSES AND RESPIRATORY PROTECTION
• educational workshops at occupational health and safety profes-
sional meetings and conferences, such as those hosted by nation-
al organizations (e.g., AAOHN, AIHA, American College of
Occupational and Environmental Medicine, American Public
Health Association) and state and local affiliate groups, among
others;
• workplace reviews of case studies and lessons learned from ex-
periences on the value of respiratory protection;
• interdisciplinary activities within and outside NIOSH ERCs that
emphasize respiratory protection; and
• focused efforts to include respiratory protection in research, edu-
cational, and clinical activities as part of master’s and doctoral
programs for nurses.
Incentives for improving respiratory protection knowledge and skills
would by created if professional (e.g., AAOHN, ABOHN) and organiza-
tional (e.g., Joint Commission) accreditation and credentialing programs
increased emphasis on respiratory protection. AAOHN develops and qu-
adrennially updates a set of occupational health nursing competencies,
which are used as the basis for curriculum development and the devel-
opment of the ABOHN certification examination (AAOHN, 2007). The
AAOHN competencies are divided into nine broad categories: (1) clini-
cal practice; (2) case management; (3) workforce, workplace, and the
environment; (4) regulatory or legislative; (5) management, business, and
leadership; (6) health promotion and disease prevention; (7) health and
safety education and training; (8) research; and (9) professionalism
(AAOHN, 2007). The competencies highlight safety but do not focus on
respiratory protection or other types of PPE; they are written broadly to
cover the range of occupational health nursing practices that are integral
to the work of OHNs. The committee suggests that AAOHN consider
emphasizing knowledge of PPE and its appropriate use as a core compe-
tency. ABOHN, which offers certification exams, could then place a
greater emphasis on questions relevant to PPE, including respiratory pro-
tection and respirators.
AAOHN (2006b) has also developed the Core Curriculum for Occu-
pational and Environmental Health Nursing to guide occupation health
nursing programs in developing their curricula. The AAOHN core curri-
culum includes information on respiratory protection. However, its focus
is on the relevant federal regulations (AAOHN, 2006b). Further empha-
sis in the core curriculum on the value of respiratory protection for
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39
LETTER REPORT
nurses themselves as well as workers, on the consequences of not using
appropriate respiratory protection, and on instilling a culture of safety
(including curricular components on behavioral and organizational
change and leadership) would enhance this resource. Revisions to the
AAOHN core curriculum and competencies with specificity regarding
respiratory protection could potentially influence curricular changes.
NPPTL could facilitate action toward these goals by exploring the
development of core competencies that focus specifically on respiratory
protection.
Recommendation 7: Explore the Development of a Set of Core
Competencies in Respiratory Protection
NPPTL, in collaboration with relevant professional organiza-
tions, should explore the development of a set of interdisciplinary
core competencies in respiratory protection that could be used to
guide the education and training of OHNs and other occupation-
al health and safety professionals.
A further emphasis on the proper use of PPE, including respirators,
in organizational accreditation would signal the importance of know-
ledge and skills in respiratory protection. In addition to OSHA regula-
tions requiring respiratory protection programs for workplaces with po-
tential respiratory hazards, other worksite inspection and accreditation
criteria influence the culture of workplace safety and the degree of em-
phasis placed on respiratory protection. For hospitals and other health
care settings, Joint Commission standards are a key driver of quality im-
provement. Requirements for an infection control program are currently
a part of the Joint Commission’s criteria. Focused attention on PPE and
respiratory protection by the Joint Commission could promote consistent
respiratory protection practices in health care facilities and add an em-
phasis on and incentive for improving knowledge and skills in respirato-
ry protection.
A 2008 IOM report stated that “[a] Joint Commission initiative fo-
cused on PPE compliance would be an immediate action that could have
significant ramifications in improving awareness and appropriate use of
PPE” (IOM, 2008, pp. 155-156). Further, the committee endorses the
recommendation of the 2008 report: “Appropriate PPE use and health-
care worker safety should be a priority for healthcare organizations and
healthcare workers, and in accreditation, regulatory policy, and training.
Healthcare accrediting and credentialing organizations should ensure that
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40 OCCUPATIONAL HEALTH NURSES AND RESPIRATORY PROTECTION
PPE training is part of the accreditation and testing curricula of health
professional schools of nursing, medicine, and allied health and that PPE
concepts and practice are included on certification examinations and as
continuing education training requirements” (IOM, 2008, p. 140).
CONCLUSIONS
As key members of an occupational and environmental health and
safety effort, OHNs contribute to the nation’s health and productivity by
helping to protect workers’ health. Their knowledge, skill, and expe-
rience in respiratory protection are vital to protecting and promoting the
nation’s health and security during emergency and disaster situations,
such as pandemic flu, severe acute respiratory syndrome, and terrorist
events. OHNs partner with occupational medicine physicians, industrial
hygienists, safety engineers, infection preventionists, and other dedicated
health and safety professionals to promote and advance respiratory pro-
tection. These essential roles and responsibilities require OHNs who are
well informed, engaged, and proficient in respiratory protection prin-
ciples, practice, and motivation.
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