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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 Laboratory (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 respiratory 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



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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. REFERENCES AAOHN (American Association of Occupational Health Nurses). 2006a. 2006 compensation and benefits study: A statistical survey of job profiles, sala- ries and benefits. Atlanta, GA: AAOHN. ———. 2006b. Core curriculum for occupational and environmental health nursing. Third ed. St. Louis, MO: Saunders Elsevier. ———. 2007. Competencies in occupational and environmental health nursing. Journal of the American Association of Occupational Health Nurses 55(11):442-447. ———. 2011. The occupational and environmental health nursing profession. https://www.aaohn.org/fact-sheets/the-occupational-and-environmental-health- nursing-profession.html (accessed April 11, 2011). ABOHN (American Board for Occupational Health Nurses). 2004. Occupational health nursing safety management examination handbook. http://www.goamp. com/Publications/candidateHandbooks/abohn-cohn-s-handbook.pdf (accessed July 5, 2011). ———. 2008a. COHN-S examination candidate handbook. http://www.goamp. com/Publications/candidateHandbooks/abohn-cohn-s-handbook.pdf (accessed July 5, 2011).

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41 LETTER REPORT ———. 2008b. COHN examination candidate handbook. http://www.goamp. com/Publications/candidateHandbooks/abohn-cohn-handbook.pdf (accessed July 5, 2011). ———. 2009. Case management examination candidate handbook. http://www. goamp.com/Publications/candidateHandbooks/abohn-cm-handbook.pdf (accessed July 5, 2011). ANA (American Nurses Association). 2010. Code of ethics for nurses with in- terpretive statements. http://www.nursingworld.org/MainMenuCategories/ EthicsStandards/CodeofEthicsforNurses/Code-of-Ethics.aspx (accessed May 6, 2011). Banga, A., M. J. Reilly, and K. D. Rosenman. 2011. A study of characteristics of Michigan workers with work-related asthma exposed to welding. Journal of Occupational and Environmental Medicine 53(4):415-419. Bayer, F. 2011. Respiratory protection curriculum for occupational health nurs- ing programs: PowerPoint presented at the IOM Workshop on Respiratory Protection Curriculum for Occupational Health Nursing Programs in Pittsburgh, PA. http://iom.edu/~/media/Files/Activity%20Files/Education/ RespiratoryProtectionNurses/Panel%203-4%20Bayer.pdf (accessed May 6, 2011). Brown, K. 2011. Respiratory protection curriculum for OHN students at the University of Alabama at Birmingham: PowerPoint presented at the IOM Workshop on Respiratory Protection Curriculum for Occupational Health Nursing Programs in Pittsburgh, PA. http://iom.exu/~/media/Files/Activity %20Files/Education/RespiratoryProtectionNurses/Panel%201-4%20Brown. pdf (accessed July 6, 2011). Buckheit, K. 2011. Respiratory protection for nurses—University of North Car- olina at Chapel Hill: PowerPoint presented at the IOM Workshop on Respi- ratory Protection Curriculum for Occupational Health Nursing Programs in Pittsburgh, PA. http://iom.edu/~/media/Files/Activity%20Files/Education/ RespiratoryProtectionNurses/Panel%202-1%20Buckheit.pdf (accessed May 5, 2011). Burns, C. 2011. Respiratory protection curriculum—University of South Flori- da: PowerPoint presented at the IOM Workshop on Respiratory Protection Curriculum for Occupational Health Nursing Programs in Pittsburgh, PA. http://iom.edu/~/media/Files/Activity%20Files/Education/Respiratory Protection Nurses/Panel%201-1%20Burns.pdf (accessed May 5, 2011). Carpenter, H. 2011. Respiratory protection—continuing education for registered nurses: PowerPoint presented at the IOM Workshop on Respiratory Protection Curriculum for Occupational Health Nursing Programs in Pittsburgh, PA. http://iom.edu/~/media/Files/Activity%20Files/Education/RespiratoryProtection Nurses/Panel%202-3%20Carpenter.pdf (accessed May 6, 2011). Carrico, R. M., M. B. Coty, L. K. Goss, and A. S. Lajoie. 2007. Changing health care worker behavior in relation to respiratory disease transmission with a

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42 OCCUPATIONAL HEALTH NURSES AND RESPIRATORY PROTECTION novel training approach that uses biosimulation. American Journal of Infec- tion Control 35(1):14-19. CDC (Centers for Disease Control and Prevention). 2010. Occupational trans- mission of Neisseria meningitidis—California, 2009. Morbidity and Mortal- ity Weekly Report 59(45):1480-1483. Davis, S. 2011. Current respiratory curricula at the University of Cincinnati College of Nursing: PowerPoint presented at the IOM Workshop on Respi- ratory Protection Curriculum for Occupational Health Nursing Programs in Pittsburgh, PA. http://iom.edu/~/media/Files/Activity%20Files/Education /RespiratoryProtectionNurses/Panel%201-2%20Davis.pdf (accessed May 5, 2011). Donham, K. J., J. L. Lange, A. Kline, R. H. Rautiainen, and L. Grafft. 2011. Prevention of occupational respiratory symptoms among certified safe farm intervention participants. Journal of Agromedicine 16(1):40-51. Hofmann, D. A., R. Jacobs, and F. Landy. 1995. High reliability process indus- tries: Individual, micro, and macro organizational influences on safety per- formance. Journal of Safety Research 26(3):131-149. HRSA (Health Resources and Services Administration). 2006. The registered nurse population: Findings from the March 2004 National Sample Survey of Registered Nurses. http://bhpr.hrsa.gov/healthworkforce/rnsurveys/rnsurvey 2004.pdf (accessed July 5, 2011). ———. 2010. The registered nurse population: Findings from the 2008 Nation- al Sample Survey of Registered Nurses. http://bhpr.hrsa.gov/healthwork force/rnsurveys/rnsurveyfinal.pdf (accessed July 5, 2011). IOM (Institute of Medicine). 2000. Safe work in the 21st century: Education and training needs for the next decade’s occupational safety and health person- nel. Washington, DC: National Academy Press. ———. 2003. Health professions education: A bridge to quality. Washington, DC: The National Academies Press. ———. 2008. Preparing for an influenza pandemic: Personal protective equip- ment for healthcare workers. Washington, DC: The National Academies Press. ———. 2011. The future of nursing: Leading change, advancing health. Wash- ington, DC: The National Academies Press. Mackey, T. A., F. L. Cole, and S. Parnell. 2003. Occupational health nurses’ educational needs: What do they want? American Association of Occupa- tional Health Nurses Journal 51(12):514-520. Maples, E. 2011. Deep South Center for Occupational Health and Safety: Po- werPoint presented at the IOM Workshop on Respiratory Protection Curri- culum for Occupational Health Nursing Programs in Pittsburgh, PA. http://iom.edu/~/media/Files/Activity%20Files/Education/RespiratoryProtection Nurses/Panel%202-2%20Maples.pdf (accessed May 5, 2011). McCullagh, M. 2011. Respiratory protection curriculum—University of Michi- gan Occupational Health Nursing Program: PowerPoint presented at the

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43 LETTER REPORT IOM Workshop on Respiratory Protection Curriculum for Occupational Health Nursing Programs in Pittsburgh, PA. http://iom.edu/~/media/Files/ Activity%20Files/Education/RespiratoryProtectionNurses/Panel%201-3%20 McCullagh.pdf (accessed May 5, 2011). NIOSH (National Institute for Occupational Safety and Health). 2009. About NPPTL. http://www.cdc.gov/niosh/npptl/about.html (accessed May 5, 2011). ———. 2011a. Health hazard evaluations: Frequently asked questions. http:// www.cdc.gov/niosh/hhe/faq.html (accessed May 5, 2011). ———. 2011b. List of NIOSH education and research centers (ERCs). http:// www.cdc.gov/niosh/oep/centers.html (accessed April 11, 2011). ———. 2011c. NIOSH education and research centers (ERCs). http://www.cdc. gov/niosh/oep/cedirlst.html (accessed April 11, 2011). North Carolina Division of Public Health. 2011. Respiratory protection curricu- lum content: Data gathering, submitted to the IOM Committee, March 16. Oestenstad, R. K. 2010. The Deep South Center for Occupational Health and Safety, Summary Annual Report July 1, 2009-June 30, 2010: NIOSH train- ing grant T42OH008436. Birmingham, AL: Deep South Center for Occupa- tional Health and Safety. OSHA (Occupational Safety and Health Administration). 2011. Respiratory protection. http://www.osha.gov/SLTC/respiratoryprotection/index.html (ac- cessed April 7, 2011). Rice, C., and T. Reponen. 2010. University of Cincinnati Education and Re- search Center for Occupational Safety and Health, Summary Annual Re- port: July 1, 2009-June 30, 2010: NIOSH training grant T42OH008436. Cincinnati, OH: University of Cincinnati Education and Research Center for Occupational Safety and Health. Robbins, W. 2011. Southern California Education and Research Center— Occupational and Environmental Health Nursing (OEHN) Program at the University of California, Los Angeles: PowerPoint presented at the IOM Workshop on Respiratory Protection Curriculum for Occupational Health Nursing Programs in Pittsburgh, PA. http://iom.edu/~/media/Files/Activity %20Files/Education/RespiratoryProtectionNurses/Panel%201-5%20Robbins.pdf (accessed May 5, 2011). Rupe, K. 2011. Respiratory protection curriculum—University of Iowa College of Nursing: PowerPoint presented at the IOM Workshop on Respiratory Pro- tection Curriculum for Occupational Health Nursing Programs in Pittsburgh, PA. http://iom.edu/~/media/Files/Activity%20Files/Education/ Respiratory ProtectionNurses/Panel%201-6%20Rupe%20v2.pdf (accessed May 5, 2011). Ryan, M. G. 2001. Developing a respiratory protection program. Understanding the written elements. American Association of Occupational Health Nurses Journal 49(6):293-307; quiz 308-309. Strasser, P. B., H. K. Maher, G. Knuth, and L. J. Fabrey. 2006. Occupational health nursing 2004 practice analysis report. American Association of Oc- cupational Health Nurses Journal 54(1):14-23.

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44 OCCUPATIONAL HEALTH NURSES AND RESPIRATORY PROTECTION Thompson, M. C. 2010. Review of occupational health nurse data from recent National Sample Surveys of Registered Nurses—part I. American Associa- tion of Occupational Health Nurses Journal 58(1):27-39. Townsend, M. 2011a. NIOSH-approved spirometry training. http://www.mctown send.com (accessed July 6, 2011). ———. 2011b. Respiratory protection training for OHNs—developing a one- day fit-testing workshop: PowerPoint presented at the IOM Workshop on Respiratory Protection Curriculum for Occupational Health Nursing Programs in Pittsburgh, PA. http://iom.edu/~/media/Files/Activity%20Files/ Education/RespiratoryProtectionNurses/Panel%203-1%20Townsend.pdf (access- ed May 6, 2011). UCLA (University of California, Los Angeles) School of Public Health. 2011. Respiratory protection curriculum content: Data gathering from NIOSH ERC Nursing Programs, submitted to the IOM Committee, March 16. UCSF (University of California, San Francisco). 2011. Respiratory protection curriculum content: Data gathering from NIOSH ERC Nursing Programs, submitted to the IOM Committee, March 16. University of Alabama at Birmingham School of Nursing. 2011. Respiratory protection curriculum content: Data gathering from NIOSH ERC Nursing Programs, submitted to the IOM Committee, March 16. University of Iowa College of Public Health. 2011. Respiratory protection curri- culum content: Data gathering from NIOSH ERC Nursing Programs, sub- mitted to the IOM Committee, March 16. University of Michigan School of Nursing. 2011. Respiratory protection curricu- lum content: Data gathering from NIOSH ERC Nursing Programs, submit- ted to the IOM Committee, March 16. University of South Florida College of Public Health. 2011. Respiratory protec- tion curriculum content: Data gathering from NIOSH ERC Nursing Pro- grams, submitted to the IOM Committee, March 16.