EDUCAnON
Current Factors Affecting Nursing Practice
and OCcupational Health Nursing
by Judy Hayes Bernhardt, RN, MPH, PhD
Changes in nursing education tend to
follow changes in nursing practice so if
one is interested in factors affecting
nursing education, one would first look
for factors influencing practice. The first
halfof this paper will attempt to identify
some of the factors that are currently
affecting nursing practice. Selected
issues in four major areas will be consid-
ered:government, the health care deliv-
ery system, industry and the nursing
profession. The second half of the paper
will be concerned with how these
issues mayaffect occupational health
nursing education.
FACTORS AFFECTING
NURSING PRACTICE
GOVERNMENT
In the 1970s after the passage of the
Occupational Safety and Health Act,
occupational health and safety was fea-
tured in a position of prominence and
seemingly held in high regard in the
United States. During the 1980s, both
occupational and environmental health
have been demoted in importance in
the overall ordering of priorities by the
government at the national level, and to
a lesser extent, at state and local levels.
With this shift in priority ranking has
come decreased budgetary appropria-
tions with the attendant loss of man-
power, and research and training funds.
For occupational health nurse educators,
perhaps this can best be exemplified by
changes that have occurred with the
Educational Resource Centers (ERCs).
In the late1970s, ERCs were flourish-
ing. The initial program announcement
called for an occupational health nursing
academic program in each Center, as
well as programs in occupational medi-
cine, industrial hygiene, and safety In
Centers where previously only one or
two components had existed, funding
210
Changes in tedere'
government priorities
regarding occupational
health and safety have a
decided impact on
occupational health nursing
education.
was made available to initiate the miss-
ing core programs, usually occupational
health nursing and safety Continuing
education was also expected in all four
program areas. Applicants proposing
less were told they would not be
considered as a Center and could only
apply for individual project grants. It is
no longer mandatoryto propose an
academic program in each of the four
core disciplines. Revised guidelines
issued in 1981 for eligible renewal and
new applicants state "It would be most
desirable for a Center to have the full
range of core programs; however, a
Center with two or three core programs
will be eligible for support providing it
is demonstrated that students will be
exposed to the principles and issues of
the core programs that don't exist"
(National Institute for Occupational
Safety and Health, 1981). Occupational
health nursing and safetyare the two
programs most likelyto be omitted.
They are also the two program areas
most frequently denied renewed fund-
ing in established Centers.
Before raising issues affecting curricu-
lum, perhaps a more basic concern
should be addressed. Changes in federal
government priorities regarding occupa-
tional health and safety have a decided
impact on occupational health nursing
education. Most of the occupational
health nursing programs in existence
today would not have begun without
federal funding; it affects the number,
size, and location of the programs.
In a climate of diminishing federal
resources, how are occupational health
nursing programs being affected? Of the
16 graduate occupational health nursing
programs in existence in 1984, 11 were
partially funded as part of an ERe.
Occupational health nurse educators
contemplating future goals and direc-
tions of academic programs should also
address the financial realities of maintain-
ing existing programs and the advis-
ability of creating others. How many
master's prepared occupational health
nurses (OHNs) are needed? How many
occupational health nursing programs at
the master's level are necessary to edu-
cate this number of students? Should all
master's level programs produce similar
products as graduates? Is more than one
type of master's prepared occupational
health nurse needed? How many doc-
torally prepared occupational health
nurses are needed? How many pro-
grams are needed to educate this
numberof graduates? Answers to these
questions will surely impact on matters
of content and curriculum.
HEALTH CARE
DELIVERY SYSTEM
Anyone who has recently experi-
enced a medical problem and entered
the health care delivery system at almost
any point is aware that drastic changes
have occurred in the system and still
others are taking place. Most hospitals in
the United States, particularly small- and
medium-sized ones, have experienced a
decrease in census; frequently one or
more wards and/or floors have been
closed. Naturally occurring attrition and
layoffare being used to decrease the
number of staff members, including
nurses. Fewer patients are being hospi-
AAOHN JOURNAL
 Ba che lor or ,1,'1';£'1/1'(' Pro gra m 27

pro b-
ily, and com mu nit y
pIe x ind ivid ual . fam
. Thr ee are pro -
biochemical pathology lem s. Dir ect ed nur sin
g exp eri enc es
body lluids; nutrition;
I st scm . set tin gs.
hou rs lect ure . 2 cr, vid ed in a var iety of
Ins truc - sing
CLA EN 104 Expository Composition Intr odu ction to Professional Nur
es suc h as com pos itio nSON NU 140 tran sfe r stud ent s.
cal typ en and
tion in basic rhetori Required of all freshm
tion , role
, classification. des crip cing dev elo pm ent of the
and con tras t. definition . Eig ht to twe lve Stu dy of tren ds influen
pa- rela tion ship s of the
sua sion role
arg um ent atio n. and per leng of professional nursing
th.
and
lth
pers required. usually
three to ten pag es in con sum er and oth er hea
professional nurse with
4 cr. eith er scm . I cr. eith er scm.
Individual con fere nce s. care team mem ber s.
Basic intro- sing Pre-
CLA PS 101 General Psychology SON NU 245 Social Foundation in Nur
cho log y; topi cs incl ude N NV 140 . Req uire d of sop hom ore s
duction to field of psy req or cor eq: SO influenc-
ern ing learning. me mo
ry, tion of societal forces
theorie s and find ings gov and transfers. Exp lora s of sign ificant
lity , social and sing . Ana lysi
per cep tion , dev elo pm ent . rers ona ing development of nur
ure and fess ion . I cr. either
Thr ee hou rs large lect historical tren ds affectin
g the pro
abnormal p,y cho log y. e hou rs of small
tion or thre
one hou r disc uss ion sec Stu-scm.
s. Req uire me nts vary. Introduction to Resear
ch Prereq:
lecture with no sec tion e a, sub ject s in nsycho
lo-
SON NU 314 ctio n to
req uire d to par tici pat r to NU 404 . Intr odu
den ts NU 318; required prio ts as
4 cr. eith er scm . basic statistical con cep
gy studies. the rese arc h pro ces s and
Prereq: roa che s. inte rna l
Psychology of Personality ear ch app
CLA I'S 251 tua l frame- part of that pro ces s. Res well as con cep ts of
. Pro vid es a con cep vali dity of eac h, as
CLA PS 101 or 105 and external rela -
dev elo pm ent . org ani zati
on, ersi on. esti ma tion , cor
work for und erst and ing ual by con tras central ten den cy and disp
ting exa min ed with in the
ind ivid ing are
and change of the normal tion, and hyp oth esis test
lyti c, us is on
itions, e.g .. psy cho ana nursing literature. Foc
diverse theoretical pos cus sion section. 4 cr. framework of existing atic al formula or
soc ial lear ning . Dis ces s, not mat hem
humanistic. the rese arc h pro tion of
but sele ctio n/in terp reta
eith er 'em .
Thiscalculation pro ced ure s, riat e to the rese arc h
rop
etA so 100·107 is des Principles in Sociology statistical tech niq ues as
app
igne d to brin g to majors and Em pha sis on inte rpre tati on for implications
series of cou rse s process.
ghts and con cep ts; to
give eith er sern.
nonrnajors imp orta nt insi in nursing practice. 4 cr,
p
tast e of soc iolo gy as a cra ft; and to dev elo wth and Development Prereq:
them a of facts. figures. SON NU 317 Gro
cou rses .
abil ities in the face of pre pro fess ion al
their critical satisfactory com ple tion
-
(See UIlJerWIIJUll/e Pro tern s related to physica
l,
opinions. and theories. s.) 4 cr. eith er Con cep ts of gro wth pat
grams Bulletin for cou rse des crip tion
soc ial, and emo tion al dev elo pm ent thro ugh
mental, uenced
y dev elo pm ent as infl
scm. the life cycle. Personalit
Prereq: tion ships. 2 cr. eith er
Hu ma n Nutrition Science com mu nity rela
SAR HS 351 al cou by family and
rses .
of pre pro fess ion
satisfactory com ple tion scm.
i-
and req uire me nts in hum an nutr Prereq: satis-
Nutrien t fun ctio n
on as related to physi- SON NU 318 Nursing Science I
the life spa n. Nut riti pro fess ion al cou rse s and
tion ove r factory com ple tion of
blems. pre
cte d public health pro 245. Exa min es health
cal per form anc e and 'ele inte nan ce. 4 cr. 2nd SON NV 140 and SON NV
. and
for hea lth ma of individuals, families
Dietary planning variables and beh avi ors
scm. cha nge s in fam ily pat tern related to
com mu niti es and n of
ring issues. Intr odu ctio
es parenting and child rea lth pro-
Pass-Fail Ele ctiv nursing pro ces s and the
nur sing role of hea
ava ilab le to stu den ts lth ass ess me nt. In-
are in hea
Som e CL A cou rse s Nu rs- moter. Beginning skills
de opt ion . Sch ool of clinical com pon ent s. 10
on a pas s-fa il or gra of two clud es both theoretical and
y sel ect a ma xim um .
ing stu den ts ma cr. eith er scm
tow ard the fre e ele c- Nursing Science IIA
Prereq: satis-
cou rse s to be app lied (th is inc lud es SON NU 319 I. Co nce pt,
d pre pro fes sio nal of Nu rsin g Sci enc e
tive s. Pre scr ibe factory com ple tion ing;
sci enc e ele ctiv es) and erie nce ; teaching-learn
hum ani ties and soc ial gra de include the illness exp cod yna mic s within
mu st be tak en on a t: pha rma
pro fes sio nal cou rse s age nt/h ost/ env iron men alte rati ons in safe ty,
pas s-fa il opt ion , pro ces s fram ewo rk.
ing the the nursing
bas is, Be for e sel ect fac ulty l exc han ge, awa ren ess
, rc-
to con sul t wit h the ir comfort. activity. materia s of goal-
stu den ts arc urg ed kno win g and pat tern
lationships, pat tern s of nts
adv ise r. Nu rsin g res pon se to clie
seeking are add ress ed. ces ses . disr upt ion s
of deg ene rati ve pro
with pro ble ms e.
Nursing Courses atio n. dis turb ed affectiv
the exc ept ion of SO N in per cep tion and coo rdin ses . and disr upt ion s
s wit h l pro ces
Nu rsin g cou rse s. cognitive, and behaviora
upp er- div isio n cou rse theoretical and clinical
NU 140 and 245 are ma int e- in met abolism. Inc lud es both
jor firs t em pha siz es cr, eith er scm .
Th e nur sin g ma com pon ent s. 12
tus .
ce and pro mo tio n of ma n's hea lth sta hys iolo gical Concepts Pre-
nan SON NU 341 Pathop
den t pro gre sse s to the ma nag e- of all nat ura l scie nce
Th en the stu req: satisfactory com ple
tion
dev iati ons in hea lth pathophysiological
me nt of clie nts wit h e dev elo p- req uire ments. Intr odu ctio n to
Th e fina l lev el foc use s on rol
with oxy gen atio n. circulation, me-
stu tus . con cep ts dealing
se in the ma nag em ent of com -
,'('c'ilt of the nur

.5
MAY1986; VOL. 34, NO 21
 tanzed and those who are appear to be
more acutely ill. The length of hospi-
talization for the majority of those admit-
ted has been drastically reduced. These
changes in health care delivery are not
being initiated by health care recipients
or health care providers, but by those
who provide financial reimbursement for
health care. The major impetus for these
changes is the high cost of health care,
particularly institutional care. Diagnostic
related groups (DRGs) or unit charging
per hospitalization has become a fact of
business. Ten years ago hospitalization
was required before most insurance
policies would pay for medical services.
Certain services are now reimbursable
only if performed on an outpatient basis.
In 1983, nearly 90% of all health policies
covered ambulatorysurgery
As a result of changes in the hospital,
people who previously would have
been treated there are increasingly being
treated in the community Health care
delivery is slowly shifting to the com-
munityand to services in outpatient
facilities, clients' homes, and urgent care
centers. It is no longer considered
unusual that someone goes through the
entire course of an extended illness
without hospitalization. For example, a
man recently experienced biopsies, two
courses of radiation treatments, surgery,
several courses of chemotherapy and
numerous palliative treatments over a
period of two years and never spent a
night in the hospital. He was cared for in
the oncologist's office, in day-surgery, in
the hospital radiology department, and
at home. "Nursing" care was rendered
by family members, the oncology office
nurse, home health nurses, and finally,
hospice nurses. Had this man been
employed by an establishment with an
employee health service, it is likely that
the occupational health nurse would
have been involved in his care also, at
least for the 14 months he continued to
work after being diagnosed as having
cancer.
These changes in health care delivery
are not the result of any evaluation
process to determine the most efficient
and effective way to deliver quality
service to clients but are the re-
sultof sudden changes in reimburse-
ment schemes by third-party payers. As
a result of this lackof planning, there has
been no accompanying shift of funds to
support such services nor personnel
prepared to work in the different set-
tings. Research is only beginning to
measure the health effects of these
changes, changes brought about by the
212
Workers and their families
need to understand the
need for care, particularly
the need for health
promotion and disease
prevention services.
advent of extensive day-hospital surgery,
shorter confinements for medical condi-
tions and surgical procedures, shorter
stays in intensive care units and the use
of second surgical opinions and generic
drugs. What is forthcoming. are early
reports of millions of dollars saved by
these changes.
While manybelieve the right to health
care is one of the inalienable rights of all
citizens in this country, the financial
resources to pay for this right have not
materialized. The technology that has
added years to our lives has also added
dollars to health care costs. Wealthy
citizens can afford any type of health
care they choose. Government
assistance is available to the poorest
citizens. Those people who may require
health care but are unable to afford
more than emergency and acute care
maywell be workers in the establish-
ments served by occupational health
nurses. Even if the employer provides
health insurance at no cost to the worker
and at a reduced group rate to the
employee for his dependents, there are
still numerous conditions and services
not cavered for payment or only par-
tially covered. Chiefamong non-reim-
bursable items is preventive health care.
Health care must not only be afford-
able but also accessible. Health care is
not always available in rural and sparsely
populated areas at any cost. Even when
it is available, the usual hours of opera-
tion generally conflict with the
employee's work time, discouraging the
scheduling of anything less than urgent
in nature.
Even affordable, available health care
is not enough. Workers and their families
need to understand the need for care,
particularly the need for health promo-
tion and disease prevention services.
They must be educated to the fact that
while utilization of preventive services
may increase cost initially, lack of care
will probably lead to much greater
expenditures in the future, in terms of
disability and suffering as well as dollars.
INDUSTRY
Due to rising health care costs, the
most common occupational health com-
plaint today is not an illness or an injury,
but cost containment. Workers' compen-
sation costs will exceed $30 billion in
1985, up more than 600% from $5 billion
in 1970 (Victor, 1985). General Motors
Corporation spent $2.3 billion on health
care in 1984, more than $2700 per
employee for the year (Kurt, 1984).
Occupational health and safety profes-
sionals must be knowledgeable regard-
ing this topic or be considered obsolete
and ineffective.
Cost containment features currently
used generally include reimbursement
for ambulatory surgery, hospital pre-
admission testing, convalescent and
home health care, and required second
surgical opinions for manytypes of
surgery other than emergency (Same Day
Surgery, 1983). One occupational health
nurse recently reported her experience
with a telecommunications manufactur-
ing industry with 15,000 employees,
dependents and retirees. After one year
in operation, a mandatorysecond sur-
gical opinion program resulted in savings
of $364,932, less start-up and operating
costs of $70,000 and fees paid for
second opinions (Spain, 1985).
Worksite disease prevention and well-
ness programs are also being used to
help contain cost. Such programs are
based on the logical idea that it is
cheaper to keep employees healthy and
on the job than to pay the cost of ill
health, including treatment, rehabilitation
and possibly replacement of the worker.
A recent survey by the National Associa-
tion of Employers of Health Care Alter-
natives polled Fortune 500 companies
and found a 100% increase in the
implementation of worksite wellness
programs from that found in a similar
survey conducted in 1979 (Cain, 1983).
WHERE THE BATTLE
IS BEING WAGED
Nursing continues to struggle for
autonomy and recognized peer status
among the professions. One of the
places where this battle is being waged
is in academia. Nurses and nursing
schools are still trying to legitimize
themselves in institutions of higher edu-
cation and to assume full, respected
positions in the academic community
One of the measures necessary to assure
credibility is to have nursing faculty with
educational preparation equivalent to
that of other disciplines, i.e., doctoral
preparation. Nursing has pleaded a case
MOHN JOURNAL
 for being different, of being a newer
professional school and thus needing
time to catch up in the academic world.
Faculty members whose highest aca-
demic credentials are less than those
required for a starting position in other
disciplines have been routinely pro-
posed for promotion and tenure. Related
to this have been discussions of why
nursing faculty should be allowed to
substitute "creative activities" for schol-
arly publications and how hard it is for
master's prepared faculty to get research
funded.
Today, baccalaureate nursing schools
prefer candidates with a doctoral
degree for a faculty position and many
are now requiring such credentials. Fac-
ulty already employed are receiving
strong encouragement to begin the pur-
suit of a doctorate if they intend to
remain past six years or be considered
for promotion if they are already ten-
ured. This places an added burden on
the occupational health nursing pro-
grams which are already having difficulty
finding adequately prepared faculty
members with master's level education.
NURSE PRACTITIONERS
Another group of nurses still seeking
autonomy and recognition is Nurse Prac-
titioners. The development of the role of
Nurse Practitioner encompasses areas of
patient management traditionally
reserved for physicians, specifically
diagnosis and treatment. In the 25 years
since the University of Colorado began
an innovative program to train nurses to
act as primary care providersto mothers
and their children, the Nurse Practitioner
movement has spread rapidly and has
had a tremendous impact on the nursing
profession.
The Nurse Practitioner may become
increasingly important in the face of the
changes currently taking place in the
health care delivery system. The use of
the Nurse Practitioner as primary health
care provider may be one way to
provide more economical services
which are also better utilized by con-
sumers.
FACTORS AFFECTING
OCCUPATIONAL
HEALTH NURSING EDUCATION
In addition to issues affecting nursing
practice discussed in the first part of this
paper, certain others impact on program
content. In 1945 the National League for
Nursing, the National Organization for
Public Health Nurses, and the American
Association of Industrial Nurses agreed
MAY 1986; VOL. 34, NO. 5
Due to rising health care
costs, the mostcommon
occupational health
complaint today is not an
illness or an inju~ but cost
containment.
that courses in industrial nursing should
not be a part of the undergraduate
program which is a foundation in nurs-
ing; specialization should be at the post-
graduate level (American Association of
Industrial Nurses, 1976).
BACCALAUREATE PROGRAMS
Specialty preparation at the graduate
level has presented a problem, however,
since less than half of 1% of occupa-
tional health nurses have graduate
degrees. The majority of practicing
OHNsare diploma graduates; 2.3% are
associate degree graduates and 6.3% are
graduates of baccalaureate schools of
nursing (U.S. Department of Health, Edu-
cation and Welfare, 1975). This means
that the overwhelming majority of OHNs
have had no academic coursework in
their area of specialization. A further
problem is that most associate degree
and diploma graduates are trained
exclusively in hospital settings and are
prepared to work with ill patients in an
acute care setting.
Iodevs graduate of a baccalaureate
school of nursing (BSN) is better pre-
pared to work in occupational health
nursing than past graduates. The shift to
utilization of nurses in a wide varietyof
non-hospital settings is currently being
reflected in undergraduate nursing cur-
riculums. With the census in hospitals
composed of fewer and sicker patients,
altemate clinical sites are being chosen
for students at all levels. Day care
centers, developmental evaluation
clinics, schools, adolescent detention
centers, day-hospitals, prisons, alcohol
rehabilitation centers, mental health
clinics, home health agencies, senior
citizen nutrition sites, employee health
services, and other settings are being
used. Current BSN graduates possess
health assessment skills and are better
able to deal with health education,
counseling, and utilization of community
resources than in the past because of
the different types of experiences they
are having as undergraduate students.
The BSN graduate also has an advantage
by being in a program that includes a
community health component.
In June 1985, the National League for
Nursing proposed a revised position for
its paper Characteristics of Baccalaureate
Education in Nursing. A part of this
proposed revision includes the state-
ment that graduates will "practice in a
varietyof settings, emphasizing com-
prehensive health care, which includes
health promotion and maintenance, ill-
ness care, rehabilitation, health counsel-
ing and education." The statement
concludes "Consistent with the forego-
ing characteristics and related to the
Criteria for the Evaluation of Baccalaure-
ate and Higher Degree Programs in
Nursing, the graduate of the baccalaure-
ate program in nursing is able to: ... Par-
ticipate in designing nursing roles to
meet emerging needs of consumers in a
rapidly changing technological society."
In the past, several techniques have
been used to infuse occupational health
nursing content into baccalaureate pro-
grams and prepare students for nursing
roles in occupational health settings.
Techniques used include elective
courses in occupational heatlh nursing,
the use of observational experiences in
an occupational health setting, lectures
on occupational health nursing in com-
munity health courses, and integration of
occupational health nursing content
throughout the undergraduate curricu-
lum. In 1949 Emily Smith first sought to
integrate occupational health nursing
into the curriculum at Yale University
(Smith, 1952). These methods, coupled
with the use of the employee health
service as a clinical site, hopefulfv are
increasing the baccalaureate nursing stu-
dent's awareness and interest in occupa-
tional health nursing. What is needed
now is research to show if, in fact, this is
occurring, and if so, what techniques are
most effective in reaching the student.
Before we explore further undergraduate
teaching methods, evaluation is needed
of the modalities currently being used.
Problems that discourage use of
employee health services as clinical sites
for undergraduate students include the
following: most establishments have
employee health services that are too
small to accommodatean adequate
numberof students for a clinical section,
usually six to ten students; most OHNs
are diploma graduates and in many
states cannot serve as preceptors for
BSN students; and, there is not a suffi-
cient number of faculty members with
expertise in occupational health settings
213
to facilitate the experience. Discussion
by nurse educators is needed to help
alleviate these problems.
CONTINUING EDUCATION
While today's graduates do not come
out of baccalaureate programs prepared
as occupational health nurses, they do
graduate better prepared to be begin-
ning OHNs and, realistically, this is the
type of nurse who will be staffing most
OHN positions. The majority of occupa-
tional health nurses are hired by com-
panies employing only one nurse, or one
nurse per shift, and they are usually
unable or unwilling to employ a master's
prepared occupational health nurse. By
increasing the number of student place-
ments in the work setting, the BSN
student becomes more visible. Hope-
fully management will see what this type
of nurse can do and prefer a BSN
graduate over the associate degree or
diploma graduate.
Until the BSN is the educational prep-
aration for all entry level positions,
continuing education programs aimed at
narrowing the gap between both associ-
ate degree and diploma programs and
the BSN program will be needed. Only
21% of practicing registered nurses in
the United States currently hold the BSN
degree so this leaming deficit is likelyto
exist for some time.
OHNs without the BSN degree should
be strongly encouraged to retum for this
educational opportunity. Registered
nurses retuming for baccalaureate
degrees fit well into the mainstream of
higher education. In the fall of 1985, a
head count of 12,247,000 students is
expected on the college campuses in
the United States <Jacobson, 1985).
Included in this number are more than
5,000,000 part-time students and a com-
parable share (43%) is expected to be
older students (age 25 and over); there
is often overlap in these two groups.
Perhaps even more OHNs would
retum to school on a part-time basis if
educators and consultants could advise
them how to assess their work assign-
ments and identify ways to decrease
their load while they are in school. For
example, identification of non-nursing
activities that can be delegated to other
personnel or the use of a technician to
do audiometric screening, pulmonary
function testing, vision screening, and
the fitting of personal protective equip-
ment. Also, perhaps OHN educators
could develop a pamphlet explaining to
the practicing OHN the need for return-
214
Wol'1<ers' compensation
costs exceeded $30 billion
in 1985, up more than
600% from $5 billion in
1970.
ing to school and its relevance to his/her
practice.
GRADUATEPROG~S
At the master's level, the concept of
using the Nurse Practitioner in occupa-
tional health needs discussion. One way
to meet the need for affordable, avail-
able primary health care for America's
working population would be with the
use of Nurse Practitioners in establish-
ments of various sizes. Nurse Practi-
tioners employed by industry would be
able to render less expensive and more
accessible care than is currently avail-
able. Quality of care received would not
diminish. Sox (1979) reviewed over 40
studies comparing the quality of care
given by Nurse Practitioners with that
given by physicians and concluded that
the quality of care provided was indis-
tinguishable by provider. Those studies
were primarily conducted in offices and
thus further research is needed to con-
firm these findings at other sites as the
employee health service.
There may be many other benefits to
the use of company Nurse Practitioners.
Fewer clients would probably be lost to
follow-up treatment. Long-term manage-
ment of chronic conditions would be
facilitated by proximity. Manyof the
same arguments used to justify the
placement of health promotion pro-
grams in industry could also be used to
justify the placement of primary care
providers there also. Collings (1979) lists
these reasons as: a good way to reach a
large number of people; the majorityof
the workforce is a very stable group with
which to work; periodic acquisition of
health data can be obtained with rela-
tive ease; the willingness of workers to
participate in health programs at the
work site; and, the difficulty in differen-
tiating truly non-occupational disease
and injury if occupational is defined as
arising from or contributed to by work.
Consideration of the use of Nurse
Practitioners in industry to provide pri-
mary care provokes numerous questions
including the following: How would this
master's prepared nurse work with the
master's prepared OHN Specialist?
Would they be one in the same or two
separate people? While it is certainly
advantageous for the OHN to have good
health assessment skills, and desirable
for the Nurse Practitioner to be able to
assess, plan, implement and evaluate an
occupational health program, it is not
too much to expect one master's degree
program to provide all this knowledge?
Should an OHN obtain practitioner edu-
cation at the master's level and occupa-
tional health and safetyexpertiseat the
doctoral level? Would the services
provided by a company employed
Nurse Practitioner be reimbursable by
third party payers?
The idea of the Nurse Practitioner in
industrycan be expanded still further, to
the utilization of a nurse practitioner in a
health maintenance organization (HMO)
structure in large industries for the deliv-
ery of health services. HMOs, like Nurse
Practitioners, have been documented as
delivering services of equal quality and
at lower cost than those traditionally
available (Ramsay, McKenzie & Fish,
1982). Creative alternatives for third party
reimbursement of health care costs are
certainlyworth consideration. Such alter-
natives are even more attractive when
they demonstrate potential to improve
accessibility and increase utilization of
preventive health care, and not serve
only as a means of cost containment.
Available data suggests that on-site treat-
ment is more cost effective than com-
munity care but concern should be
expressed not only for "doing it
cheaper" but also for "doing it better."
Certain courses have become almost
universally accepted at the graduate
level as co-requisites with occupational
health nursing courses. These include
beginning courses in biostatistics, epi-
demiology, toxicology, and industrial
hygiene practice. Considered highly
desirable are courses in occupational
safety, ergonomics, occupational dis-
eases, and organizational management.
These courses could be taken as con-
tinuing education by the BSN prepared
occupational health nurse who is not
engaged in graduate study. Most univer-
sities allow a student to take some
courses before being required to for-
mallyenroll in a graduate program.
In consideration of some of the issues
previously presented in this paper, aca-
demic work in several related areas also
seems highly desirable. Current impor-
tance being given to cost containment
MOHN JOURNAL
 demands that now more than ever, the
OHN work with employees and their
families to promote individual respon-
sibility in achieving and maintaining
health. It is necessary that the nurse
actively involve these people in decision
making, leading to the efficient utilization
of health care services. Additional areas
that would be useful include course
work in health promotion and disease
prevention, behavioral epidemiology,
budgeting and financial management for
health programs, social and behavioral
change, environmental risk assessment,
occupational health policy and policy
development, resource development,
and quality and utilization control for
health programs. To deal effectively with
the issue of cost containment, the mas-
ter's prepared nurse will need courses in
management skills, fiscal management
and statistical computing including
application and inferences.
More and more the master's and
doctoral programs in the country have
less required courses, and in fact allow a
large amount of flexibility so that stu-
dents may take courses that they are
interested in and need for their specialty
area. These courses may not be in
nursing. Some of them may be in
business schools, schools of public
health, education, and medicine. In June
1985, the National League for Nursing
Council of Baccalaureate and Higher
Degree Programs proposed revisions of
the characteristics of Graduate Education
in Nursing Leading to the Master's
Degree. One section states "The con-
current study of appropriate graduate
level cognate courses serves to broaden
the student's understanding of relevant
knowledge from other disciplines"...
"The learning climate for study at the
master's degree level enables students
to experience a collegial relationship
with peers in their own and other
disciplines."
The OHN prepared at the master's
degree level will be able to work
MAY 1986; VOL. 34, NO. 5
Current importance being
given to cost containment
demands that no~ more
than evet; the OHN work
with employees and their
families . . .
knowledgeably with other members of
the occupational safety and health team
as an equal partner. The need for OHNs
prepared at the doctoral degree level for
faculty positions has been discussed.
The doctorally prepared OHN should be
equally competent with the physician
who has an MPH degree to direct a
corporate occupational health and
safety department. This nurse should
also be involved in submitting research
proposals and directing funded research
in occupational health and safety
CONCLUSION
The issues selected for discussion in
this paper fell in four major areas:
government, health care delivery system,
industry, and the profession of nursing. It
is interesting to note that these four areas
are similar to four major concepts identi-
fied by Yura and Torres (1975). They
found in their analysis of 50 baccalaure-
ate nursing programs the concepts of
man, society, health, and nursing. The
areas found by Yura and Torres are
similar to the four central concepts of
the nursing discipline as given by
Fawcett (1984). She found consensus in
the literature about the concepts of
person, environment, health, and nursing
and identified them as the beginning
development of nursing's metaparadigm.
Discussion and study by OHN edu-
cators of the issues evolving from the
concepts of the metaparadigm may lead
to refinement of these concepts and the
beginning of development of a dis-
tinctive frame of reference or paradigm
of occupational health nursing.
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