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OCCUPATIONAL HEALTH NURSES AND RESPIRATORY PROTECTION I MPROVING EDUCATION AND TRAINING LETTER REPORT Committee on the Respiratory Protection Curriculum for Occupational Health Nursing Programs Board on Health Sciences Policy Linda Hawes Clever, M. E. Bonnie Rogers, Andrea M. Schultz, and Catharyn T. Liverman, Editors

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THE NATIONAL ACADEMIES PRESS • 500 Fifth Street, N.W. • Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Go- verning Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was requested by the National Institute for Occupational Safety and Health of the Centers for Disease Control and Prevention and supported by Award No. 200-2011-38580, T.O. #1, between the National Academy of Sciences and the Centers for Disease Control and Prevention. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. International Standard Book Number-13: 978-0-309-21548-0 International Standard Book Number-10: 0-309-21548-X Additional copies of this report are available from The National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624- 6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2011 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among al- most all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine). 2011. Occupational health nurses and respiratory protection: Improving education and training: Letter report. Washington, DC: The National Academies Press.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal gov- ernment on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of out- standing engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Re- search Council. www.national-academies.org

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COMMITTEE ON THE RESPIRATORY PROTECTION CURRICULUM FOR OCCUPATIONAL HEALTH NURSING PROGRAMS LINDA HAWES CLEVER (Co-Chair), California Pacific Medical Center, University of California, San Francisco M. E. BONNIE ROGERS (Co-Chair), Occupational Safety and Health Education and Research Center, University of North Carolina at Chapel Hill EDIE ALFANO-SOBSEY, Wake County Human Services, Raleigh, North Carolina BARBARA DEBAUN, Cynosure Healthcare Consultants, San Francisco, California OISAENG HONG, Occupational and Environmental Health Nursing Program, University of California, San Francisco LESLIE M. ISRAEL, Department of Medicine, University of California, Irvine JAMES S. JOHNSON, JSJ and Associates, Pleasanton, California HERNANDO R. PEREZ, Drexel University School of Public Health, Philadelphia, Pennsylvania PATRICIA QUINLAN, School of Medicine, University of California, San Francisco Study Staff CATHARYN T. LIVERMAN, Study Co-Director ANDREA M. SCHULTZ, Study Co-Director LARISA M. STRAWBRIDGE, Research Associate JUDITH L. ESTEP, Program Associate ANDREW M. POPE, Director, Board on Health Sciences Policy v

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Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its pub- lished report as sound as possible and to ensure that the report meets in- stitutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confi- dential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Felicia Bayer, Alcoa, Inc. Lisa M. Brosseau, University of Minnesota School of Public Health Kathleen Buckheit, North Carolina Occupational Safety and Health Education and Research Center, University of North Carolina at Chapel Hill Howard J. Cohen, Independent Consultant Karen Coyne, U.S. Department of the Army Sue L. Davis, College of Nursing and Health, University of Cincinnati Joanna Gaitens, University of Maryland School of Medicine Elaine L. Larson, Columbia University School of Nursing Although the reviewers listed above have provided many construc- tive comments and suggestions, they were not asked to endorse the conclusions or recommendations, nor did they see the final draft of the report before its release. The review of this report was overseen by Ada Sue Hinshaw, Graduate School of Nursing, Uniformed Services vii

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viii REVIEWERS University of the Health Sciences. Appointed by the Institute of Medi- cine, she was responsible for making certain that an independent exami- nation of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Re- sponsibility for the final content of this report rests entirely with the au- thoring committee and the institution.

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Contents ACRONYMS xi LETTER TO NIOSH 1 CHARGE TO THE COMMITTEE 6 STUDY PROCESS 7 BACKGROUND 9 Overview of Occupational Health Nursing, 9 RESPIRATORY PROTECTION ROLES AND RESPONSIBILITIES 15 Assessing the Respiratory Protection Roles and Responsibilities of OHNs, 16 Responsibility to Ensure Safety, 18 RESPIRATORY PROTECTION EDUCATION AND TRAINING 20 Graduate-Level Curricula and Training, 21 Continuing Education and Training, 26 Challenges to Improving Respiratory Protection Education and Training, 28 Essential Content of Respiratory Protection Education and Training for OHNs, 30 Teaching Methods and Resources for Respiratory Protection Education and Training, 33 ix

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x CONTENTS INCENTIVES FOR RESPIRATORY PROTECTION EDUCATION AND TRAINING 37 CONCLUSIONS 40 REFERENCES 40 APPENDIXES A Workshop Agenda 45 B Workshop Participants 49 C Recent Institute of Medicine Reports Related to Personal Protective Equipment and Education Needs of the Workforce 53 D Committee Biographies 57

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Acronyms AAOHN American Association of Occupational Health Nurses ABOHN American Board for Occupational Health Nurses ADN associate degree in nursing AIHA American Industrial Hygiene Association ANA American Nurses Association ANSI American National Standards Institute APIC Association for Professionals in Infection Control and Epidemiology BSN baccalaureate of science in nursing CDC Centers for Disease Control and Prevention CFR Code of Federal Regulations CM case management COHN certified occupational health nurse COHN–S certified occupational health nurse– specialist ERC Education and Research Center for Occupational Safety and Health (NIOSH) HRSA Health Resources and Services Administration xi

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xii ACRONYMS ICOH International Commission on Occupational Health IH industrial hygiene IOM Institute of Medicine LLNL Lawrence Livermore National Laboratory NFPA National Fire Protection Association NIOSH National Institute for Occupational Safety and Health NPPTL National Personal Protective Technology Laboratory NSSRN National Sample Survey of Registered Nurses OHN occupational health nurse OSHA Occupational Safety and Health Administration PHRST Public Health Regional Surveillance Team PPE personal protective equipment RN registered nurse SM safety management UCLA University of California, Los Angeles UCSF University of California, San Francisco