Nurse practitioners boost EH service offerings
Nurse practitioners boost EH service offerings
Move routine evaluations in-house
Routine examinations that once were referred out to occupational medicine physicians are increasingly being performed by nurse practitioners in employee health departments.
Mercy Hospital Medical Center in Des Moines, IA, has been sending injured workers to an occupational medicine group, but now the 4,200-employee facility is advertising for a nurse practitioner (NP) with employee health experience. The idea is to spend money to save money, says Sharon Louis-Goldford, RN, BSN, MPA, employee health service manager.
"We'll be able to save money on the one hand, but on the other hand, it will cost us a little bit," she says. Plans are for a nurse practitioner to perform the hospital's preplacement physicals, which for the last few years have been handled by new employees' private physicians at the workers' own expense.
Louis-Goldford says the cost of those physicals will be more than worth the increased goodwill and time savings produced by performing the screenings in-house.
"There sometimes is a real negative when [employees] have to spend their own money prior to starting a job, before they have insurance," she notes.
Louis-Goldford estimates that cost savings of about $50,000 a year will be realized by having an NP handle fitness-for-duty exams following work-related injuries, which usually cost at least $30 per visit; minor physical therapy, which will save around $20 per visit; and about one-third of the functional capacity exams, which run $200 to $300 each. The NP also will perform worksite ergonomic analyses.
Glenna Bradshaw, RN, MSN, Mercy's occupational health coordinator, is about 18 months away from becoming an NP. She says the midlevel clinician duties required by an EHS can be handled by an NP.
"It doesn't make any sense to send these employees out with relatively minor [injuries], which about 80% of them are," says Bradshaw. "Most are strains and sprains, routine or minor lacerations, and needlesticks. It's very rare that any [injury] requires emergency care, and there's a fully equipped emergency room here if that's the case."
Injured employees still would be referred to occupational medicine physicians for impairment ratings, which are established according to American Medical Association guidelines, as well as for fractures that must be set and conditions that do not respond to routine care, she adds.
Practice limits vary by state
The scope of an NP's practice varies from state to state, with state laws defining who a treating provider is in the workers' compensation system. Each state also has its own nursing practice act, as well, says Barbara Burgel, RN, MS, ANP, COHN-S, clinical professor in the occupational health nursing program at the University of California in San Francisco.
Providing treatment for work-related illness and injury has traditionally been thought of as medical practice, Burgel points out. Many states' nursing practice acts include "standardized procedure clauses" that give some registered nurses more practice overlap with medicine, as long as they work under the authority of a nursing administrator, physician, or clinic administrator.
NPs usually work under a "collaborative arrangement" with a physician who functions mainly as a consultant, coming in for a few hours per week or month according to need, she explains.
"Usually in hospital employee health, you don't need active consultation on weekly basis," Burgel says. "If you have someone who doesn't want to see a nurse practitioner or whose symptoms are not following a normal course of events and are getting worse instead of better, that's when you would bring in a medical consultant or you would refer."
While preplacement evaluations can be performed competently by a trained nurse who is not necessarily an NP, diagnosing and treating workers' compensation injuries requires the advanced practice skills of a nurse practitioner, she adds.
"Nurses do head-to-toe physical exams all the time without being nurse practitioners. A preplacement evaluation is based upon a set of skills, and one has to be competent to look at all the essential criteria in a specific job description and see if the person has any current physical problems that would preclude him from doing the full duties of that position. A certified occupational health nurse with physical assessment skills could do that very well," Burgel says.
"There's nothing that says a nurse can't do a physical if she's been properly trained," concurs Kathleen VanDoren, RN, BSN, COHN, executive president of the Association of Occupational Health Professionals in Healthcare, which is based in Reston, VA.
VanDoren, who took a year's training in physical assessments, performs preplacement physicals at TriHealth, Good Samaritan/Bethesda Hospitals in Cincinnati, where she is coordinator of employee health services.
Nurses with the COHN (certified occupational health nurse) or COHN-S (certified occupational health nurse-specialist) credential also are well-qualified to do preplacement physicals, "which is part of their job descriptions," and illness and injury return-to-work evaluations, she says.
"I've been able to do just about all of them," VanDoren adds. "If I have a very complicated one, I'll consult with a physician, but I very rarely have had to refer [an injured employee] to a physician. I can take care of it myself and collaborate with the department manager in setting up a modified-duty position."
NPs also are cost-effective additions to an EHS, she adds, because they can eliminate much of the cost for physician referrals.
Nurses perform job placement exams
"You don't really have to use a physician to do a job placement exam, and having run job placement programs in hospital-based settings, my personal observation is that nurses did a much more thorough job on the physicals," says Sharon D. Kemerer, RN, MSN, COHN-S, executive director of the American Board for Occupational Health Nurses in Hinsdale, IL. "Physicians are on such a tight schedule. It's not the best use of their expertise because a physical can be done extremely well by a nurse practitioner."
For workers' compensation examinations, "if a nurse is familiar with the workplace, he or she can do a very competent and reliable job in that capacity," Kemerer adds. "The key there is being familiar with the workplace and understanding what kinds of modified-duty options are available."
Physicians outside a hospital's system may not know the choices available for return-to-work assignments. They often can be "overly conservative" and may not bring employees back to work as soon as they actually are able, she says.
Charlene Gliniecki, OHNP, COHN-S, MS, director of employee health and safety at the 2,500-worker Camino Health Care in Mountain View, CA, says occupational medicine physicians are an essential part of the employee health team, but using NPs allows those physicians to do what they do best.
"Physicians can provide help with complicated cases and support nurse practitioners and other [employee health] nurses in providing care. In most cases, a nurse practitioner needs to have a supervising physician as part of the working relationship," she says.
Nevertheless, NPs are valuable additions to an employee health service, says Gliniecki, who supervises one and a half full-time NPs in her department.
One reason for this is that NPs' education and experience give them a "broader perspective" on employee health issues. They look not just at a medical problem itself, but also at the "root causes," which may include underlying depression, family difficulties, or other factors that can affect a person's health. In such cases, NPs often can refer employees to a hospital's employee assistance program or other sources of help.
"It's a more holistic approach," Gliniecki explains. "Physicians can do this, too, but historically nurse practitioners have been more in tune with the bigger picture. Anyone with a delayed recovery from an injury generally is dealing not only with the medical consequences of the injury but also with other social and psychological problems. Many physicians just don't have an interest in that."
Also, NPs are more familiar with the workplace in a way that physicians, especially those who work primarily outside the hospital setting, traditionally have not been.
"Physicians in occupational medicine usually see themselves more as consultants and experts in areas such as toxicology or infectious disease," she says. "They generally are not as interested in the more tedious things such as [injury] tracking and follow-up."
NPs are skilled at providing effective coordination of modified-duty jobs and health surveillance, but Gliniecki notes that occupational health experience and interest are essential to successful utilization of NPs in an employee health department.
"They must be able to look at things from an epidemiological point of view, to look at health problems as sentinel events, and to identify what needs to change in the work environment. They must be prevention-focused and must have reasonable working knowledge of the kinds of occupational health problems that can present," she says.
Nurse practitioners without occupational health experience find that some of the "trials and tribulations" of handling workers' compensation and functioning in the dual role of provider for the organization and for the employee can be uncomfortable, Gliniecki adds. *
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