Nursing in Occupational Health

MARY LOUISE BROWN, R.N.

THE KEY to occupational health nursing isthe environment in which it is practiced.

The mere fact that the occupational health nursepractices her profession not in the hospital, notat the bedside, but at the work place opensup a new and broad vista of service and offersan incomparable challenge to her professionalcapabilities.The people to whom the occupational health

nurse gives service are not traditional "pa¬tients" but workers. The care at times is cura¬

tive, at other times, rehabilitative. Increas¬ingly, in modern programs it is preventive, as

the nurse participates in health maintenanceand health promotion activities.In 1895 the first industrial nurse in the United

States assumed her duties. The president ofthe Vermont Marble Company, motivated byhis own concern for employee welfare, in-fluenced his board of directors to employ a

"district" nurse. Ada Mayo Stewart was en¬

gaged to work among the employees of the com¬pany. Her work was that of a visiting nurse.

She went into the homes of the workers togive care to the sick and into the schools toteach health to children (./).In 1897 the Benefit Association of the John

Wanamaker Company of New York City em¬

ployed a nurse. She gave first aid, arrangedfor medical care, and made followup visits toinsure that the doctors orders were understoodand followed. She distributed the financial as-

Miss Brown is chief, Occupational Health NursingSection, Division of Occupational Health, PublicHealth Service.

sistance which the benefit fund provided for itsmembers. By 1900 there were 21 companiesknown to have employed nurses (1).The first major growth period for occupa¬

tional health nursing was between the years 1914and 1930, when 47 States enacted workmen'scompensation laws (2). This social legislationprovided the incentive for accident preventionand inplant care to workers with industrialinjuries. During these years increased produc¬tion for World War I greatly influenced thegrowth of occupational health nursing. Nurseswere employed to staff first aid rooms in heavymanufacturing industries and shipyards.The early industrial nurse sometimes found

that foremen did not realize the benefits of im¬mediate care for minor injuries and objectedto workers leaving their jobs to report to thenurse. The worker, accustomed to applyinghis own first aid, sometimes objected to beingsent to the nurse. Workers, skillful in remov¬

ing foreign bodies from a fellow workers eyes,often were critical of the nurse's techniques.Despite their difficulties, these first industrialnurses established once and for all that thenurse has a place in industry.The period from 1930 to 1946 includes im¬

portant milestones for occupational health nurs¬

ing brought about by depression. social securitylegislation, and World War II.Many occupational health nurses lost their

jobs in the 1930's because the country was inthe midst of a serious economic depression.Those who were retained found that workerswere seeking help with family-related healthand welfare problems. Workers did not have

Vol. 79, No. 11, November 1964 967

unemployment compensation insurance nor

medical and hospital care insurance, as so manydo today. It was during this period thathealth counseling and health education becamean accepted role for the occupational healthnurse, just as care for industrial injuries can

be traced back to the influence of workmen'scompensation insurance.The Social Security Act of 1935 made Fed¬

eral funds available to the Public Health Serv¬ice for grants-in-aid to the States for publichealth work, including industrial hygiene.These grants stimulated the development ofState industrial hygiene units. Before 1936there were only seven industrial hygiene divi¬sions in six States, and one city health depart¬ment. By the mid-1940's there were some 47units operating in 38 States, 7 cities, and 2 coun¬

ties (3). The first industrial nursing consult¬ant was employed in 1939 by the Indiana StateBoard of Health, and in 1940 Michigan addeda similar position to its staff.In 1941 the Division of Industrial Hygiene

of the Public Health Service was asked to guidethe development of industrial health programsin defense industries (i). Because nursing wasan essential part of these programs, a full-timenursing consultant, Olive Whitlock, was as¬

signed to the division, where she worked closelywith physicians, engineers, and chemists inplanning nursing as part of the complete in¬dustrial hygiene program. Miss Whitlock gaveleadership to the first nationwide survey of du¬ties of nurses in industry.In 1940 the public health nursing section of

the American Public Health Association ap¬pointed a committee to study duties of nurses

in industry. Before this survey got underway,industry was in the midst of expansion frompeacetime to wartime production, and the num¬ber of nurses employed in industry increasedfrom 5,512 in 1941 to about 10,000 at the end of1942, and 11,200 in 1943.The Division of Industrial Hygiene, through

Miss Whitlock, collaborated with the APHAcommittee to obtain factual information on in¬dustrial nursing practices in the country. Thereport of their survey (5) served as a basis fordetermining the range of industrial nursingpractices, defining current problems, and formu-lating standards of practice.

During World War II it became increasinglyimportant to think in terms of conserving thehealth of the worker. Many women were em¬

ployed by the heavy manufacturing industries,and handicapped and older workers were drawnin large numbers into the labor force. Indus¬trial health services gave more attention to pre¬ventive measures designed to maintain thehealth and productivity of the workers.

In the cold-war years that have followedWorld War II, women have continued to be a

substantial part of the labor force. The ad-vancing age level of the working populationand the rising incidence of chronic and de-generative diseases have increased the need forearly detection and prevention of all diseases,not only those related to the occupations. Theimportance of conserving the total health ofthe worker continues to gain recognition in in¬dustry. Many companies now require periodichealth examinations. Workers, too, are healthconscious and participate in immunization pro¬grams and mass screenings to detect disease.Health education and counseling are being

increasingly recognized as essential componentsof effective health maintenance programs inindustry. Moreover, the role of the able oc¬

cupational health nurse in this area is takingon new importance with the growing recogni¬tion of psychological factors in illness. Herneed for special preparation in this area is ob¬vious. The mental health disorders are of suf¬ficient magnitude to pose a serious problem toindustry in terms of employee health efficiency.Some of the larger occupational health pro¬grams already include psychiatrists as membersof the staff, and industrial mental health pro¬grams are beginning to be developed. Effectivehandling of workers' reactions to stress willin large part depend on the ability of the oc¬

cupational health nurse to recognize workerneeds and to plan for and to give care. Aprecedent for this enlarging role exists.Mental health has long been accepted as a

part of public health programs, and the nurse

plays an important part in recognizing theemotionally disturbed child and adult andplanning for care. In a modern occupationalhealth program, the occupational health nursecan perform a similar function for employedadults. Health evaluation and counseling of

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emotionally disturbed workers are today'schallenges to occupational health nurses.The effect of two world wars, the depression

of the 1930's, the Social Security Act, and work¬men's compensation legislation are forces thathave influenced the character of industrialhealth programs and thereby changed thecharacter of occupational health nursingpractice.

Industry's concern for workers with com-

pensable injuries provided the foundation on

which broader programs of worker healthmaintenance have been built. However, thetransition from the accident prevention periodto the adult health maintenance phase is stillonly a trend. In many instances occupationalhealth nursing has not achieved its potentialbecause it has been held fast in the bedrockconcept of emergency care. The true role ofthe occupational health nurse was visualized in1923 by the Committee for the Study of PublicHealth Nursing Education (Josephine Gold-mark, secretary). In the now famous Gold-mark report (6"), the chairman, C.-E. A.Winslow, said:

Clearly, if industrial medicine and nursing were

organized on the proper scale and had the personneladequate to reach these individuals effectively forthe care of their health, for protection against occupa¬tional hazards and diseases, and for the teaching ofgood hygienic habits, the health of the nation wouldsoon be appreciably affected.

The individuals referred to in the 1920's werethe 15 million men and women in the laborforce. In 1964 there are 73 million workers.Occupational health nursing has made muchprogress, but it has never reached its potentialfor improving the health of the nation.

If occupational health nursing is ever to havea significant impact on the health of the nation,the nurse in industry, her employer, thephysician, and the employees as well must cometo recognize that the role of the occupationalhealth nurse includes all of the following:

1. Giving expert nursing care to injured andill workers.

2. Advising and helping workers use com¬

munity health and welfare resources for theirown and their families' needs.

3. Teaching and motivating employees to besafety and health minded.

4. Participating in health evaluation pro¬grams.

5. Keeping the health unit and themselvesready to handle any emergency, large or small.

6. Knowing the inherent hazards associatedwith the industry products or services, and thesigns and symptoms of the acute and chronicreactions to them.

7. Understanding the interdependence of thecontribution of labor and management to thefree enterprise system of American business.Two factors have been the principal limiting

influence in occupational health nursing. Oneis isolation and the other is lack of educationand training available in this field. Unfortu¬nately, these two factors create a vicious circle.The isolation of occupational health nursesinhibits stimulus and development of trainingand, without adequate preparation for theirrole, nurses cannot free themselves from theisolation imposed on them by circumstance.Approximately two-thirds of all occupational

health nurse positions are in establishments toosmall to justify a full complement of staff. Alltoo often the occupational health nurse has beeneducated for work in a hospital. The part-timedoctor with whom she works is often a generalpractitioner with a limited knowledge of occu¬

pational medicine. And the industrial man¬

agement person who employs her has no realconcept of what role the nurse can and shouldplay.This is not to say that individual occupational

health nurses, part-time physicians, and indus¬trial management people have not created excel¬lent occupational health programs. It is fromthe experience of creative and dedicated peopleworking within such limitations that the truepotential of occupational health has been visual¬ized. Too often, however, the occupationalhealth nurse, working alone and without regu¬lar contact with her colleagues, has been unableto recognize the full potential of her profession.The isolation of the occupational health nurse

has another aspect. Her relationship with com¬munity nursing agencies has not always beenone of mutual support. Often the direct oppo-site has been true, despite the natural alliancebetween occupational and community healthrecognized by public health leaders from Wins-low's time to the present day. Seldom are the

Vol. 79, No. 11, November 1964745-528.64-3

969

services of public health agencies made avail¬able to workers through the place of employ¬ment.

Furthermore, lack of communication existsbetween the occupational health nurse and thehospital. At a time when continuity of patientcare is the watchword of the profession, theoccupational health nurse's record is seldom in¬cluded in referrals. Indeed, a patient may gofrom industry to the hospital, from the hospitalto his home, and back to work without theoccupational health nurse being involved withthe public health nurse or any other person inplanning care.

The occupational health nurse must herselfbear a part of the blame for this lack of cooper¬ation. The nurse in industry needs a thoroughunderstanding of her role if she is to bridgethe gap which separates her from her colleaguesin the community.In addition to its immediate and direct effect

upon the individual nurse, isolation has inhib¬ited the development of training. The need forspecial training for the occupational healthnursing specialty has long been recognized. In1915 nurses working in industry in the Bostonarea took note of the problems faced by nurseswho were hospital oriented but who were now

working in factory and shipyard emergencyrooms. In 1916, through their efforts and thatof the women's division of the National CivicFederation, a 16-week course in industrial serv¬

ice for nurses was given in weekly 2-hour even¬

ing sessions. This course was repeated annu¬

ally for the next 5 years by the college of busi¬ness administration of Boston University (7).Unfortunately, this early training effort did notcreate a trend for concerted action. The 1923Goldmark report (6) pointed out the need:In justice to the nurse herself in view of her pro¬

spective responsibilities, in justice to those whose wel¬fare is entrusted to her, in justice above all to thecommunity which pays in deteriorated manhood andwomanhood for the unrepaired injuries of industry, theindustrial nurse needs a sound and rounded training.In the 41 years since the Goldmark report

was published, "sound and rounded" trainingfor the nurse who works in industry has notbeen available to occupational health nurses ex¬

cept briefly in the post-World War II years,when several schools of nursing offered special

courses in industrial nursing. These programswere not oversubscribed and, as nursing educa¬tion patterns changed in the 1950's to nonspe-cialization on a baccalaureate level, they were

discontinued.Two graduate-level programs were estab¬

lished, one in 1950 and the other in 1959. Thesewere not widely accepted, and in 1964 none

are in operation. Why has this happened whensuch programs have expanded in all other areas

of nursing? Isolation and the resulting lackof leadership provide the clue.An enlightening contrast can be seen in the

development of training for public healthnurses. Nurse supervisors and administratorsin public health agencies recognized early theneed and stimulated the demand for specializedtraining. Working as part of a staff underthe supervision of a nurse administrator or

nurse supervisor, the public health nurse was

urged to seek special preparation for her field,first in certified courses and then at the bacca¬laureate level.On the other hand, if an occupational health

nurse sought to learn about the developmentof occupational health nursing programs, in¬dustrial hygiene, and workmen's compensation,she found not only that these were unavailablebut that no organized and well-directed demandexisted for them. Instead, she was referred topublic health nursing courses. It is not sur¬

prising that many an occupational health nurse

concluded that additional preparation for herspecialty was superfluous.

Orientation and ongoing inservice educationfor nurses in industry also have suffered fromthe circumstance of isolation. The nurse whoworks alone or with a small staff has no one toorient her, and ongoing inservice education pro¬grams are not feasible unless a group of nurses

take part.Isolation is not the only obstacle to dynamic

ongoing inservice training. In the large indus¬tries, the occupational health nurse is a memberof a staff that may include as many as 60 othernurses. In these the full-time medical directorsprovide the guidance. The creation of posi¬tions at the level of nursing service director,supervisor, or head nurse has been slow.Although some occupational health nurses havehad these titles, few have had both the status

970 Public Health Reports

and the authority to create effective occupa¬tional health nursing programs, including in¬service training.Too many large programs have been carried

on as if they were small programs, with thephysician trying to provide nursing supervisionin addition to providing entire administrationof the program. Long ago it was recognized asa basic principle of health service administra¬tion that an essential qualification for the super¬visor is professional orientation similar to thatof his subordinates. One wonders why busymedical administrators of occupational healthprograms, unlike their counterparts in hospitalclinics and health departments, have failed todelegate responsibility to a chief nurse or nurse

supervisor.Here again a word of tribute should be given

to the few who have been different. Some med¬ical directors and industrial management per¬sonnel not only have established occupationalhealth nurse supervisory and administrativepositions but filled them with competent nursesand established an administrative frameworkwhich enabled the nurse in the leadership posi¬tion to create the nursing aspects of the pro¬gram and supervise the nurses carrying it on.

In 1914 it was recognized that industrialnursing was a demanding, responsible position

for a nurse. It was early recognized that prep¬aration beyond that possible in a hospital schoolof nursing was necessary, but such training hasnever been available to any significant degree.The report of the 1963 evaluation conference(8) states that of the 5,178 nurses who hadtraineeships for full-time study only 12 were

employed in industry during the years 1958-63.Of the 10,184 nurses who had short-term train¬eeship, only 42 were from industry, and 35 ofthese attended the one course planned for occu¬

pational health nurse supervisors. Until prep¬aration for occupational health nursing is avail¬able, nurses will have to learn by trial anderror.

The potential of occupational health nursingwill not be achieved until education at the bac¬calaureate and graduate levels, supplementedby inservice training, is wanted by occupationalhealth nurses and their employers. Prepara¬tion must be available to nurses before they takea position in occupational health and after theydo so. "Knowledge and skills of professionalpersonnel cannot be once learned. They mustbe renewed continuously to keep pace with therush of demands and new knowledge in thespace age" (8).

It is estimated that as of January 1, 1964,there were more than 17,000 occupational health

Vol. 79, No. 11, November 1964 971

nurses in the United States and that by 1970an additional 5,000 nurses will be needed tomaintain the present ratio of nurses to workersin light of the growth rate of the labor force.This estimate does not allow for attrition, whichcan be predicted to be about 50 percent in thenext decade, since those presently employed arelargely in the age group 35 years and older.Nor does this provide staffing of new programsfor workers in smaller industries.In the future the supply of adequately pre-

pared occupational health nurses will dependon provision of educational and training oppor-tunities in several areas. While all are essen-tial, first priority should be given to thepreparation of nurses for consultation. Of ap-proximately 70 occupational health nurse con-sultants now employed in the United States, one-half are expected to retire within this decade.

Activities of half of all occupational healthnurse consultants are concentrated in industriesinsured by the companies that employ thosenurse consultants. Hence, consultation for im-provement of nursing service in the whole fieldof occupational health is in limited supply.The likelihood that preparation will be avail-able will depend in large part on the creation ofa demand for occupational health nursing con-sultation. Of the 17,000 occupational healthnurses employed in 1963, it is estimated thatonly 750 have academic preparation beyond adiploma in nursing, and less than 75 of thosehave preparation in occupational health per se.It is fair to assume, therefore, that leadershippreparation is scarce. Indeed, it is known thattwo-thirds of the occupational health nurseswork where they must be self-directive orable to direct the activities of less-preparedpersonnel.The Surgeon General's Consultant Group on

Nursing directed its recommendations "to theareas in which Federal assistance can be ofparticular and immediate significance in m-creasing and improving nursing personnel andnursing service" (9). They did not single outoccupational health nursing. However, as onelooks at the record it is clear that significantapplication must be made of Federal funds forpreparation of occupational health nurses ifthe potential identified in the Goldmark report(6) is to be fulfilled.

REFERENCES

(1) McGrath, B.: Fifty years of industrial nursingin the United States. Public Health Nurs 37:119-124, March 1945.

(2) Klem, M. C., McKiever, M. F., and Lear, W. J.:Industrial health and medical programs. PHSPublication No. 15. U.S. Government PrintingOffice, Washington, D.C., 1950.

(3) Trasko, V. M.: The work of State and local indus-trial hygiene agencies. Public Health Rep 64:471-484, Apr. 15, 1949.

(4) Bloomfield, J. J.: Governmental industrial hygienepractice in 1942. Ind Med 12: 491-495 (1943).

(5) Whitlock, 0. M., Trasko, V. M., and Kahl, F. R.:Nursing practice in industry. PHS Bull. No.283. U.S. Government Printing Office, Wash-ington, D.C., 1944.

(6) Committee for the Study of Nursing Education:Nursing and nursing education in the UnitedStates. The Macmillan Co., New York, 1923,pp. 149-160.

(7) McKiever, M. F.: Data of occupational health In-terest on American labor force. U.S. PublicHealth Service, 1962. Mimeographed.

(8) U.S. Public Health Service: Nurses for leader-ship: professional nurse traineeship programreport of 1963 Evaluation Conference. PHSPublication No. 1098. U.S. Government PrintingOffice, Washington, D.C., 1964.

(9) U.S. Public Health Service: Toward quality innursing, needs and goals. PHS Publication No.922. U.S. Government Printing Office, Wash-ington, D.C., 1963.

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