Professional Autonomy of Occupational Health Nurses in the United States

by Margaret C. Thompson, PhD, RN, COHN-S, FAAOHN

abstract Autonomy, the freedom to practice independently and to exercise professional judgment in practice activities, is a central element for professional practice. Numerous articles and studies have reported on professional autonomy in general practice; however, professional autonomy for occupational health nurses has not been explored in depth. This article advances the development of a body of knowledge relative to professional autonomy in the practice of occupa- tional health nursing. This article also provides an overview of professional autonomy in nursing practice; discusses the nature and importance of professional autonomy in the occupational health practice setting; reports findings from a seminal study of occupational health nurse autonomy; and addresses professional autonomy in the context of collabora- tive practice.

ociologists’ writings throughout most of the 20th alism” (Engel, 1970, p. 12). Freidson (1984) described century identified concerns with defining profes- autonomy as traditional for professions and later referred Ssions to clearly distinguish them from other occu- to a profession as “an institution that controls its own pations, addressed internal homogeneity within profes- work, organized by a special set of institutions sustained sions, and incorporated professions’ network of social in part by a particular ideology of expertise and service” and economic relations. Many writings presented or de- (Freidson, 1994, p. 10). Scott (1998) noted, “One of the bated various positions on definitions and characteristics primary strengths of a full-fledged professional is that he of professions and the process of “professionalization.” or she is deemed capable of independent decision mak- Among the characteristics consistently identified was ing and performance, and this includes coordinating work a profession’s ability to function independently. “Autono- with others as required by the situation” (p. 256). my is regarded as an important dimension of profession- Historically, nursing has not always been viewed as a profession (Etzioni, 1969), but changes in the philoso- phies and structure of nursing, the educational pathways ABOUT THE AUTHOR Dr. Thompson is Principal/Occupational Health Consultant, Croft-Taylor for nurses, the system, and society have led Consulting, LLC, Ridgefield, CT. to generalized recognition of nursing as a profession. The author received an honorarium from the American Association of Oc- Where that recognition is withheld, it may be attributed cupational Health Nurses, Inc., to write this article. Address correspondence to Margaret C. Thompson, PhD, RN, COHN-S, to structural constraints that are applicable to all health FAAOHN, Principal/Occupational Health Consultant, Croft-Taylor Consult- care professionals: “given the organizational structure of ing, LLC, 19-25 Prospect Ridge, Ridgefield, CT 06877. E-mail: mcthomps@ health care practice environments today there are few if comcast.net. Received: November 20, 2011; Accepted: February 22, 2012. any autonomous decision makers” (Liaschenko & Peter, doi:10.3928/21650799-20120328-23 2004, p. 489).

WORKPLACE HEALTH & SAFETY • Vol. 60, No. 4, 2012 159 According to MacDonald (2002), “Professional bod- team of interprofessional practitioners at the worksite ies typically have the authority to determine educational and in the community. Wachs (2005b) noted that “oc- and licensing standards, to set and enforce standards of cupational health and safety is best safeguarded with all technical excellence and ethical propriety and to grant members of the occupational health team working togeth- and revoke licenses to practice” (p. 196). Timmermans er as a unit to ensure American workers are safe today and Oh (2010) consider the implicit social contract be- and will not experience adverse health effects because of tween the profession and the state a defining characteris- uncontrolled exposures decades later” (p. 158). The oc- tic that distinguishes professions from other occupations. cupational health team includes occupational health nurs- A profession “makes successful claims for specialized es, occupational physicians, industrial hygienists, safety and valued skills meriting legal protection provided by professionals, behavioral health professionals, epidemi- the state”; enjoys the “legal privilege of training and cer- ologists, toxicologists, ergonomists, and human resource tifying new members”; and meets the state expectation specialists (U.S. Department of Labor, Occupational of focusing “on the needs of its clients using scientifi- Safety and Health Administration, 2011b). Occupational cally validated knowledge” (Timmermans & Oh, 2010, health nurses comprise “the largest group of health care p. S95). Nursing satisfies these criteria for a profession. providers serving workers, worker populations and com- State licensure ensures that only nurses who have met munity groups” (American Association of Occupational regulatory standards call themselves nurses; licensure Health Nurses, Inc. [AAOHN], 2009). is regulated by state nursing boards; standards for nurs- Data from the most recent (2008) NSSRN indicate ing education are set by boards of nursing; and licensed that an estimated 19,000 occupational health nurses are nurses are held to the requirements of state nurse practice currently employed in the United States (Health Resourc- acts and standards of practice (National Council of State es and Services Administration, Office of Information Boards of Nursing, 2011). Technology, 2011). A summary of descriptive character- The literature about professional autonomy has fo- istics of occupational health nurses, based on secondary cused on general nursing practice, including how profes- analysis of responses from nurses reporting employment sional autonomy is conceptualized and actualized, is per- in occupational health settings in the 2008 NSSRN, was ceived by nurses in various settings at different stages of recently reported by Thompson and Wachs (2012). their careers, is measured, and affects other facets of nurs- AAOHN describes modern occupational health ing. In part to understand and find solutions for the current nurses’ roles as diverse and their position responsibilities , the relationship between autonomy and as wide ranging: “Today, the scope of practice includes nurses’ job satisfaction and the impact of dissatisfaction on disease management, , emergency nurse retention have been studied. Searches for explana- preparedness and disaster planning in response to natural, tions of high nursing turnover rates and factors contribut- technological and human hazards to work and communi- ing to the nursing shortage often focus on job satisfaction. ty environments” (AAOHN, 2009). Ward, Beaton, Bruck, Job satisfaction, a complex of organizational, individual, and de Castro (2011) describe occupational health nurses and environmental characteristics, has long been viewed as as facing “an array of professional practice demands and a critical factor in nurse retention (Aiken, Clarke, Sloane, responsibilities, including combinations of direct care, Sochalski, & Silber, 2002; Blegen & Mueller, 1987; administration, consultation, management, teaching, and Kovner, Brewer, Wu, Cheng, & Suzuki, 2006). research” (p. 402). Autonomy in their work environment has been de- The 2008 NSSRN questionnaire asked respondents scribed as an important element for nurses (Nevidjon & to indicate the percent of time spent on various nursing Erickson, 2001) and autonomy of practice has been iden- activities during a usual work week (Human Resources tified as a key contributor to nurses’ job satisfaction (Ai- and Services Administration, 2010). In aggregate, occu- ken et al., 2002; Blegen, 1993; Finn, 2001; Kangas, 1999; pational health nurses reported spending half their time Kovner et al., 2006). In 2004, a survey of a national sam- (50%) in patient care and charting; 11% in consultation ple of registered nurses found that dissatisfied nurses re- with agencies and/or professionals; 9% in administration; ported limited opportunity to influence decision making; 8% in non-nursing tasks; 7% in teaching, precepting, or nurses who were more satisfied reported more opportuni- orienting students or new hires; 6% in supervision and ties as did those nurses who held master’s and doctoral management; 2% in research; and 9% in non-specified degrees (Ulrich, Buerhaus, Donelan, Norman, & Dittus, activities (Thompson, 2011). “Care of workers was the 2005). Sochalski (2002) suggested that lower levels of dominant function (more than 50% of the nurses’ time) satisfaction reported by staff nurses in the 2000 National for more than two fifths (44%) of occupational health Sample Survey of Registered Nurses (NSSRN) may have nurses. Approximately 14% of occupational health nurses been related to perceptions of control over work. A cross- reported having no client care included in their position sectional study by Kovner et al. (2006) found high auton- description” (Thompson & Wachs, 2012, p. 128). omy to be among the work attitude variables significantly Occupational health nurses practice in a variety of contributing to satisfaction. settings. The employment setting reported by occupation- al health nurse NSSRN respondents shifted somewhat Occupational health nursing practice from 1992 to 2008. The majority (55%) of occupational The practice of occupational health is multifaceted health nurses responding to the 2008 NSSRN described and considered to be highly collaborative, requiring a their employment setting as private industry (Thompson

160 Copyright © American Association of Occupational Health Nurses, Inc. & Wachs, 2012), a proportion that has steadily declined ology and limitations can be found in Thompson [2008].) from the 81% reported in 1992 (Thompson, 2011). Al- Abbott’s System of Professions (1988) emphasizes com- though the proportion of occupational health nurses cur- petition for control of tasks as a way of understanding rently reporting employment in a government setting professions and identifies jurisdictional claims, boundar- (18%) (Thompson & Wachs, 2012) has fluctuated over ies, and disputes within the overall system of professions the years, it has not changed significantly from the 19% as the interdependent sequences that define professions. reported in 1992 (Thompson, 2011). Other employment In Abbott’s System of Professions (1988), work is one settings for occupational health nurses are not specified in of three major interacting elements that influence the the survey response data. In 2008, as in previous survey development, form, and fate of professions; jurisdiction years, most occupational health nurses reported working and competition are the other two. Although the study’s full-time (70%) and as employees of the facility (79%) theoretical framework focused on the process and results (Thompson & Wachs, 2012). of jurisdictional competition among occupational health Reflecting their diverse roles, occupational health professions, the collaborative nature of occupational nurse respondents to the 2008 NSSRN selected a variety health practice was noted. of job titles from the list provided in the questionnaire. Less than half (42%) selected staff or direct care nurse as Study of Autonomy in Occupational Health Nursing best corresponding to their job title; 11% selected nurse The first phase of the study consisted of a structured practitioner; 8% selected nurse; 6% review of published materials addressing or generated by selected charge nurse or team leader; 6% selected middle occupational health professions and their professional management/administration; 6% selected patient care institutions. The review focused on materials relative to coordinator, case manager, or discharge planner; and 5% the outcomes of jurisdictional competition and autonomy selected first-line management. The remaining responses for occupational health nurses. The review considered were scattered among various job titles in numbers too elements of the developmental process for the specialty small to reliably categorize (Thompson, 2011). practice of occupational health, and the work (i.e., roles, functions, tasks), knowledge systems, and institutions of Professional autonomy in the occupational health nursing and medical professions. occupational health nursing practice The review identified evidence of increasing professional In the early years, occupational health nursing was autonomy for occupational health nurses. viewed as an independent nursing practice, with many According to Abbott (1988), creation of organiza- occupational health nurses the only tions is a powerful force in defining and controlling pro- at the worksite; however, it was not necessarily viewed as fessional jurisdictions. Since the mid-20th century, the autonomous practice. In the preface to her second book prominent professional organization for nurses practicing on occupational health nursing, Brown (1981) noted her in occupational health has been what is now known as earlier delineation of the occupational health nurse-phy- the American Association of Occupational Health Nurs- sician relationship, describing it as collaborative but as es, Inc. (AAOHN). AAOHN traces its origins to groups “based on the physician’s responsibility for medical prac- initially formed in the early decades of the 20th century tice” (p. x). In the years since that publication, occupa- that changed, merged, and formed again over time. The tional health nursing practice, reflecting both internal and public position of AAOHN provides evidence of its sta- external forces of change, has progressed from that initial tus. AAOHN’s voice is heard by regulatory agencies that limited frame. The roles of today’s occupational health impact occupational health, principally the Occupational nurses are diverse and their position responsibilities have Safety and Health Administration (OSHA). AAOHN was greater breadth. Numerous writings note the expanding influential, using an intense lobbying effort that spanned role of the occupational health nurse and describe that several years, in creating an Office of Occupational role as one of autonomous practice (Garrett, 2005; Rog- Health Nursing, added to OSHA on the same organiza- ers, Randolph, & Ostendorf, 2011; Salazar, Kemerer, tional level as the Office of (U.S. Amann, & Fabrey, 2002). Department of Labor, Occupational Safety and Health The value of autonomy in occupational health prac- Administration, 2011a). tice settings as a component of job satisfaction or a fac- Regulatory standards issued by OSHA during the tor in recruitment and retention has not been a focus of prior administration have changed the usual requirement research. In a small study of job satisfaction that drew its for medical surveillance to be supervised by physicians to sample from AAOHN members in one Midwestern state, a broader requirement (i.e., medical surveillance provid- researchers found that occupational health nurse respon- ed by a physician or other licensed health care provider) dents were significantly more satisfied with independence that includes occupational health nurses (e.g., OSHA’s than the normative group of hospital nurses to whom they Respiratory Protection Standard 29 CFR 1910.134) (U.S. were compared (Conrad, Conrad, & Parker, 1985). Department of Labor, Occupational Safety and Health Autonomy in occupational health nursing practice Administration, 1998). In 2003, AAOHN formed an al- was the central topic of a 2008 dissertation study that liance with OSHA, committing to working with OSHA used both structural and individual levels of analysis and on specific projects to improve workplace health and was guided by the concepts of Abbott’s System of Profes- safety (U.S. Department of Labor, Occupational Safety sions (1988). (A detailed description of the study method- and Health Administration, 2003). Currently, AAOHN

WORKPLACE HEALTH & SAFETY • Vol. 60, No. 4, 2012 161 describes itself as “active on a number of Public Policy education, professional certificates, advanced practice issues that impact the profession and/or the health and preparation and certification, and expert-rated position safety of workers, worker populations and community autonomy or non-staff position (i.e., positions not includ- groups. The association takes actions in addressing and/or ed in the NSSRN researchers’ list of staff positions). A supporting occupational and environmental health nurse composite autonomy measure was constructed from the advocates with local, state and federal issues through a four autonomy indicator variables based on the number of number of strategies, such as providing comments/testi- autonomy indicators reported by each nurse respondent. mony and writing letters, developing position statements Chi-square tests were used for population compari- and practice resources and establishing partnerships with sons and ordinary least squares and logistic multiple re- other agencies and organizations” (AAOHN, 2011). gression analyses to examine effects of the independent In Abbott’s System of Professions (1988), work is variables on the predicted outcomes. Analyses considered one of three major interacting elements that influence the and controlled for the influence of other characteristics development, form, and fate of professions, and master- relevant to the dependent variables age, gender, race/eth- ing the abstract knowledge necessary to the profession is nicity, region of employment, work-time status, and sal- noted as supporting jurisdictional strength. AAOHN has ary. The Table summarizes the results of the chi-square delineated a scope of practice (AAOHN, 2004) as well tests. as competencies (AAOHN, 2007) for occupational health Overall, the quantitative empirical data provided nurse practitioners. support for the premise that differences in characteristics Within the scope of practice are clinical and non- of autonomy exist between occupational health nurses clinical elements such as health evaluation of workers, and nurses employed in comparison settings. The results assessment and treatment of occupational illnesses and indicated that certain indicators of autonomy were sig- injuries, worker surveillance and hazard detection, case nificantly higher for occupational health nurses than for management, and promotion, regula- nurses in comparison settings. tory compliance, emergency preparedness, research, and Of the autonomy indicators examined, occupational program management. These practice elements fit with health nurses were significantly more likely to have high- the characteristic described by Abbott for tasks of profes- er proportions of professional certificates than all three of sions (i.e., they are amenable to expert service). Addition- the comparison groups. The composite autonomy score ally, they require a specialized knowledge that is clearly for occupational health nurses was significantly higher linked to the professional practice of occupational health than scores for hospital and school health nurses. and reflected in the competencies delineated for occupa- Occupational health nurses had significantly more tional health nurse practitioners. autonomy indicators than hospital nurses. Occupational The second phase of the study consisted of quan- health nurses were significantly more likely to hold mas- titative analysis of data from the 2004 NSSRN, which, ter’s or doctoral degrees, report having one or more pro- among other hypotheses, tested the prediction that occu- fessional certificates, have a non-staff/more autonomous pational health nurses would exhibit more characteristics position, and have a higher composite autonomy score of autonomy than nurses in other strategically selected than nurses in hospital settings. Although more occupa- settings. (Details about the NSSRN study methodology tional health nurses had advanced practice education and can be found in Human Resources and Services Admin- certification than hospital nurses, the difference was not istration, Bureau of Health Professions [2006a, 2006b].) significant. No significant differences were found in the The primary comparison group was nurses employed in proportion of nurses with advanced practice education hospital settings because this is the most studied of the and certification when comparing occupational health nursing employment settings and is generally viewed as nursing with the other nursing settings, perhaps reflecting less supportive of nursing autonomy than other settings, the generalized nature of this autonomous nursing char- despite recent efforts to encourage institutional structures acteristic. that increase nursing empowerment (Ulrich, Buerhaus, The significance of noted differences varied slightly Donelan, Norman, & Dittus, 2007; Upenieks, 2003). Two in the regression models, with variations primarily re- other employment settings, community/ and flecting the complex nature of the control variables in- school health, were also used for comparison, based on cluded in the models. (Tables 5.10 to 5.22 in Thompson published studies reporting higher levels of autonomy [2008] provide details of the regression model analyses.) for nurses in these settings than for hospital-based nurses The study findings substantiated that characteristics of (Passarelli, 1994; Schutzenhofer & Musser, 1994; Smith, autonomy vary by nursing settings, with the occupational McAllister, & Crawford, 2001; Smith Battle, Diekemper, health setting providing particular support for autonomy & Drake, 1999). among nurses. Because a direct measure of autonomy was not avail- Since that study, data reported by Thompson and able in the NSSRN data set, the study used characteris- Wachs (2012) showed that occupational health nurses are tics indicative of autonomy based on Abbott’s concepts “continuing the trend toward higher educational prepara- regarding the value, power, and prestige of knowledge tion, 18% of occupational health nurses reported having for jurisdictional strength, the autonomy inherent in ad- a master’s or doctoral degree . . . . An estimated 2,464 vanced nursing practice, and the autonomy reflected by occupational health nurses (~14%) have advanced prac- position title. These characteristics included graduate tice certification, and almost half (47%) of the estimated

162 Copyright © American Association of Occupational Health Nurses, Inc. Table Chi-square Analysis of Autonomy Indicators Comparing Nurses Employed in Hospital, Community/Public Health, and School Health Settings to Nurses Employed in Occupational Health Settings Expert- Rated Graduate Professional Advanced Non-Staff Position Composite Education Certificates Practice Position Autonomya Autonomyb Hospital (n = 16,720) 9.5% 15.5% 6.3% 24.8% 7.3% 37.2% chi-square 3.9* 4.7* 1.8 115.3** 71.5** 74.1** Community/public health 13.3% 12.2% 8.3% 70.8% 26.9% 82.8% (n = 3,256) chi-square 0.02 12.6** 0.03 14.2** 76.5** 32.4** School health (n = 967) 21.2% 7.6% 12.0% 18.8% 10.9% 35.4% chi-square 5.6* 29.6** 1.8 119.9** 410.7** 70.2** Referent occupational 13.6% 21.2% 8.6% 58.1% 18.8% 67.5% health (n = 277) Overall chi-square 117.2** 50.4** 44.2** 2025.4** 6588.6** 1756.5** Note. aCompared having a position rated as 1 (low autonomy) to positions having higher ratings (1.9 to 5); % = 4, 5 ratings. bCom- pared having no autonomy indicators to having one or more; % = 1 to 4. *p < .05. **p < .001. occupational health nurse population hold one or more regardless of the nature of their role within the team, can current national nursing certificates, including skill based influence the success of the team by understanding the (e.g., life support, resuscitation), case management, or elements necessary to maximize team performance and occupational health certificates” (p. 129). Although these ensuring those elements are in place. According to Pe- data have not been comparatively analyzed with data tri (2010), “The elements that must be in place before from other nursing settings, the increase in the propor- interdisciplinary collaboration can be successful are in- tions of these two autonomy indicators for occupational terprofessional education, role awareness, interpersonal health nurses provides additional support for earlier find- relationship skills, deliberate action and support” (p. 73). ings. In discussing the relational nature of nursing au- tonomy, MacDonald (2002) contended, “Attention to the Autonomy and collaborative practice social and contextual factors that facilitate meaningful Rogers et al. (2011), discussing occupational health autonomous action is crucial to advancing our under- nursing education, noted, “Occupational health nurses standing of the relationships between professionals and practice with a significant degree of autonomy comple- patients, as well as between different groups of profes- mented by an interdependent role with other interpro- sionals” (p. 194). Factors such as trust and respect have fessional members of the occupational health team” been consistently identified as essential for collaboration (p. 243). Occupational health nursing, as indicated earli- (Tschannen et al., 2011). Grover (2005) described com- er, is considered a highly collaborative practice; the scope munication as “essential to occupational health nurse of practice for occupational health nurses delineated by practice,” given the importance of its interdisciplinary AAOHN begins with a requirement for collaboration nature (p. 182). The occupational health nurse can model with “employees, employers, members of the occupa- effective communication styles that support trust and re- tional health and safety team and other professionals” spect and be attentive to communication barriers. (AAOHN, 2004, p. 270). Collaboration has been defined as “individuals with The organization and structure of the occupational varying background and expertise communicating ef- health team will be influenced by the characteristics fectively with one another in a non-hierarchical fashion, of the specific occupational health setting. As Wachs committed to problem-solving, in search of solutions that (2005a) points out, “Not all occupational health and cannot be determined with one’s own limited scope of safety programs, services, and challenges require a team knowledge” (Tschannen, 2005, p. 17). The April 2005 approach. The occupational health nurse is often the co- issue of the AAOHN Journal focused on collaboration, ordinator of the team and must decide in which situations with articles discussing many aspects of collaboration, a team is necessary” (p. 170). Occupational health nurses, including the importance of collaboration to occupational

WORKPLACE HEALTH & SAFETY • Vol. 60, No. 4, 2012 163 American Association of Occupational Health Nurses, Inc. (2007). IN SUMMARY Competencies in occupational and environmental health nursing. AAOHN Journal, 55(11), 442-447. American Association of Occupational Health Nurses, Inc. (2009). Professional Autonomy of Occupational and environmental health nursing profession fact sheet. Retrieved from www.aaohn.org/dmdocuments/OHN_ Occupational Health Nurses Profession_2009.pdf American Association of Occupational Health Nurses, Inc. (2011). in the United States AAOHN in action. Retrieved from www.aaohn.org/public-policy- Thompson, M. C. items/aaohn-in-action.html Blegen, M. A. (1993). Nurses’ job satisfaction: A meta-analysis of re- Workplace Health & Safety, 2012; 60(4), 159-165. lated variables. , 42(1), 36-41. Blegen, M. A., & Mueller, C. W. (1987). Nurses’ job satisfaction: A lon- Autonomy, the freedom to practice independent- gitudinal analysis. Research in Nursing & Health, 10(4), 227-237. Brown, M. L. (1981). Occupational health nursing. New York: Springer. 1 ly and to exercise judgment in practice activities, Conrad, K. M., Conrad, K. J., & Parker, J. E. (1985). Job satisfaction is a central element for professional practice and among occupational health nurses. Journal of Community Health an important dimension of professions. Nursing Nursing, 2(3), 161-174. satisfies stated criteria for a profession and has Engel, G. V. (1970). Professional autonomy and bureaucratic organiza- tion. Administrative Science Quarterly, 15(1), 12-21. been generally recognized as a full profession Etzioni, A. (Ed.). (1969). The semi-professions and their organization: for some time. Teachers, nurses, social workers. New York: Free Press. Finn, C. P. (2001). Autonomy: An important component for nurses’ job Occupational health nurses’ roles are diverse, satisfaction. International Journal of Nursing Studies, 38, 349-357. Freidson, E. (1984). The changing nature of professional control. An- 2 their position responsibilities cover a broad spec- nual Review of Sociology, 10, 1-20. trum, and their practice is described in the lit- Freidson, E. (1994). The theory of professions: State of the art. In Pro- erature as autonomous. Research has identified fessionalism reborn: Theory, prophecy, and policy. Chicago: Uni- evidence of increased professional autonomy for versity of Chicago Press. occupational health nurses and has shown that Garrett, L. H. (2005). Interdisciplinary practice, education and research: The expanding role of the occupational health nurse. AAOHN Jour- the occupational health setting provides particu- nal, 53(4), 159-165. lar support of nursing autonomy. Grover, S. M. (2005). Shaping effective communication skills and thera- peutic relationships at work. AAOHN Journal, 53(4), 177-182. The practice of occupational health is multifac- Health Resources and Services Administration. (2010). The population: Findings from the 2008 National Sample Survey 3 eted and is considered to be a highly collabora- of Registered Nurses. Rockville, MD: Author. tive practice, requiring a team of multidisciplinary Health Resources and Services Administration, Bureau of Health Pro- practitioners at the worksite and in the commu- fessions. (2006a). The National Sample Survey of Registered Nurses nity. The estimated 19,000 occupational health 2004 documentation for the general public use file. Retrieved from http://datawarehouse.hrsa.gov/nssrn.aspx nurses currently employed in the United States Health Resources and Services Administration, Bureau of Health Pro- comprise the largest group of occupational fessions. (2006b). The registered nurse population: Findings from health practitioners. The occupational health the March 2004 National Sample Survey of Registered Nurses. nurse, often the coordinator of the occupational Rockville, MD: Author. health team, can influence the success of the Health Resources and Services Administration, Office of Information Technology. (2011). HRSA Geospatial Data Warehouse: National team by understanding the elements necessary Sample Survey of Registered Nurses (NSSRN) public use files 2008 to maximize team performance and ensuring country. Retrieved from http://datawarehouse.hrsa.gov/nssrn.aspx those elements are in place. Kangas, S. H. (1999). The new health care environment: A research synthesis of impact on nurses’ job satisfaction. Atlanta, GA: Georgia State University. Kovner, C., Brewer, C., Wu, Y.-W., Cheng, Y., & Suzuki, M. (2006). Factors associated with work satisfaction of registered nurses. Jour- health and safety, the challenges it poses in occupational nal of Nursing Scholarship, 38(1), 71-79. health settings, and the skills, such as effective commu- Liaschenko, J., & Peter, E. (2004). Nursing ethics and conceptualiza- nication, that form the basis for successful collaboration. tions of nursing: Profession, practice and work. Journal of Ad- vanced Nursing, 46(5), 488-495. Occupational health nurses interested in enhancing their MacDonald, C. (2002). Nurse autonomy as relational. Nursing Ethics, knowledge of collaborative practice will find the informa- 9(2), 194-201. tion provided in that issue of value. National Council of State Boards of Nursing. (2011). Licensure of nurs- es: An integral part of public protection and fact sheet. Licensure of nurses and state boards of nursing. Retrieved from www.ncsbn. References org/247.htm Abbott, A. (1988). The system of professions: An essay on the division of Nevidjon, B., & Erickson, J. I. (2001). The nursing shortage: Solu- expert labor. Chicago: University of Chicago Press. tions for the short and long term. Online Journal of Issues in Nurs- Aiken, L., Clarke, S. P., Sloane, D. M., Sochalski, J., & Silber, J. H. ing, 6(1). Retrieved from www.nursingworld.org/MainMenuCat- (2002). Hospital nurse staffing and patient mortality, nurse burnout, egories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/ and job satisfaction. Journal of the American Medical Association, Volume62001/No1Jan01/NursingShortageSolutions.aspx 288(16), 1987-1993. Passarelli, C. (1994). : Trends for the future. Journal of American Association of Occupational Health Nurses, Inc. (2004). School Health, 64(4), 141-149. Standards of occupational and environmental health nursing. Petri, L. (2010, April-June). Concept analysis of interdisciplinary col- AAOHN Journal, 52(7), 270-274. laboration. Nursing Forum, 45(2), 73-82.

164 Copyright © American Association of Occupational Health Nurses, Inc. Rogers, B., Randolph, S. A., & Ostendorf, J. (2011). Occupational port of a successful intervention. Nursing Economic$, 29(3), 127- health nursing education. AAOHN Journal, 59(6), 243-246. 135. Salazar, M. K., Kemerer, S., Amann, M. C., & Fabrey, L. (2002). Defin- Ulrich, B. T., Buerhaus, P. I., Donelan, K., Norman, L., & Dittus, R. ing the roles and functions of occupational and environmental health (2005). How RNs view the work environment: Results of a national nurses: Results of a national job analysis. AAOHN Journal, 50(1), survey of registered nurses. Journal of Nursing Administration, 16-25. 35(9), 389-397. Schutzenhofer, K. K., & Musser, D. B. (1994). Nurse characteristics and Ulrich, B. T., Buerhaus, P. I., Donelan, K., Norman, L., & Dittus, R. professional autonomy. Image: The Journal of Nursing Scholarship, (2007). Magnet status and registered nurse views of the work envi- 26(3), 201-205. ronment and nursing as a career. Journal of Nursing Administration, Scott, W. R. (1998). Organizations rational, natural, and open systems 37(5), 212-220. (4th ed.). Upper Saddle River, NJ: Prentice Hall. Upenieks, V. (2003). Recruitment and retention strategies: A Magnet Smith, L. S., McAllister, L. E., & Crawford, C. S. (2001). Mentoring hospital prevention model. Nursing Economic$, 21(1), 7-13. benefits and issues for public health nurses. Public Health Nursing, U.S. Department of Labor, Occupational Safety and Health Adminis- 18(2), 101-107. tration. (1998). Respiratory Protection Standard 29 CFR 1910.134. Smith Battle, L., Diekemper, M., & Drake, M. A. (1999). Articulat- Retrieved from www.osha.gov/pls/oshaweb/owadisp.show_ ing the culture and tradition of community health nursing. Public document?p_table=STANDARDS&p_id=12716 Health Nursing, 16(3), 215-222. U.S. Department of Labor, Occupational Safety and Health Adminis- Sochalski, J. (2002). Nursing shortage redux: Turning the corner on an tration. (2003). OSHA trade news release: OSHA, American As- enduring problem. Health Affairs, 21(5), 157-164. sociation of Occupational Health Nurses form alliance. Retrieved Thompson, M. C. (2008). Autonomy in occupational health nursing: An from www.osha.gov/pls/oshaweb/owadisp.show_document?p_ application of Abbott’s Theory of Professions. Retrieved from http:// table=NEWS_RELEASES&p_id=10201 pqdtopen.proquest.com U.S. Department of Labor, Occupational Safety and Health Administra- Thompson, M. C. (2011). [Secondary analysis of occupational health tion. (2011a). Directorate of technical support and emergency man- nurses’ responses to National Sample Surveys of Registered Nurs- agement. Retrieved from www.osha.gov/dts/index.html es]. Unpublished data. U.S. Department of Labor, Occupational Safety and Health Administra- Thompson, M. C., & Wachs, J. E. (2012). Occupational health nursing tion. (2011b). Safety and health topics: Occupational health profes- in the United States. Workplace Health & Safety, 60(3), 127-133. sionals. Retrieved from www.osha.gov/SLTC/healthprofessional/ Timmermans, S., & Oh, H. (2010). The continued social transformation index of the medical profession. Journal of Health and Social Behavior, Wachs, J. E. (2005a). Building the occupational health team: Keys to 51, S94-S106. successful interdisciplinary collaboration. AAOHN Journal, 53(4), Tschannen, D. (2005). Organizational structure, process, and outcome: 166-171. The effects of nurse staffing and nurse-physician collaboration on Wachs, J. E. (2005b). Collaboration. AAOHN Journal, 53(4), 158. patient length of stay. Unpublished dissertation, University of Mich- Ward, J. A., Beaton, R. D., Bruck, A. M., & de Castro, A. B. (2011). igan, Ann Arbor, MI. Promoting occupational health nursing training: An educational Tschannen, D., Keenan, G., Aebersold, M., Kocan, M. J., Lundy, F., & outreach with a blended model of distance and traditional learning Averhart, V. (2011). Implications of nurse-physician relations: Re- approaches. AAOHN Journal, 59(9), 401-406.

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