Abstract
In the United States, occupational health nursing began toward the end of the 19th century, long before there were varying levels of nursing licensure (Wachs, 2014). The American Nurses Association (ANA; 2016) represents the interests of American nurses and specifically addresses the practice of registered nurses (RNs). Thus, the American Association of Industrial Nurses and its successor, the American Association of Occupational Health Nurses (AAOHN), included only RNs in the active member category; however, licensed practical/vocational nurses (LPNs/LVNs) could join the association as affiliate members. By 2011, many LPNs/LVNs were employed in occupational health settings, but no occupational health professional organization existed to provide guidance for their practice. During that year, AAOHN membership voted to grant LPNs/LVNs full membership status as active members of the association.
In 2015, AAOHN updated its Competencies document, which was written specifically for RNs (AAOHN, 2015). Over the course of several months, the Competencies Committee, charged with updating the AAOHN Competencies, determined that it was more realistic to write two documents than try to fit both RN and LPN/LVN competencies into one document, as LPN/LVN practice is fundamentally different from RN practice due to statutes that affect independent decision making and other requirements.
As the only occupational health nursing organization to represent both RNs and LPNs/LVNs, it is the responsibility of AAOHN to provide a Code of Ethics, Standards of Practice, and Competency guidance for all nurses who work in occupational and environmental health practice settings. Thus, LPN/LVN Competencies were developed (“Competencies for LPNs/LVNs” section). The preamble to the LPN/LVN Competencies document emphasizes the role state nurse practice acts play in determining the parameters of LPN/LVN practice. State statutes and rules define “supervision,” which differs from state to state.
Licensed practical nurses/licensed vocational nurses have a program of study of historically 12 to 18 months, though some programs are now 2 years in length (S. Johnson, personal communication, April 11, 2016). In this short time frame, only a minimal scientific and theoretical foundation can be offered. For example, some LPN/LVN educational programs teach students to conduct health assessments, but not all programs offer such classes. Without the scientific foundation, LPNs/LVNs may not accurately interpret findings or identify health problems. Licensed practical nurses/licensed vocational nurse education prepares them to be well grounded in the technical aspects of their roles. Therefore, it is essential that LPNs/LVNs working in occupational and environmental health settings have on-site or consultative supervision.
This article provides an overview of the LPN/LVN Competencies with explanations or underlying rationale for each competency. When LPN/LVN members or their employers have practice questions relative to the specific practice of occupational and environmental health nursing that cannot be answered by a state’s Board of Nursing, the AAOHN Practice Committee may be consulted.
Competencies
As members of the health care team, LPNs/LVNs
Practice nursing ethically, competently, and within the legal scope of their practices
Practice effective infection-control measures when providing direct care in a clinical setting
Licensed practical nurses/licensed vocational nurses are part of a health care team. As licensed health care members of this team, they must comply with all legal requirements of their practices with special regard to working dependently. Licensed practical nurses/licensed vocational nurses should secure in writing evidence of supervision by a health care professional (Registered Nurse [RN], Nurse Practitioner [NP], Medical Doctor [MD], Doctor of Osteopathy [DO]) who periodically reviews their work and is available for consultation. All employers of licensed health care providers should contact the state’s Board of Nursing (or other institution responsible for governing nursing practice) to verify that the presenting nurse is fully licensed. An unencumbered license tells the public that the nurse is safe to practice according to the statutes and rules of the state that issues the license or, in the case of state compacts, the state in which the nurse is practicing. Most states have an online verification system, but staff are available to respond to questions or clarify issues related to licensing. Any question of incompetence or unethical practice should be discussed with the Board of Nursing so that a thorough investigation can be conducted.
Infection control measures, such as handwashing, using clean and sterile techniques, and proper disposal of contaminated materials, are essential in all health care settings. For instance, headsets should be properly cleaned between hearing tests. Injection sites must be cleaned with alcohol before administering injections. Hands must be washed prior to touching each client/employee. The Occupational Safety and Health Administration’s (OSHA; 1992) Bloodborne Pathogens (BBP) Standard requires annual training for workers who could be exposed to blood or body fluids at work; LPNs/LVNs must adhere to the BBP requirements in their workplaces.
As members of the health care team, LPNs/LVNs
Promote safe behaviors
All members of the health care team should practice safe behaviors at work. They should use ergonomics to ensure appropriate workstation design, safe body mechanics training, and workplace hazards identification in their work environments (e.g., electrical cords in walkways, open drawers, spills on the floor). Furthermore, all members of the health and safety team should be trained to recognize hazards for their clients/employees, and methods to prevent exposure. For instance, health care team members should know the job requirements of workers to ensure appropriate consultation on safety behaviors specific to job functions (e.g., occupational chemical exposures), including specific personal protective equipment (PPE) that should be used by employees working in those jobs. When LPNs/LVNs interact with clients, they should encourage them to work safely and use appropriate PPE.
As members of the health care team, LPNs/LVNs
As directed by a supervising health care professional (RN, NP, MD, DO), maintain records within state and federal laws, ensuring confidentiality and privacy of health and personal information
Practice within budgetary constraints
Accurate and complete health records are essential to safe practice. Whether records are held electronically or in paper form, they must be maintained so to guarantee confidentiality and privacy. Health services department management must ensure that whatever system has adequate controls to prevent personal health information from being compromised. Policies should be written and employees adequately trained to ensure consistent and secure records. Members of the health care team must also ensure that they never share employees’ personal information unless a “need to know” exists.
All team members should judiciously allocate funds for the support of occupational health and safety services and programs. Members of the health care team may explore collaborations with other departments (e.g., human resources, benefits, safety, food service) in the organization to expand health, well-being, and safety programs to create a culture of health and safety within the organization. Time and resources should be used to promote the health and safety of all workers.
As members of the health care team, LPNs/LVNs
Under supervision of a registered or advanced practice nurse or physician, and using a standardized template or form, gather and document occupational and environmental health histories and employees’ statements of injuries and/or symptoms of illnesses and appropriately refer workers for further evaluation
Under supervision by a registered or advanced practice nurse or physician, and with appropriate training and certifications, may clean and dress wounds, administer first aid and cardiopulmonary resuscitation (CPR), and teach CPR classes
Under supervision by a registered or advanced practice nurse or physician, and with appropriate training, may secure informed consent for and administer adult vaccinations
Using a form or template to gather a health history ensures that essential information is gathered from injured employees. Licensed practical nurses/licensed vocational nurses should receive training on how to use the form or template, as well as clear direction for what must be documented. Does the employee’s statement of injury need to have quotation marks? Does the employee need to sign the statement? Does the LPN/LVN need to ask employees about their medication use at every visit? How are mistakes in written or electronic documentation corrected? Policies and procedures written by supervising health care professionals should standardize the gathering of such information and leave less latitude for independent decision making.
Written policies and procedures, followed by training and return demonstrations, will ensure safe treatment of workplace injuries. Directions for treatment and management of occupational injuries, including guidance on requiring further evaluation by an occupational health professional (i.e., RN, NP, DO, MD), are part of such written policies and procedures. If first aid and CPR certification are required, those requirements should be specified.
Adult vaccinations should be administered only under the authority of a health care professional with prescribing privileges (NP, physician assistant [PA], DO, MD). A “standing order” may permit LPNs/LVNs to administer certain vaccines, such as influenza. Other vaccines, such as those for travelers to international destinations, may be administered by LPNs/LVNs if specifically directed by a health care professional for a specific purpose. In that case, the order should be written on the employee’s health record, and the LPN/LVN must use a written protocol for preparation, administration, and documentation of vaccine administration. Such orders are given to an LPN/LVN only after the prescribing provider is confident that the LPN/LVN is qualified to administer the vaccine and respond in the event of an adverse reaction.
As members of the health care team, LPNs/LVNs
Under supervision of a registered or advanced practice nurse or physician, and with appropriate training and certifications, may conduct workplace health screenings, including Measuring height, weight, heart rate, respirations, temperature, and blood pressure Hearing screenings to meet OSHA requirements Pulmonary function screening to meet the National Institute for Occupational Safety and Health (NIOSH) requirements Breath alcohol screening for Department of Transportation (DOT) and non-DOT purposes Collecting urine specimens for DOT and non-DOT drug testing Blood glucose screening Administering purified protein derivative (PPD) for tuberculosis (TB) skin testing Near, distant, and color vision screening
Under OSHA, DOT, and other federal regulations, worker screenings and examinations may be required. In addition, state health departments may require screenings, such as tuberculosis testing, for employees working with high-risk populations; employers may require screenings for drugs and alcohol. Licensed practical nurses/licensed vocational nurses can earn required certificates through training and retraining for many of these mandated screening programs. Employer policies may allow LPNs/LVNs to read and interpret TB skin tests according to established written protocols. Conducting tests such as blood glucose finger-stick tests and urine dipstick tests do not require certification, but the supervising health professional must be confident that the tests are conducted and interpreted correctly before delegating the task.
As members of the health care team, LPNs/LVNs
Under supervision, and with appropriate training, may assist with EHS (environmental health and safety) worker training Hazard identification Ergonomic evaluations PPE programs, and promote the use of PPE
Safety training, hazard identification, ergonomic evaluations, and teaching proper use of PPE are not considered traditional functions in nursing; however, most nurse practice acts do not provide a waiver of accountability just because the job does not require a licensed nurse (J. Wachs, personal communication, May 1, 2016). The supervising health care professional should ensure delegation of these tasks is appropriate.
Summary
A meeting of the LPN/LVN practice group was held during the 2016 AAOHN Conference in Jacksonville, Florida. At this meeting, group members reviewed the LPN/LVN Competencies document and agreed that the competencies are appropriate. Licensed practical nurses/licensed vocational nurses do contact their state’s Board of Nursing to request clarity on practice issues. Participants said that they have conversations with their employers about the need for supervision and the limitations of their practice; as licensed nurses, LPNs/LVNs are responsible for their practices.
Licensed practical nurses/licensed vocational nurse members of the occupational health and safety team require supervision by health care professionals (RN, NP, MD, DO). Licensed practical nurses/licensed vocational nurses who work in occupational and environmental health settings should be trained and certified for tasks that contribute to the efficiency of the occupational health department. Health care professionals who supervise LPNs/LVNs should be familiar with the nurse practice act in the state where those LPNs/LVNs practice. Employers should not be hiring LPNs/LVNs for positions in which supervision—as defined by the state’s nurse practice act—by a designated health care professional is not available. Licensed practical nurses/licensed vocational nurses should ensure they are supervised by an appropriate health care professional and ensure that documentation of this relationship exists; if the state permits supervision remotely, documentation should include methods for contacting the health care supervisor and process for reviewing LPN/LVN work documents. For professional growth, LPNs/LVNs are encouraged to secure continuing education to increase their knowledge and practice skills, as well as pursue education to become RNs.
Competencies for LPNs/LVNs Working in Occupational and Environmental Health Settings
The LPN/LVN Competencies provide the guidance for practice in the specialty of occupational and environmental health. Although LPN/LVN practice is governed by state nurse practice acts and rules, those working in occupational and environmental health settings can, with supervision and appropriate additional training, provide valuable assistance to RNs and physicians. The assumption is predicated on the fact that the LPN/LVN is competent in general nursing because the individual is an LPN/LVN and has had general practical experience. Definitions of supervision may differ from state to state.
As members of the health care team, LPNs/LVNs
Practice nursing ethically, competently, and within the legal scope of their practices
Practice effective infection-control measures when providing direct care in a clinical setting
Promote safe behaviors
As directed by supervising health care professional (RN, NP, MD, DO), maintain records within state and federal laws, ensuring confidentiality and privacy of health and personal information
Practice within budgetary constraints
Under supervision of a registered or advanced practice nurse or physician, and using a standardized template or form, gather and document occupational and environmental health histories, and employees’ statement of injuries and/or symptoms of illnesses
Under supervision by a registered or advanced practice nurse or physician, and with appropriate training and certifications, may clean and dress wounds, administer first aid and CPR, and teach CPR classes
Under supervision by a registered or advanced practice nurse or physician, and with appropriate training, may obtain informed consent for, and administer, adult vaccinations
Under supervision by a registered or advanced practice nurse or physician, and with appropriate training and certifications, may conduct workplace health screenings, including Measuring height, weight, heart rate, respirations, temperature, and blood pressure Hearing screenings to meet OSHA requirements Pulmonary function screening to meet NIOSH requirements Breath alcohol screening for DOT and non-DOT purposes Collecting urine specimens for DOT and non-DOT drug testing Blood glucose screening Administering PPD for TB skin testing Near, distant, and color vision screening
Under supervision, and with appropriate training, may assist with EHS worker training Hazard identification Ergonomic evaluations PPE programs, and promote use of PPE
Footnotes
Conflict of Interest
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.