Scope of Practice

KelRN215, BSN, RN · May 15, 2013

Doesn't your employer have guidelines for this? I am not an occupational health nurse, but I had my own experiences dealing with that department when I worked in the hospital. I had a note from my doctor that outlined the restrictions, the NP who worked in OH approved them and emailed them to my manager. The recommendations for my restrictions came from my doctor, OH just determined whether they were compatible with my job.

lovethecrazylife · May 23, 2013

At my company I can assign restrictions if needed. I usually won't as then the employee becomes recordable according to OSHA. (If work injury) I figure if I'm going to have to put it on the log, they might as well see a provider. Check your company policy to verify their process though.

Welcome to OHN world. I'm fairly new myself and I love it!

42pines · May 23, 2013

Scope of Practice questions should be referred to--yup, your state nursing board "Scope of Practice." Each state has its own. If after reading it you are still confused write to the BON and ask. Even if they don't answer directly they will put you in touch with someone who can.

This being said, I find it doubtful that you'll find much in the SOP because the question is too specialized to Occ Health Nursing.

As an RN you should have a relationship with a Medical Director which might be an MD, or if allowed a ANP or PA. If you do not have such a relationship in your company which might be the case, well this would make me cringe as you need Standing Orders even to give aspirin in the case of a suspect heart attack as well as Tetorifice Immunizations, oxygen, etc. I would not work for a company without such a line of command though the strength and ease of the connection varies. I've worked where I have a MD (Medical Director, who is an MD) available at all times and have worked where I theoretically had one available (but getting a response was difficult).

To turn back to restrictions. I've (following protocols handed down to me) have been able to create restrictions for 24 hours and could extend them for good reason (inability for the EE to see a Practitioner) and have always felt comfortable with that. Restrictions like "no push/pull" or "no lift more than 5lbs" or "no work more than 8 hours for the day," as well as "you're out'a here right now." (That's a CYA move when I have an EE who is not taking an issue as seriously as I want him/her to do). I'd generally (at most places) follow that up with a call or note to the covering Practitioner explaining what and why I've done what I've done, and I've never been called back to change such a short term set of restrictions. But as for creating modified/light duty work specs for more than a day I'll say right out "no way."

As Aarakoto pointed out creating restrictions can create recordables though prophylactic same day restrictions is not medical treatment and does not. Create work restrictions for a longer period of time may create a recordable and in my opinion is not w/in your realm.

Often I'd have a form connected to that company that listed what that EE did on what job, a "Job Analysis" it had a series of questions from "does EE drive," to "lift 0-5lb," "5-10lb," etc. It included climbing, running, kneeling, and had check-off spaces for "never," "occasionally," "frequently," etc. With the EE and the Supervisor (if needed) I'd utilize this tool and give the EE a copy of it to take with him/her to see their Practitioner with a request that specific restrictions or limits be returned. Often with the EE's permission I'd communicate with the Practitioner as to enable that person to see the complete picture.

The EE is often (but not always) the best source of what to do for temporary restrictions and if I thought a worker could lift 0-5lbs but the worker said: "no." Well, that's a warning to go up the chain, even if the worker is a slacker--there is too much risk to do otherwise. I've always found most workers quite willing to be vocal about what they can do and can't do. True abusers/slackers are rare, but they do occur and can be a pain--though be careful for someone who is clearly abusing the system may have other reasons that need to be teased out that in fact point to medical necessity such as panic/anxiety attacks.

Very short term restrictions are generally accepted with good reasoning and documentation and with a required "do not come back until you have a Practitioner's ok unrestricted or with restrictions. But document well and be conservative and if in doubt--don't. Just my thoughts--good luck.

RNBScNOHN · Jul 19, 2013

Hi there - I'm Canadian OHN (RN) required by my provinicial licensing authority to practice under direction of an MD. Therefore, I would obtain any work restrictions for an ee from the ee's doctor. The exception to this would be if a company protocol existed which was created by me and an MD that specified the conditions under which I could write work restrictions. The protocol needs to include a document signed by the MD that certifies I have adequate specialty training and demonstrated competence to perform skills & tasks in the protocol.

nurseEsteve · Jul 21, 2014

I have been a resort nurse for 6 months and we do necessary means aslong its not invasive, restriction is an independent work of an OHNs at least here in the philippines and aslong you can justify your nursing orders thats ok...

nurse.Esteve

RheumNurse · Jul 24, 2014

In my experience being an Occupational Medicine Nurse it is always the provider, whether it be a NP, PA, MD, and/or a Physical Therapist to set restrictions. It's often we nurses get a phone call from the patient asking if the provider will change or remove their restrictions because they are feeling better. This hardly ever, if at all happens over the telephone. In order to have restrictions be changed or removed the patient must be evaluated by the provider. I'm not sure if this is set in stone, because we work a lot with Workman's Compensation claims, or because it is what we call "best practice" where I work. I would say know what your state BON has in writing and/or what your facilities protocol(s) are. I would rather those decisions be riding on the provider and not myself. Without a full and detailed exam you may return a patient back to regular duty before they are actually ready and cause further and perhaps worse issues down the road due to not fully finalizing the initial issue. As a nurse, when I'm interviewing a patient and they state that they want their restrictions removed because they are resolved, I often probe and ask why they feel that way. Another question I ask is, "Are you really feeling better and ready for regular duty or are you just done with being on light duty and want to go back to work?" I feel you have to be real and realistic with your patients. I think some patients feel like they are a bother and just want to be released from restrictions. I tell them, "I don't want you back on regular duty until you are truly ready. It might sound good right now, but in the long run it's not worth it. I'm sure you want to get back to work, but don't rush it. If you need time to heal, then allow it."

Rbeck911, BSN, RN · Jul 31, 2014

A good rule of thumb is to have a good relationship with your medical director. Nurses in Occ Health do often set restrictions for 24 hours or less. This is not necessarily due to SOP's but more of a good practice. If an injured worker files an adjustment of claims and attempts to sue the company for their treatment, or lack of, you don't want a nurse on the stand stating why they did what they did. If it has an MD's signature, the defense of the claim will go a lot smoother. The reason for the 24 hour restrictions is that OSHA reg's state that an incident is not recordable if restricted only for the day of the injury. It is actually good practice for nurses to give restrictions. It is cost effective for the company. And always remember that you are not there to keep people from turning recordable. You are a risk manager that provides cost effective care with conservative treatment always as the first line. If you can harness that, you will be successful as an OHN. A lot of new nurses to occ health, myself included, struggle with it at first. You will at times feel that you are not being allowed to act in the best interest of your patient because you will think, "well what if it's broken, he should have an x-ray". The simple answer is this, if there is an acute problem that you feel jeapordizes life or limb, then send them to the clinic/ER. If there is no mechanism of injury other than repetitive movement (epicondylitis, strains, etc) then the ER or MD will do nothing more than you can do there, short term. If it doesn't get better with your conservative treatment, then send them out. Come to terms with this mindset. It has to be a win for the worker and a win for the company, with no single parties interest out weighing the other. This is a hard thing to do day by day, for every injury, especially when you get an awesome patient who you really want to help.

skyburp27 · Aug 9, 2014

In my experience, since our company doesn't have our own MD, the decision whether to send the ee or not, is always up to me. So far our company haven't questioned my decisions. When it comes to work related injuries and perceived a need for further evaluation such as x-ray or suturing, I send them to a gov't hospital and restrictriction always come from them. Once a restriction is given it's up to the safety officers whether to hide it or report it. But whatever there decision is, I make sure i made and send my personal report indicating the nature/ type of injury, the interventions i gave, and the reason for sending.

jollydogg_RN, ADN, BSN · Oct 7, 2014

please remove

jollydogg_RN, ADN, BSN · Oct 7, 2014

A good rule of thumb is to have a good relationship with your medical director. Nurses in Occ Health do often set restrictions for 24 hours or less. This is not necessarily due to SOP's but more of a good practice. If an injured worker files an adjustment of claims and attempts to sue the company for their treatment, or lack of, you don't want a nurse on the stand stating why they did what they did. If it has an MD's signature, the defense of the claim will go a lot smoother. The reason for the 24 hour restrictions is that OSHA reg's state that an incident is not recordable if restricted only for the day of the injury. It is actually good practice for nurses to give restrictions. It is cost effective for the company. And always remember that you are not there to keep people from turning recordable. You are a risk manager that provides cost effective care with conservative treatment always as the first line. If you can harness that, you will be successful as an OHN. A lot of new nurses to occ health, myself included, struggle with it at first. You will at times feel that you are not being allowed to act in the best interest of your patient because you will think, "well what if it's broken, he should have an x-ray". The simple answer is this, if there is an acute problem that you feel jeapordizes life or limb, then send them to the clinic/ER. If there is no mechanism of injury other than repetitive movement (epicondylitis, strains, etc) then the ER or MD will do nothing more than you can do there, short term. If it doesn't get better with your conservative treatment, then send them out. Come to terms with this mindset. It has to be a win for the worker and a win for the company, with no single parties interest out weighing the other. This is a hard thing to do day by day, for every injury, especially when you get an awesome patient who you really want to help.

This has probably been the single most helpful response on the role of OHN that I have read. Thank you for that. I've been an RN for 5+ years now, with my ADN, BSN, and even first semester of my FNP program completed. I'm pretty intuitive and learn fast, so I caught onto the OHN role fairly quickly, but was still confused about a few things because the mindset is VERY different. I just recently started a role as the Monday-Friday day nurse in a medical clinic for a large production warehouse.

I think any nurse starting for the first time in OHN could benefit from reading this.

Rbeck911, BSN, RN · Oct 7, 2014

Thanks for that, I am glad to see I was helpful in some way. lol. Occ Health nurses need to support eachother... There aren't many of us and other nurses think we are aliens..