An I nservice Continu ing Education and Expanded Role Program for Occupational Health Nurses M.A. Amundsen, M.D. Dr. Amundsen
J.J. Appelbaum, M.D.
Dr. Amundsen is Colorado-Wyoming Medical Director, Mountain Bell, and Dr. Appelbaum is Corporate Medical Director, Mountain Bell. Dr. Appelbaum
THE NEED The requirement for nurses who can do more than direct patient traffic and record vital signs has become apparent to people in the health care professions today including those in occupational medicine. Coinciding with physicians recognizing their need to be relieved of many traditional steps in the practice of medicine is a restless movement among nurses to be more involved in functions formerly performed only by doctors. It has become more obvious also that increasing numbers of patients seeking and needing health care make it more and more difficu It to provide adequate care by traditional methods alone. There are many reports in the literature of expanded nurse programs. One of the best known and oldest examples in the United States of the successful use of nurses in disease management is the Memphis Chronic Disease Program conducted by the University of Tennessee College of Medicine. Doctor John Runyan in his most recent review of the Memphis experience I concludes that with proper special training, detailed protocols and physician support nurses can successfully participate even in the management of such serious chronic medical Presented by Dr. Amundsen at the Thirty- Third Annual Meeting of the American Association of Industrial Nurses, San Francisco, California, April 15-17, 1975. 10
problems as glycosuria, blood pressure elevation and digitalis regulation. THE CONCEPT The role of occupational medicine in the American health care system and the characteristic functions of a typical "company medical department" require expanded nursing skills lying somewhere between the traditional nurse concept and the modern nurse practitioner. In the latter category much training is directed towards an ongoing primary care relationship which is not ordinarily present in the occupational health setting. Our decision to develop an expanded role and inservice education program for our nursing staff was arrived at for the following reasons: First, in 1972 the Mountain Bell Medical Department decided to create a district nurse program. This was to consist of a number of single-nurse satellite medical units located in outlying areas intended to provide occupational health services for more employees than cou Id be served directly by a central headquarters department. Such a program had originally been developed by Doctor Don Bews in Bell Canada 20 years before and had proved to be quite successtul.' Such nurses, of course, require special training and skills in the performance of preplacement and fitness evaluations, and are actively involved in health education, counseling of employees, assessment of the ill and injured and emergency care.
Second, it was apparent that we wou Id not be able to upgrade the skills of enough nurses in a short enough period of time through the local university practitioner course, at the rate of two people per year, to fill the proposed number of district nurse positions, as well as expand the functions of the Denver headquarters staff. Third, we believe that continuing education is essential to reinforce the new skills learned through any training program if a high quality of performance is to be maintained. Such a program would have to be available to all of the nursing staff at frequent intervals and contain subject matter relevant to our needs and functions. The most practical means of providing such a program therefore was felt to be through the use of our own medical staff on site. THE THEORY Articles dealing with continuing education of nurses first appeared in nursing periodicals in 1929 according to Cooper and Hornback J in their book entitled Continuing Nursing Education. They also comment that such training was obtained "frequently on the nu rse' s off-du ty ti me." Today, according to Elda Popiel in a text 4 edited by her on the subject, "The avenues for continuing education in nursing are many and varied. The organizations that offer continuing education to nursing personnel are even more prolific and seem to be growing each year." She goes on to describe some of the elements of a successful program as including '''stable financial and verbal support" and "thorough and sound assessment of the educational needs of the practicing nurse." I n addition, the successfu I program should provide "well planned and organized course content" leading to "knowledge increase, teaching of new skills or improving present skills, and attitudinal changes." Other elements include "willingness to experiment and use new and untried teaching methods" and "evaluation of program effectiveness." With these guidelines in mind let us examine our program. THE PROGRAM The Denver Mountain Bell Medical Department inservice program began in early 1973 under the direction of Doctor M.B. Bond and the authors who had been actively engaged in teaching medical students and hospital house staff members. Another Bell System medical department (New York Telephone Company) had previously reported its experience with a nurse clinician training proqram,' however, teaching was primarily provided in a formal university setting and inservice education was used in a supplemental way only. None of the nurses in our original physical assessment training group had participated in the University of Colorado practitioner program although they had been given some prior training in limited Occupational Health Nursing, July 1975
examination procedures. Emphasis was placed on teaching physical examination skills first, especially as related to preplacement evaluations. Methods used included individual and group demonstration of examination techniques, group lectures and a printed protocol to be used with the examination form. Each nurse was also provided with a copy of a physical diagnosis text as a reference to be used at her discretion. The ability to do a complete "solo" examination was determined for each nurse after multiple observations and a certain amount of individual variation in reaching an acceptable level of competence was noted. This appeared to be related primarily to the nurses' level of self-confidence rather than to age, prior training or other apparent motivating factors. Throughout the training and post-training period the policy of free access to department physicians for consu Itation has been rigorously adhered to and is felt to be a vital part of the learning process. The most difficult skill for all nurses in the program to learn was, of course, cardiac assessment. Special teaching techniques were used including the use of recordings 6 of the heart sound simulator devised by Abe Ravin, M.D. of the University of Colorado. Heart examinations were performed by both a nurse and physician for each patient long after the nursing staff was otherwise performing complete physical examinations independently. Eventually, all nurses developed a level of skill and confidence allowing them to satisfactorily differentiate between normal and possible or probable abnormal physical findings. Auditing of nurses' assessment skills has, of course, been an ongoing daily process, however, each nurse has periodically been specifically observed while performing a history review and complete physical examination of an applicant. In every instance, the Registered Nurse has been able to follow a wellorganized procedure adapted to her particu lar style and in no case were any major omissions or errors in technique uncovered. Further expansion into a continuing education program began in September 1973, aimed at formally increasing nursing skills in assessment and other areas including treatment of the ill or injured employee, the performance of certain fitness evaluations and counseling. Since that time, once-aweek, noon-hour presentations have been made, generally following a predetermined curriculum, (Figure 1). These major subject headings are further divided into as many sub-topics and as many sessions as required to cover the material. Each organ system is discussed from a functional standpoint beginning with anatomy and including pertinent aspects of physiology, pathology, laboratory procedures and principles of therapy. A collection of appropriate reference texts has been readily available for elective use, however. a core of required training materials is 11
AN INSERVICE CONTINUING EDUCATION AND EXPANDED ROLE PROGRAM FOR OCCUPATIONAL HEALTH NURSES
continued LECTURE SCHEDULE
History taking and medical records Skin Ear. nose and throat Cardiovascu lar system Gastroi ntesti na I system Genitourinary system Musculoskeletal system Neurologic system Hemotologic system Endocrine system Psychiatry I nfectious diseases Drug Abuse Traumatic Disorders - bites. burns, breaks. wounds, sprains, etc. Figure 1
now used consisting of a general physical diagnosis
text,' a book called Clinical Assessment for the Nurse Practitioner by Fowkes and Hunn 8 and a programmed study of anatomy and physiology by Dean, et aI.' In addition, all pre-lecture reading assignments are now made from an abbreviated, paperback textbook of medical diagnosis and treatment," The use of a standardized list of some reading materials, agreed upon by our nurses and physicians, has given needed uniformity and direction to the project in terms of what the nurse is expected to know. Lectures are prepared and delivered primarily by medical department physicians, the majority of whom are trained in internal medicine. One staff physician has had some training in psychiatry. The subject matter and depth of discussion is governed largely by the type of patient seen in our medical units, as well as by the specific function of an occupational health department. Guest lecturers have spoken occasionally and audio-visual aids are used when available and pertinent. Periodically a session is devoted to reviewing non-curricu lum SUbjects such as safety and benefit plans or administrative, legal and management matters. Because of its special impact on all phases of medical practice, psychiatry has been made an ongoing part of our continuing education program. Didactic teaching is provided by an attending psychiatrist on a monthly schedu Ie with case correlation when possible. Nurses and physicians alike are encouraged to present and discuss cases of interest to them or with which they have been involved. The foundation of good medical practice has always required a properly taken history and we have therefore placed great emphasis on history taking sk i lis and the use of the problem oriented record format of Doctor Lawrence L Weed. II Characterizing, quantitating and qualifying the chief complaint is a skill neglected in traditional nurse training and we 12
have therefore stressed the liberal use of descriptors when eliciting and recording complaints. Even though our medical practice is of an "episodic" type rather than total primary care we have found the S.O.A.P. (subjective, objective, assessment and plan) format for recording data promotes more meaningful and better organized notes by all staff members. A problem sheet is also placed in many employee records and provides a valuable timesaving index to these records; some of which contain over a decade of medical data and are in their second inch of thickness. Both the S.O.A.P. method and problem sheet provide a means for better measurement of performance by nurses and physicians alike and can identify areas needing more emphasis in our education program. Because of the remoteness of our district nurse offices we have attempted to create an audio network using conference calls and speaker phones to include these people in our continuing education programs. A similar system using a telelecture network 4 has been used successfully by the West Virginia School of Nursing to facilitate continuing nursing education in that state. I t is ou r hope to someday expand ou r network into a video system as well. THE RESULTS If our educational program for nurses is truly successful it should achieve some measurable objectives. There should be: an increase in knowledge with the ability to transfer knowledge, improved handling of patient/employee problems, enhanced feelings of personal satisfaction and, in our situation, the release of physicians for administrative and special consu Itative functions. We have not specifically tested for increased knowledge through the use of written tests before and after the educational process and admittedly our evidence for the success of the program is largely based on personal impression and clinical observation. There are many examples, however, of the expansion of our nursing staff role which lead us to believe that the program has achieved its objectives. Of major importance has been the replacement of physicians by nurses in the preplacement evaluation and screening of normal applicants. Skills in history taking, use of medical terminology and identification of abnormal physical findings has improved substantially. The nurse's ability and willingness to independently assess and manage certain illnesses and injuries based on prescribed guidelines has notably increased during the two years that the program has been in effect. We have also noted more participation by nurses in the continuing process of employee/patient counseling. The benefits of our program have been especially apparent in the district nurse units where a Company physician is not present most of the time. These
nurses are able to evaluate the ill and injured and make proper disposition with greater confidence and Company physicians can rely much more securely on telephone descriptions of physical findings in cases requiring a doctor's opinion. Our medical department has also been selected by the University of Colorado Adu It Health Nurse Practitioner Program and the Denver Metro College Nursing Program to provide clinical experience for some of their students. We have had a very positive response from them concerning our educational endeavors. Of no small benefit has been the opportunity for continuing education of physicians resu Iti ng from thei r preparation of lectu res and programs for the nursing staff. THE ANALYSIS What began two years ago as a simple effort to teach our nursing staff to do preplacement physical assessment has developed into a more comprehensive continuing education concept. Questions have occurred to us during the evaluation of this program concerning teaching-learning theory that we feel obligated to deal with especially if the program is to achieve its full potential. James Kuethe in his test, The Teaching-Learning Process 12 quotes a well known axiom among educators; "when there is no learning there is no teaching" and it behooves us to be sure that we are applying proven principles of teaching in our program. Learning can be defined as a change in performance resulting from experience and is influenced by multiple determinants. Among these are; motivation, interest, meaningfulness, reinforcement, feedback, transfer, competition, as well as other factors both environmental and behavioral. It is important for the teacher to avoid conditions which have a negative effect on learning such as frustration, boredom, fatigue or the establishing of unreachable goals. It is said that we learn best by seei ng and we remember the most by simultaneously saying and doing. Of the traditional teaching methods lecturing is probably the most commonly used and is primarily a listening experience for the student. This allows the teacher to present exactly what he wants the student to know but provides little opportunity for interaction between the two. The discussion format, however draws out the extrovert and self-confident but not the timid. Project assignments are time consuming and often impractical for our purposes. We have found through the use of simulated situations or "roleplaying" to work well in stimulating group participation and we do intend to use this technique more in the future. Finally, programmed instruction methods have had good acceptance by our nurses. This format seems well adapted to teaching medical topics and allows for individuals to progress at their own pace. A good Occupational Health Nursing, July 1975
example of this technique can be found in the current American Journal of Nursing series dealing with the eye 13 and other subjects. Undoubtedly the best parts of each of these teaching methods should be selected and used with the liberal addition of audiovisual aids when appropriate. THE FUTURE I n summary, physicians and nurses alike are faced today with a greater need than ever before for organized continuing medical education. Licensing boards, federal bureaus and other accrediting organizations are now or will be insisting on documentation of participation in such programs, as well as recertification of our competence to deliver health care. We in occupational medicine and nursing should be seriously and creatively looking at what the role of our medical departments will be in filling these needs. ACKNOWLEDGEM ENT We wish to thank Virginia Anderson, R.N., Corporate nurse supervisor, and Dorothy Burnell, R.N., Colorado nurse supervisor, as well as the entire staff of the Colorado-Wyoming medical department of Mountain Bell for their dedication and efforts which have made our program possible. REFERENCES 1. Runyan, J.W., Jr.: The Memphis Chronic Disease Program. JAMA, January 20, 1975, p. 264. 2. Bews, D.C.: "Extending the Role of the Occupational Health Nurse." Bell System Medical Conference, 1974. 3. Cooper, S.S. and Hornback, M.S.: Continuing Nursing Education. New York: McGraw-Hili, Inc., 1973, p. 261. 4. Popiel, M.S. (ed.): Nursing and the Process of Continuing Education. SI. Louis: C. V. Mosby Co., 1973, p. 515. 5. Plotz, C.M. et al.: The Training of the Nurse Clinician. Journal of Occupational Medicine, November 1971, p. 515. 6. Ravin, A.: Cardiac Auscultation, An Audio Presentation. University of Colorado School of Medicine. Merck Sharp and Dohme, 1968. 7. Judge, RD. and Zuidema, G.D. (eds.): Methods of Clinical Examination: A Physiologic Approach. Boston: Little, Brown and Company. 1974 (3rd ed.), p. 439. 8. Fowkes, C.W. and Hunn, V.K.: Clinical Assessment for the Nurse Practitioner. SI. Louis: C. V. Mosby Company, 1973,
p. 190. 9. Dean, W.B. et al.: Basic Concepts of Anatomy and Physiology. Philadelphia: J. B. Lippincott Company, 1966,
p. 346. 10. Krupp, M.A. and Chatton, M.J.: Current Medical Diagnosis and Treatment. Lange Medical Publications, 1975, p. 1044. 11. Weed, L.L.: Medical Records, Medical Education and Patient Care. Cleveland: Cleveland Press of Case Western Reserve University, 1969, p. 297. 12. Kuethe, J.L.: The Teaching-Learning Process. Chicago: Scott, Foresman and Company, 1968, p. 161. 13. Patient Assessment: Examination of the Eye. Part I. American Journal of Nursing, November 1974, p. 2039.
13
J.J. Appelbaum, M.D.
Dr. Amundsen is Colorado-Wyoming Medical Director, Mountain Bell, and Dr. Appelbaum is Corporate Medical Director, Mountain Bell. Dr. Appelbaum
THE NEED The requirement for nurses who can do more than direct patient traffic and record vital signs has become apparent to people in the health care professions today including those in occupational medicine. Coinciding with physicians recognizing their need to be relieved of many traditional steps in the practice of medicine is a restless movement among nurses to be more involved in functions formerly performed only by doctors. It has become more obvious also that increasing numbers of patients seeking and needing health care make it more and more difficu It to provide adequate care by traditional methods alone. There are many reports in the literature of expanded nurse programs. One of the best known and oldest examples in the United States of the successful use of nurses in disease management is the Memphis Chronic Disease Program conducted by the University of Tennessee College of Medicine. Doctor John Runyan in his most recent review of the Memphis experience I concludes that with proper special training, detailed protocols and physician support nurses can successfully participate even in the management of such serious chronic medical Presented by Dr. Amundsen at the Thirty- Third Annual Meeting of the American Association of Industrial Nurses, San Francisco, California, April 15-17, 1975. 10
problems as glycosuria, blood pressure elevation and digitalis regulation. THE CONCEPT The role of occupational medicine in the American health care system and the characteristic functions of a typical "company medical department" require expanded nursing skills lying somewhere between the traditional nurse concept and the modern nurse practitioner. In the latter category much training is directed towards an ongoing primary care relationship which is not ordinarily present in the occupational health setting. Our decision to develop an expanded role and inservice education program for our nursing staff was arrived at for the following reasons: First, in 1972 the Mountain Bell Medical Department decided to create a district nurse program. This was to consist of a number of single-nurse satellite medical units located in outlying areas intended to provide occupational health services for more employees than cou Id be served directly by a central headquarters department. Such a program had originally been developed by Doctor Don Bews in Bell Canada 20 years before and had proved to be quite successtul.' Such nurses, of course, require special training and skills in the performance of preplacement and fitness evaluations, and are actively involved in health education, counseling of employees, assessment of the ill and injured and emergency care.
Second, it was apparent that we wou Id not be able to upgrade the skills of enough nurses in a short enough period of time through the local university practitioner course, at the rate of two people per year, to fill the proposed number of district nurse positions, as well as expand the functions of the Denver headquarters staff. Third, we believe that continuing education is essential to reinforce the new skills learned through any training program if a high quality of performance is to be maintained. Such a program would have to be available to all of the nursing staff at frequent intervals and contain subject matter relevant to our needs and functions. The most practical means of providing such a program therefore was felt to be through the use of our own medical staff on site. THE THEORY Articles dealing with continuing education of nurses first appeared in nursing periodicals in 1929 according to Cooper and Hornback J in their book entitled Continuing Nursing Education. They also comment that such training was obtained "frequently on the nu rse' s off-du ty ti me." Today, according to Elda Popiel in a text 4 edited by her on the subject, "The avenues for continuing education in nursing are many and varied. The organizations that offer continuing education to nursing personnel are even more prolific and seem to be growing each year." She goes on to describe some of the elements of a successful program as including '''stable financial and verbal support" and "thorough and sound assessment of the educational needs of the practicing nurse." I n addition, the successfu I program should provide "well planned and organized course content" leading to "knowledge increase, teaching of new skills or improving present skills, and attitudinal changes." Other elements include "willingness to experiment and use new and untried teaching methods" and "evaluation of program effectiveness." With these guidelines in mind let us examine our program. THE PROGRAM The Denver Mountain Bell Medical Department inservice program began in early 1973 under the direction of Doctor M.B. Bond and the authors who had been actively engaged in teaching medical students and hospital house staff members. Another Bell System medical department (New York Telephone Company) had previously reported its experience with a nurse clinician training proqram,' however, teaching was primarily provided in a formal university setting and inservice education was used in a supplemental way only. None of the nurses in our original physical assessment training group had participated in the University of Colorado practitioner program although they had been given some prior training in limited Occupational Health Nursing, July 1975
examination procedures. Emphasis was placed on teaching physical examination skills first, especially as related to preplacement evaluations. Methods used included individual and group demonstration of examination techniques, group lectures and a printed protocol to be used with the examination form. Each nurse was also provided with a copy of a physical diagnosis text as a reference to be used at her discretion. The ability to do a complete "solo" examination was determined for each nurse after multiple observations and a certain amount of individual variation in reaching an acceptable level of competence was noted. This appeared to be related primarily to the nurses' level of self-confidence rather than to age, prior training or other apparent motivating factors. Throughout the training and post-training period the policy of free access to department physicians for consu Itation has been rigorously adhered to and is felt to be a vital part of the learning process. The most difficult skill for all nurses in the program to learn was, of course, cardiac assessment. Special teaching techniques were used including the use of recordings 6 of the heart sound simulator devised by Abe Ravin, M.D. of the University of Colorado. Heart examinations were performed by both a nurse and physician for each patient long after the nursing staff was otherwise performing complete physical examinations independently. Eventually, all nurses developed a level of skill and confidence allowing them to satisfactorily differentiate between normal and possible or probable abnormal physical findings. Auditing of nurses' assessment skills has, of course, been an ongoing daily process, however, each nurse has periodically been specifically observed while performing a history review and complete physical examination of an applicant. In every instance, the Registered Nurse has been able to follow a wellorganized procedure adapted to her particu lar style and in no case were any major omissions or errors in technique uncovered. Further expansion into a continuing education program began in September 1973, aimed at formally increasing nursing skills in assessment and other areas including treatment of the ill or injured employee, the performance of certain fitness evaluations and counseling. Since that time, once-aweek, noon-hour presentations have been made, generally following a predetermined curriculum, (Figure 1). These major subject headings are further divided into as many sub-topics and as many sessions as required to cover the material. Each organ system is discussed from a functional standpoint beginning with anatomy and including pertinent aspects of physiology, pathology, laboratory procedures and principles of therapy. A collection of appropriate reference texts has been readily available for elective use, however. a core of required training materials is 11
AN INSERVICE CONTINUING EDUCATION AND EXPANDED ROLE PROGRAM FOR OCCUPATIONAL HEALTH NURSES
continued LECTURE SCHEDULE
History taking and medical records Skin Ear. nose and throat Cardiovascu lar system Gastroi ntesti na I system Genitourinary system Musculoskeletal system Neurologic system Hemotologic system Endocrine system Psychiatry I nfectious diseases Drug Abuse Traumatic Disorders - bites. burns, breaks. wounds, sprains, etc. Figure 1
now used consisting of a general physical diagnosis
text,' a book called Clinical Assessment for the Nurse Practitioner by Fowkes and Hunn 8 and a programmed study of anatomy and physiology by Dean, et aI.' In addition, all pre-lecture reading assignments are now made from an abbreviated, paperback textbook of medical diagnosis and treatment," The use of a standardized list of some reading materials, agreed upon by our nurses and physicians, has given needed uniformity and direction to the project in terms of what the nurse is expected to know. Lectures are prepared and delivered primarily by medical department physicians, the majority of whom are trained in internal medicine. One staff physician has had some training in psychiatry. The subject matter and depth of discussion is governed largely by the type of patient seen in our medical units, as well as by the specific function of an occupational health department. Guest lecturers have spoken occasionally and audio-visual aids are used when available and pertinent. Periodically a session is devoted to reviewing non-curricu lum SUbjects such as safety and benefit plans or administrative, legal and management matters. Because of its special impact on all phases of medical practice, psychiatry has been made an ongoing part of our continuing education program. Didactic teaching is provided by an attending psychiatrist on a monthly schedu Ie with case correlation when possible. Nurses and physicians alike are encouraged to present and discuss cases of interest to them or with which they have been involved. The foundation of good medical practice has always required a properly taken history and we have therefore placed great emphasis on history taking sk i lis and the use of the problem oriented record format of Doctor Lawrence L Weed. II Characterizing, quantitating and qualifying the chief complaint is a skill neglected in traditional nurse training and we 12
have therefore stressed the liberal use of descriptors when eliciting and recording complaints. Even though our medical practice is of an "episodic" type rather than total primary care we have found the S.O.A.P. (subjective, objective, assessment and plan) format for recording data promotes more meaningful and better organized notes by all staff members. A problem sheet is also placed in many employee records and provides a valuable timesaving index to these records; some of which contain over a decade of medical data and are in their second inch of thickness. Both the S.O.A.P. method and problem sheet provide a means for better measurement of performance by nurses and physicians alike and can identify areas needing more emphasis in our education program. Because of the remoteness of our district nurse offices we have attempted to create an audio network using conference calls and speaker phones to include these people in our continuing education programs. A similar system using a telelecture network 4 has been used successfully by the West Virginia School of Nursing to facilitate continuing nursing education in that state. I t is ou r hope to someday expand ou r network into a video system as well. THE RESULTS If our educational program for nurses is truly successful it should achieve some measurable objectives. There should be: an increase in knowledge with the ability to transfer knowledge, improved handling of patient/employee problems, enhanced feelings of personal satisfaction and, in our situation, the release of physicians for administrative and special consu Itative functions. We have not specifically tested for increased knowledge through the use of written tests before and after the educational process and admittedly our evidence for the success of the program is largely based on personal impression and clinical observation. There are many examples, however, of the expansion of our nursing staff role which lead us to believe that the program has achieved its objectives. Of major importance has been the replacement of physicians by nurses in the preplacement evaluation and screening of normal applicants. Skills in history taking, use of medical terminology and identification of abnormal physical findings has improved substantially. The nurse's ability and willingness to independently assess and manage certain illnesses and injuries based on prescribed guidelines has notably increased during the two years that the program has been in effect. We have also noted more participation by nurses in the continuing process of employee/patient counseling. The benefits of our program have been especially apparent in the district nurse units where a Company physician is not present most of the time. These
nurses are able to evaluate the ill and injured and make proper disposition with greater confidence and Company physicians can rely much more securely on telephone descriptions of physical findings in cases requiring a doctor's opinion. Our medical department has also been selected by the University of Colorado Adu It Health Nurse Practitioner Program and the Denver Metro College Nursing Program to provide clinical experience for some of their students. We have had a very positive response from them concerning our educational endeavors. Of no small benefit has been the opportunity for continuing education of physicians resu Iti ng from thei r preparation of lectu res and programs for the nursing staff. THE ANALYSIS What began two years ago as a simple effort to teach our nursing staff to do preplacement physical assessment has developed into a more comprehensive continuing education concept. Questions have occurred to us during the evaluation of this program concerning teaching-learning theory that we feel obligated to deal with especially if the program is to achieve its full potential. James Kuethe in his test, The Teaching-Learning Process 12 quotes a well known axiom among educators; "when there is no learning there is no teaching" and it behooves us to be sure that we are applying proven principles of teaching in our program. Learning can be defined as a change in performance resulting from experience and is influenced by multiple determinants. Among these are; motivation, interest, meaningfulness, reinforcement, feedback, transfer, competition, as well as other factors both environmental and behavioral. It is important for the teacher to avoid conditions which have a negative effect on learning such as frustration, boredom, fatigue or the establishing of unreachable goals. It is said that we learn best by seei ng and we remember the most by simultaneously saying and doing. Of the traditional teaching methods lecturing is probably the most commonly used and is primarily a listening experience for the student. This allows the teacher to present exactly what he wants the student to know but provides little opportunity for interaction between the two. The discussion format, however draws out the extrovert and self-confident but not the timid. Project assignments are time consuming and often impractical for our purposes. We have found through the use of simulated situations or "roleplaying" to work well in stimulating group participation and we do intend to use this technique more in the future. Finally, programmed instruction methods have had good acceptance by our nurses. This format seems well adapted to teaching medical topics and allows for individuals to progress at their own pace. A good Occupational Health Nursing, July 1975
example of this technique can be found in the current American Journal of Nursing series dealing with the eye 13 and other subjects. Undoubtedly the best parts of each of these teaching methods should be selected and used with the liberal addition of audiovisual aids when appropriate. THE FUTURE I n summary, physicians and nurses alike are faced today with a greater need than ever before for organized continuing medical education. Licensing boards, federal bureaus and other accrediting organizations are now or will be insisting on documentation of participation in such programs, as well as recertification of our competence to deliver health care. We in occupational medicine and nursing should be seriously and creatively looking at what the role of our medical departments will be in filling these needs. ACKNOWLEDGEM ENT We wish to thank Virginia Anderson, R.N., Corporate nurse supervisor, and Dorothy Burnell, R.N., Colorado nurse supervisor, as well as the entire staff of the Colorado-Wyoming medical department of Mountain Bell for their dedication and efforts which have made our program possible. REFERENCES 1. Runyan, J.W., Jr.: The Memphis Chronic Disease Program. JAMA, January 20, 1975, p. 264. 2. Bews, D.C.: "Extending the Role of the Occupational Health Nurse." Bell System Medical Conference, 1974. 3. Cooper, S.S. and Hornback, M.S.: Continuing Nursing Education. New York: McGraw-Hili, Inc., 1973, p. 261. 4. Popiel, M.S. (ed.): Nursing and the Process of Continuing Education. SI. Louis: C. V. Mosby Co., 1973, p. 515. 5. Plotz, C.M. et al.: The Training of the Nurse Clinician. Journal of Occupational Medicine, November 1971, p. 515. 6. Ravin, A.: Cardiac Auscultation, An Audio Presentation. University of Colorado School of Medicine. Merck Sharp and Dohme, 1968. 7. Judge, RD. and Zuidema, G.D. (eds.): Methods of Clinical Examination: A Physiologic Approach. Boston: Little, Brown and Company. 1974 (3rd ed.), p. 439. 8. Fowkes, C.W. and Hunn, V.K.: Clinical Assessment for the Nurse Practitioner. SI. Louis: C. V. Mosby Company, 1973,
p. 190. 9. Dean, W.B. et al.: Basic Concepts of Anatomy and Physiology. Philadelphia: J. B. Lippincott Company, 1966,
p. 346. 10. Krupp, M.A. and Chatton, M.J.: Current Medical Diagnosis and Treatment. Lange Medical Publications, 1975, p. 1044. 11. Weed, L.L.: Medical Records, Medical Education and Patient Care. Cleveland: Cleveland Press of Case Western Reserve University, 1969, p. 297. 12. Kuethe, J.L.: The Teaching-Learning Process. Chicago: Scott, Foresman and Company, 1968, p. 161. 13. Patient Assessment: Examination of the Eye. Part I. American Journal of Nursing, November 1974, p. 2039.
13
