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Population Health for Nurses

29.1 Occupational Health

Population Health for Nurses29.1 Occupational Health

Learning Outcomes

By the end of this section, you should be able to:

  • 29.1.1 Describe the history of occupational health nursing.
  • 29.1.2 Examine competencies in occupational health nursing.
  • 29.1.3 Describe the scope of practice in occupational health nursing.
  • 29.1.4 Define the role of the Occupational Safety and Health Administration and the National Institute for Occupational Safety and Health.
  • 29.1.5 Differentiate between various occupational health risks to promote safety.
  • 29.1.6 Describe occupational health practice settings and nursing roles.
  • 29.1.7 Explain how to conduct an incident investigation to ensure continuous improvement in safety.

Occupational and environmental health nursing focuses on providing preventive health care, health promotion, and health restoration in work environments. With origins in public health, this specialty focuses on integrating occupational safety and health protection efforts with health promotion activities to protect workers, promote health, and prevent disease, illness, and injury (Topcu & Ardahan, 2019; American Board for Occupational Health Nurses [ABOHN], n.d.; Topcu & Ardahan, 2019). Occupational health nursing is research-based with a conceptual framework reflecting an interprofessional background of nursing science, medical science, public health science, occupational health science, social and behavioral sciences, and principles of business management and administration (American Association of Occupational Health Nursing [AAOHN], 2012). Occupational health nurses (OHNs) help clients make informed decisions regarding health care concerns, advocate for clients by fostering equitable and quality health care, and ensure the environments in which clients work and live are healthy (AAOHN, 2012).

In 2022, the U.S. workforce numbered approximately 160 million (U.S. Bureau of Labor Statistics [USBLS], 2023c). These numbers support the need for OHNs to ensure a safe and healthy work environment.

  • In 2021, private industry reported 2.6 million nonfatal workplace injuries and illnesses (USBLS, 2022b).
  • In 2021, private industry reported 5,190 fatal work injuries, an 8.9 percent increase from 2020 (USBLS, 2022a).
  • In 2021, transportation incidents were the largest cause of fatalities, accounting for almost 40 percent of all work-related fatalities (USBLS, 2022a).
  • Black workers bore a disproportionate burden of work-related deaths in 2021, accounting for 12.6 percent of total fatalities, a 20.7 percent increase from 2020 (USBLS, 2022a).
  • In 2022, more than 25 percent of Black worker fatalities resulted from violence and other injuries by people or animals (USBLS, 2022a).

History of Occupational Health Nursing

Occupational health nursing, first called industrial health nursing, arose in the United States in the late 1800s when companies in Pennsylvania and Vermont hired Betty Moulder and Ada Mayo Stewart, respectively, to care for their employees and families. Since little is known about Moulder, Stewart is often credited with being the first industrial nurse (Thompson & Wachs, 2012; Topcu & Ardahan, 2019). Stewart’s primary duties included health promotion, disease prevention, home visits, and maternity care.

The industrial health nursing profession continued to evolve with the second industrial revolution. Around the beginning of the twentieth century, factories employed OHNs to assist in stopping communicable disease spread—such as tuberculosis—and to prevent injuries to reduce costs (Thompson & Wachs, 2012). In addition to industrial settings, retail stores, hotels, and insurance companies also employed nurses who practiced from a preventive and public health perspective, frequently providing health and childcare education to the community and employee families. They were expected to care for workers injured on the job, assist physicians in company-provided clinical sites, and visit ill or injured workers in their homes (Thompson & Wachs, 2012). Industrial health nursing thrived during this period; the first book on the topic was published in 1919, and the American Industrial Nurses Association (AINA) was formed in 1942 to develop training for industrial nursing (Topcu & Ardahan, 2019).

More changes to this nursing specialty occurred in the latter half of the twentieth century. The Coal Mine Safety and Health Act of 1969 and the Occupational Safety and Health Act of 1970 contributed to the growth of industrial health nursing, driven by concerns for workers’ health and welfare, costs associated with injuries, and public health considerations. The Coal Mine Safety Act was passed in response to a 1968 underground coal mine explosion that killed 78 miners in West Virginia, becoming a turning point for reform after decades of mine fatalities and increasing awareness of lung disease related to working in the coal mines (U.S. Department of Labor [USDL], n.d.-c). This act was the most stringent health and safety law of its time. It required regular federal inspections of all coal mines and added health protections against lung disease (USDL, n.d.-c).

On the heels of this act, the Occupational Safety and Health Act of 1970 created two federal agencies, the National Institute for Occupational Safety and Health (NIOSH) and the Occupational Safety and Health Administration (OSHA) (Centers for Disease Control and Prevention [CDC], 2020b; USDL, n.d.-b). In 1971, AINA established a certification organization for industrial health nursing that later became known as the American Board for Occupational Health Nurses, founded officially in 1972, and is now the sole certification body for occupational health nursing. In 1977, AINA renamed itself the American Association of Occupational Health Nursing to reflect the growing diversity of workplaces and the roles of the occupational health nurse (Topcu & Ardahan, 2019). The AAOHN is the professional association for OHNs.

In 1988, OSHA hired its first nurse to provide consultation and support; in 1993, OSHA established a nursing office (Topcu & Ardahan, 2019). As discussed in the next section, OSHA has made progress in decreasing work-related injury and death by setting and enforcing standards for safe and healthy working conditions and providing training, outreach, and education (USDL, n.d.-b). In 1998, the AAOHN adopted environmental health as an essential component of occupational health nursing application; occupational health nursing became known as occupational and environmental health nursing. Environmental health focuses on the connections between people and their surrounding environments (American Public Health Association, n.d.). The AAOHN published the first standards of occupational and environmental health nursing in 1999, and they have been updated periodically, with the last update in 2019 (AAOHN, 2019; Topcu & Ardahan, 2019).

Competencies in Occupational and Environmental Health Nursing

The AAOHN provides four overarching categories and 22 competencies that define the foundation for scope and standard of practice, knowledge, and skills and a legal and ethical framework for this specialty (AAOHN, 2015). The four categories include:

  • Manage Total Worker Health® (TWH)
  • Adhere to professional nursing practice principles
  • Demonstrate an understanding of the business climate and its impact on a community’s health
  • Practice culturally appropriate and evidence-based nursing care within the scope of practice

Total Worker Health® (TWH) refers to policies, programs, and practices focused on work-related safety and protection, promoting illness and injury prevention endeavors to advance worker well-being (CDC, 2020b). The TWH approach builds on the idea of a hazard-free work environment and views where an individual works as a social determinant of health (SDOH). Wages, hours, workload, health benefits, and access to paid leave impact the overall well-being of workers, families, and communities. The long-term vision is to protect safety and health and to advance workers’ well-being by creating safer and healthier work (CDC, 2020b).

Workplace risk factors—such as sitting at a desk, performing shift work, or driving for long periods of time—can contribute to long-term health problems. There are work-related risk factors for obesity, sleep disorders, cardiovascular disease, and depression, among others (CDC, 2020b). The TWH approach aims to advance health and well-being by targeting work conditions.

OHNs work in various settings and roles where they may need additional competencies depending on the chosen industry. Focusing on identifying health hazards and implementing control measures to manage the risk of exposure are key roles and required competencies of the OHN. Identifying workers’ exposure to health hazards can be challenging as certain chemicals, vapors, and gases may be invisible without any obvious signs (USDL, 2016b). Table 29.1 lists common chemical, physical, biological, and ergonomic hazards in the occupational setting.

Chemical Hazards Physical Hazards Biological Hazards Ergonomic Hazards
  • Solvents
  • Adhesives
  • Toxic dusts
  • Paints
  • Substances in cleaning solutions
  • Diesel exhaust
  • Noise
  • Radiation
  • Heat
  • Electric and magnetic fields
  • Cold
  • Unsafe machinery and equipment
  • Transportation accidents
  • Fires or blasting
  • Infectious agents
  • Contaminated bodily fluids
  • Certain insects, spiders, scorpions
  • Venomous snakes
  • Heavy lifting
  • Repetitive motions
  • Vibration
Table 29.1 Common Workplace Hazards by Practice Setting

Workplace Ergonomics

Ergonomics refers to a set of practices in workplaces—such as adjustable desk heights and keyboards that more naturally fit the wrist’s contours—that increase worker efficiency and productivity while reducing injuries and discomfort (Mayo Clinic, 2023). The goal is to fit the workplace to the worker, as described in this video.

Watch the video, and then respond to the following questions.

  1. Why is ergonomics in the workplace such an important concept?
  2. What is the relationship between ergonomics and health?
  3. How can the occupational health nurse incorporate ergonomics principles into various workplace settings?

Scope of Practice in Occupational and Environmental Health Nursing

The AAOHN (2012) Scope of Practice for the OHN highlights the necessary collaboration among workers, employers, and members of the occupational health team and safety team and includes:

  • Identify health and safety needs.
  • Prioritize interventions.
  • Develop and implement interventions and programs.
  • Evaluate care and service delivery.
  • Provide comprehensive clinical and primary care, including assessment, diagnosis, management, and documentation of occupational and non-occupational illness and injury.
  • Provide comprehensive case management for occupational and non-occupational illnesses and injuries.
  • Provide holistic hazard assessment and surveillance of worker populations, workplaces, and community groups.
  • Investigate, monitor, and analyze illness and injury episodes, trends, and methods to promote and protect worker health and safety.
  • Comply with laws, regulations, and standards governing health and safety for workers and the environment.
  • Coordinate and provide management and administration of occupational and environmental health services.
  • Deliver health promotion and disease prevention strategies using primary, secondary, and tertiary principles.
  • Provide counseling, health education, and training programs using adult learning approaches.
  • Utilize and participate in research related to occupational and environmental health.

The scope of practice for OHNs is broad and will vary depending on the work site. Overarching concepts of community health, law, economy, politics, policy, and regulatory issues are evident within the scope of practice as OHNs are responsible for responding to legislative mandates governing worker health and safety.

AAOHN (2012) establishes standards of care for OHNs based on the scope of practice. Eleven professional practice standards describe a competent level of performance by the OHN (AAOHN, 2012).

Occupational Safety and Health Administration

In 1970, the Occupational Health and Safety Act created OSHA to develop and enforce standards of safety that employers must follow. A standard, also known as a regulation, is a requirement the agency uses to evaluate whether employers follow OSHA laws (USDL, n.d.-a). OSHA organizes the standards based on the following workplace sectors: general industry; construction; agriculture; and maritime (USDL, n.d.-a). The OSHA rulemaking process describes how the agency creates standards. OSHA also provides training, education, and assistance with implementing these standards (USDL, n.d.-a). OSHA educational topics include agriculture, construction, federal agencies, health care, maritime, oil and gas, and warehousing (USDL, n.d.-a).

The formation of OSHA stimulated the growth of occupational health nursing to help employers create safe and healthy work environments. Since the 1970s, the specialty has grown as OHNs can monitor workers’ health status, ensure employers meet OSHA standards, implement evidence-based interventions to prevent or mitigate adverse health effects from the work environment, and develop workplace prevention programs. OSHA describes OHNs as RNs who use specialized experience and education to recognize and prevent adverse health effects from hazardous exposures in the workplace (ABOHN, n.d.).

National Institute for Occupational Safety and Health

Part of the CDC, the NIOSH is the research agency tasked with studying worker safety and health (CDC, 2023k). NIOSH was established in collaboration with OSHA from the Occupational Safety and Health Act of 1970. While OSHA creates and enforces safety standards in the workplace, NIOSH conducts research and makes recommendations for the prevention of occupational illness and injury (CDC, 2023k). NIOSH provides evidence for many of the standards that OSHA enforces. It covers workplace safety and health topics, such as hazards and exposures, chemicals, Total Worker Health®, industries and occupations, diseases and injuries, safety and prevention, and emergency preparedness and response (CDC, 2023k).

Occupational Health Nursing Practice Settings

OHNs practice in a wide variety of sites. Wherever there are employees, there may be OHNs working with employers to design health and safety programs. OHNs use an interprofessional approach to advocate for employee rights to health and safety programs. They assist employers by decreasing work-related injuries, absenteeism, and disability claims and by ensuring compliance with local, state, and federal laws and regulations on workplace health and safety. Depending on the employment site, OHNs build expertise by incorporating knowledge of chemical hazards, biological hazards, ergonomic considerations, industrial safety issues, disease management, and business management concepts. Figure 29.2 lists the most common industries that employ certified OHNs. Hospitals, medical centers, and manufacturing are the most cited work settings for certified OHNs. Within manufacturing and production, OHNs may work in textiles, oil refining, machinery, the metal industry, rubber, and plastics (ABOHN, 2018). Other smaller industries where OHNs have an impact are food production, retail trade, amusement and recreational services, construction, communications, biotechnology, agriculture, forestry, fishing, and consulting.

A pie graph shows settings where occupational health nurses work: 37% manufacturing and production; 34% hospital or medical center; 10% government; 2% utility service; 2% academia; and 2% work in finance, real estate, or insurance. The remaining 13% work in other settings.
Figure 29.2 According to the ABOHN 2018 Practice Analysis, more than two-thirds of certified OHNs work in manufacturing and production or hospital or medical center settings. (data source: American Board for Occupational Health Nurses, Inc., 2018; attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Occupational Health Nursing Practice Roles

Many OHNs enter the field with a baccalaureate degree in nursing and experience in community health or ambulatory care. Many pursue master’s degrees in public health, business, or advanced practice nursing to further develop their professional competencies. Certification in occupational health nursing is recommended but not required. OHNs combine knowledge of health and business to provide a safe and healthy work environment while maintaining fiscal responsibility to the employer (AAOHN, n.d.). The roles and responsibilities of OHNs include:

  • Case management
  • Counseling and crisis intervention
  • Health promotion and risk reduction
  • Legal and regulatory compliance
  • Worker and workplace hazard detection

Clinician

The OHN is a skilled nurse clinician primarily responsible for preventing work-related health problems and restoring health after an injury or illness. The OHN assesses workplace hazards, monitors the workers and workplace for potential issues or patterns of illness or injury, and investigates illness or injury. Fundamental to the practice, OHNs usually take an occupational health history of every worker for information on work history, on potential occupational exposures, and on the worker’s current health status. The OHN can provide appropriate education and preventive steps during these assessments to eliminate or reduce potential adverse exposures.

Assessing workplace hazards is another foundational role of the OHN. This may take the form of a workplace walk-through to understand workflow, job requirements, materials utilized, presence of hazards, and employee work practices. A complete workplace survey enables the OHN to compile information about factors that support or impede employee health. It includes looking at building plans, exits and entrances, availability of emergency equipment, alarm and detection devices, and personal protective equipment (CDC, 2015; USDL, 2016b). The box below provides information on performing a workplace safety hazard evaluation (USDL, 2016b, pp. 13–15).

Workplace Safety Hazard Evaluation

  • Regularly inspect all operations, equipment, work areas, and facilities. Include workers on the inspection walk-through.
  • Document the inspections and be sure to verify any hazardous conditions that are found are corrected. Take photos or videos of problem areas to facilitate later discussion and brainstorming about controlling them.
  • Include all areas and activities in these inspections, such as storage and warehousing, facility and equipment maintenance, purchasing and office functions, and the activities of on-site contractors, subcontractors, and temporary employees.
  • Regularly inspect occupational vehicles such as forklifts, trucks, cars, etc.
  • Use checklists that highlight typical hazards, such as:
    • General housekeeping
    • Slip, trip, and fall hazards
    • Electrical hazards
    • Equipment operation
    • Equipment maintenance
    • Fire protection
    • Work organization and process flow
    • Work practices
    • Workplace violence
    • Ergonomic problems
    • Lack of emergency procedures

(See USDL, 2016.)

After a work-related injury or illness, the OHN should complete an initial physical assessment and provide care and treatment of any injuries per agency protocol. Treatment may include first aid measures followed by referrals depending on the severity of the injury or illness. For legal and ethical reasons, proper documentation of occupational-related injuries is necessary. OSHA must be notified within 8 hours of a work-related fatality and within 24 hours of serious injury such as an amputation, loss of an eye, or inpatient hospitalization (USDL, 2016). Reported incidents and concerns indicate to OHN that occupational hazards exist. The OHN should have a plan and procedure for conducting incident investigations that covers who will be involved, how information will be communicated, materials or supplies needed, and reporting forms to be used. An investigation aims to identify the cause or causes of the incident or the concern to prevent further injury or illness (USDL, 2016b). A root cause analysis (RCA) is used to identify, evaluate, and correct the origins of accidents (USDL, 2016a). The box below provides more information on conducting an incident investigation and RCA.

Conducting an Incident Investigation and Root Cause Analysis

  • Begin the investigation immediately when an incident occurs.
  • Conduct investigations with a trained team that includes management and workers’ representatives.
  • Investigate close calls/near misses.
  • Ask several questions to identify all factors involved in order to determine how the incident could have been prevented.
  • Identify and analyze root causes to address underlying program shortcomings that allowed the incidents to happen. The five steps in an RCA include (USDL, 2016a):
    • The Five Whys. In response to each explanation of how an incident occurred, ask between two and five why questions.
    • Build a detailed timeline around the event and analyze it.
    • Perform a change analysis, looking at all the changes in the organization that preceded the change in safety or the event, and try to define the relationship between possible causes and effects.
    • Use a cause-and-effect diagram, known as a fishbone diagram or an Ishikawa diagram, to brainstorm, categorize, and map all possible causes.
    • Avoid focusing on a single cause; identify and address all root causes for an incident.
  • Communicate the results of the investigation to managers, supervisors, and workers to prevent recurrence.

(See USDL, 2016b.)

Case Manager

OHN case managers coordinate and manage the comprehensive health care services of ill or injured workers (Figure 29.3) to provide or ensure cost-effective, quality care that facilitates a safe and timely return-to-work with cost savings (ABOHN, 2021). This can involve managing issues related to health insurance, workers’ compensation, and federal regulations such as the Family Medical Leave Act (FMLA). OHN case managers integrate the nursing process into their care while coordinating other necessary services. The case manager follows the worker after any incident, beginning immediately after the onset and continuing through the return-to-work phase. Case management includes mobilizing necessary resources during an injury or illness, developing preventive systems, and delivering care aligned to return the worker to pre-injury function if possible (ABOHN, 2021).

Counselor/Consultant

OHNs act as counselors or consultants to prevent work-related health problems. OHNs develop, implement, and evaluate occupational health and safety services within organizations and the community. OHNs investigate all potential material and chemical exposures that could result in adverse health outcomes in workers. Workers have a legal right to know the substances they may be exposed to at work and can request this information from the OHN. The OHN should use safety data sheets (SDS), which provide information from the manufacturers of chemicals or materials, when designing preventive educational materials on potential exposures. OHNs counsel workers about work-related illnesses, injuries, and wellness and health promotion concerns.

A nurse sticks a needle into the upper arm area of a person sitting in a chair.
Figure 29.3 An OHN administers an influenza immunization to a city employee during a flu shot clinic, highlighting health promotion efforts to keep workers healthy. (credit: “Duggan at Speed Bump- Flu Shot N-Conf.-2111” by City of Detroit/Flickr, Public Domain)

Educator

OHNs are educators in all their roles in occupational and environmental health. The OHN participates in developing and implementing health promotion programs that support business objectives while promoting wellness and injury prevention. Health promotion objectives include creating environments that provide work-life balance for workers and prevention programs related to potentially hazardous exposures in the workplace. Health promotion programs require the OHN to effectively teach and motivate workers on a topic. Common topics include hearing protection, eye protection, nutrition, exercise, and smoking cessation. See Health Promotion and Disease Prevention Strategies for health promotion models that could be used in the occupational health setting.

Administrator/Corporate Director

OHNs often participate in the development, management, and evaluation of the health and safety program of the organization. This requires the OHN to act in a leadership role as an administrator or corporate director. To maintain compliance with legal and regulatory requirements, organizations need written policies and procedures, and it often falls on the OHN administrator to ensure these policies are up-to-date and in full compliance with the law. Businesses must maintain compliance with OSHA standards, and this requires the OHN administrator to give the USDL data on occupational injuries, illnesses, and deaths. OSHA distributes the record-keeping forms, and the OHN administrator completes them throughout the year, submitting them to OSHA at the year-end. In addition, the OHN administrator works on compliance with other laws and regulations, such as FMLA and tracking workers who use it.

If the OHN administrator or director would like to increase the occupational health services offered to the workers or increase the availability of personal protective equipment (PPE) based on a recent incident or RCA, the administrator is expected to write up a proposal justifying the expanded services or increased PPE request. This often requires documentation of surveillance and monitoring efforts along with audits of safety conditions in the workplace. Employers must keep health records on all workers separate from their other employment records, and the OHN administrator is often the person involved in maintaining these records and adhering to strict privacy requirements. The OHN administrator also often oversees a workers’ compensation claim on behalf of the employee to ensure the worker receives appropriate benefits.

Researcher

OHNs can be researchers, identifying, analyzing, measuring, and evaluating the effects of workplace exposures and hazards for workers and community members. They can use the data they gather to implement appropriate preventive and control measures. OHNs use the data they gather on worker surveillance to identify patterns, trends, changes, and concerning issues. Utilizing this information and the identified trends, the OHN can then create targeted interventions to address the issue. Just as the NIOSH participates in occupational health-related research to arm OSHA with evidence for its standards, OHNs act as the epidemiologist or event investigator to recommend evidence-based changes to the employer to avoid future illness or injury.

The National Occupational Research Agenda (NORA) is a program to stimulate innovative occupational health research and improve workplace practices. Established in 1996, NORA has grown to cover 10 industry sectors—such as construction and manufacturing—and seven health and safety cross-sectors—such as hearing loss prevention and respiratory health—that are organized according to major health and safety issues affecting U.S. workers (CDC, 2022i). Each sector and cross-sector council develops a national agenda for improvements in occupational health and safety. NORA provides a research framework for the NIOSH as diverse groups, OHNs included, collaborate to identify the most pressing health and safety issues in the workplace. The number of workers at risk for a particular injury or illness, the severity of the hazard or issue, and the probability that new information can make a difference all inform NORA’s priority-setting process (CDC, 2022i).

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