The American Association of Occupational Health Nurses, Inc. (AAOHN), the professional association for occupational and environmental health nurses (OHNs), establishes and promulgates standards for this nursing specialty based upon scope of practice.
Standards of occupational and environmental health nursing are developed by the profession to define and establish reasonable and customary standards of care. These authoritative statements describe the accountability of the practitioner and reflect the values and priorities of the profession.
AAOHN has identified eleven (11) professional practice standards that describe a competent level of performance with regard to the nursing process and professional roles of the OHN. Criteria developed for each standard are key indicators of competent practice and provide a basis for OHNs to evaluate their practice relative to the standards.
Standards are dynamic and evolve over time to reflect the changing scope of practice and the development of new knowledge. This document represents the current scope and knowledge base in occupational and environmental health nursing. Within these standards, the term client is an inclusive term including individual workers, workers’ families, worker populations, communities/environments, and employers.
The Standards of Practice, Code of Ethics (AAOHN Code of Ethics and Interpretive Statements, 2009), and Core Curriculum (Core Curriculum for Occupational and Environmental Health Nursing, 3rd Ed., 2006), provide the basis for scope of practice, knowledge, skill, and the legal and ethical framework in occupational and environmental health nursing practice.
Definition of Occupational and Environmental Health Nursing
Occupational and environmental health nursing is the specialty practice that focuses on preventive healthcare, health promotion, and health restoration within the context of a safe and healthy environment (retrieved from www.aaohn.org, December 7, 2011). It includes the prevention of adverse health effects from occupational and environmental hazards and health promotion in general. The practice provides and delivers occupational and environmental health and safety programs and services to clients. Occupational and environmental health nursing is a specialty. Nurses provide healthcare and make nursing decisions within the scope of practice determined by state law (Strasser, AAOHN Journal, January 2011; Beitz, AAOHN Journal, August 2010; Noel, AAOHN Journal, January 2010).
The foundation for occupational and environmental health nursing is research-based. Recognizing the legal context for occupational health and safety, this specialty practice derives its theoretical, conceptual, and factual framework from a multidisciplinary base including, but not limited to:
- nursing science;
- medical science;
- public health sciences such as epidemiology and environmental health;
- occupational health sciences such as toxicology, safety, industrial hygiene, and ergonomics;
- social and behavioral sciences; and
- business management and administration principles (Core Curriculum, 3rd Ed., 2006).
Guided by an ethical framework made explicit in the AAOHN Code of Ethics, OHNs motivate and enable clients to make informed decisions about healthcare concerns. Confidentiality of health information (AAOHN Position Statement on Confidentiality of Health Information, 2004) is essential and central to the practice. OHNs are advocates for client(s), fostering equitable and quality healthcare services and safe and healthy environments in which to work and live.
Scope of Practice
OHNs collaborate with workers, employers, members of the occupational health and safety team, and other professionals to:
- identify health and safety needs;
- prioritize interventions;
- develop and implement interventions and programs; and
- evaluate care and service delivery.
The nurse is the key to the coordination of a holistic, multidisciplinary approach to delivery of safe, quality, and comprehensive occupational and environmental health programs and services that include:
- clinical and primary care, including assessment, diagnosis, management, and documentation of occupational and non-occupational illness and injury;
- case management for occupational and non-occupational illnesses and injuries;
- health hazard assessment and surveillance of worker populations, workplaces, and community groups;
- investigation, monitoring, and analysis of illness and injury episodes and trends, as well as methods to promote and protect worker health and safety;
- compliance with laws, regulations, and standards governing health and safety for workers and the environment;
- management and administration of occupational and environmental health services;
- health promotion and disease prevention strategies using primary, secondary, and tertiary principles;
- counseling, health education, and training programs using adult learning approaches; and
- research related to occupational and environmental health.
Occupational and environmental health nursing practice is dynamic and recognizes socio-cultural, community, economic, political, technological, and ecological influences and the impact of policy issues. Consequently, OHNs must understand the legal parameters of practice and respond to legislative mandates that govern worker health and safety. OHNs are professionally accountable to the client(s) (Core Curriculum, 3rd Ed., 2006).
Standard I. Assessment
The OHN systematically assesses the health status of the client(s).
The client’s(s’) immediate status and needs determine the priority of data collection.
Subjective and objective data representing the broad spectrum of client needs is collected.
Information is obtained from the client, other healthcare professionals, other professionals, and the environment as indicated using appropriate data collection techniques.
The client’s(s’) values, preferences, expressed needs, and knowledge of the healthcare situation are obtained and honored as appropriate.
The data used in making an assessment provides a baseline for future comparative purposes.
Relevant data is documented in a retrievable form that maintains confidentiality.
Findings are appropriately communicated.
The assessment process synthesizes available information, data, and knowledge relevant to the situation to identify patterns and variances.
The data collection process is systematic and ongoing.
Additional criteria for the Advanced Practice Registered Nurse (APRN):
Diagnostic tests and procedures relevant to the client’s(s’) current status are ordered and interpreted.
Standard II. Diagnosis
The OHN analyzes assessment data to formulate diagnoses.
Diagnoses are derived from the assessment data.
Diagnoses are validated with the client and, when appropriate, with healthcare professionals and other professionals while maintaining confidentiality.
Diagnoses identify actual or potential risks.
Diagnoses guide and establish priorities for intervention.
Diagnoses are documented in a manner that facilitates the determination of expected outcomes, the plan of care, choice of interventions, and evaluation.
Additional criteria for the Advanced Practice Registered Nurse (APRN):
Clinical findings are systematically compared and contrasted with normal and abnormal variations and developmental events in formulating differential diagnoses.
The APRN utilizes complex data and information obtained during interview, examination, and diagnostic processes in identifying diagnoses.
Standard III. Outcome Identification
The OHN identifies outcomes specific to the client(s).
Expected outcomes are derived from the diagnoses.
Outcomes are formulated with the client(s), healthcare professionals, and other professionals as appropriate for continuity of care.
Outcomes are culturally appropriate, realistic, and attainable in relation to available resources.
Expected outcomes include a time estimate for attainment.
Outcomes are documented as measurable goals and objectives.
Expected outcomes are modified according to changes in the status.
Standard IV. Planning
The OHN develops a goal-directed plan that is comprehensive and formulates interventions to attain expected outcomes.
The plan is developed with the client(s), healthcare professionals, and other professionals as needed to foster cost-effective health outcomes.
The plan is based on current knowledge of scientific evidence and trends in nursing, medicine, public health, occupational health, social and behavioral sciences, environmental sciences, management and administration principles, and laws and regulations governing practice.
The plan reflects realistic and measurable goals and objectives to maximize functional capabilities of the client(s), provide for continuity of care, and foster compliance with government regulations.
The plan identifies strategies that emphasize self-care capabilities, health promotion, and disease and injury prevention.
The plan is documented using standardized language and terminology.
The OHN participates in the strategic and long-range planning for the client(s) related to health and safety.
The plan is modified according to the ongoing assessment.
Additional criteria for the Advanced Practice Registered Nurse (APRN):
The plan identifies assessment, diagnostic, and therapeutic interventions based on current evidence-based medicine and clinical knowledge.
The plan creates inter-professional processes to address the current diagnoses.
Standard V. Implementation
The OHN implements interventions to attain desired outcomes identified in the plan.
Interventions are consistent with the established plan.
Interventions are evidence-based and treatments are specific to the diagnoses or problem(s).
Interventions apply appropriate knowledge of health problems and diversity.
Interventions include health teaching and health promotion.
Interventions are implemented in a professional, safe, and timely manner with the understanding, consent, and participation of the client(s).
Community resources and systems are utilized as needed to implement the plan.
Interventions may be delegated when appropriate.
Implementation is documented to provide evidence of interventions, including any modifications to the original plan.
Standard VI. Evaluation
The OHN systematically and continuously evaluates responses to interventions and progress toward the achievement of desired outcomes.
Evaluation is guided by the results of nursing intervention, alterations in the client’s(s’) health status, and achievement of desired outcomes.
Evaluation includes measurement of immediate and long-term outcomes, quality of intervention, and cost/benefit analysis.
Evaluation requires access to information that allows for coordination of optimum care regarding the client’s(s’) health status.
Evaluation of nursing intervention is documented with respect to results, effectiveness, and potential for research.
Quality is maintained by correcting deficits identified through evaluation and continuous quality improvement.
Standard VII. Resource Management
The OHN secures and manages the resources that support occupational health and safety programs and services.
Decisions to secure resources are based on the client’s(s’) goals and objectives, identified health needs, health hazards, and associated costs.
The occupational health and safety programs and services are strategically aligned within the scope of the client’s(s’) needs.
Operational management of the occupational health and safety programs and services is provided, including formulation of policies and procedures.
The OHN participates in decision-making regarding operational and capital resources needed for cost-effective occupational health and safety programs and services.
Factors related to quality, cost, safety, and availability of resources are evaluated when choosing among alternative approaches to health service delivery.
Standard VIII. Professional Development
The OHN assumes accountability for professional development to enhance professional growth and maintain competency.
Individual performance is continually evaluated using professional practice standards and other quality improvement mechanisms to identify areas of strength as well as areas where professional development would be beneficial.
Constructive feedback and peer review is sought.
A plan of action is established to achieve competence in the areas identified during the evaluation process.
Self-competency is enhanced by maintaining and updating professional knowledge and skills.
Credentialing is achieved and maintained by participation in required activities.
Professional responsibility is demonstrated by participating in professional organizations and promoting the profession.
The OHN serves as a role model and mentor.
Standard IX. Collaboration
The OHN collaborates with clients for preventive health, health promotion, and restoration of health within the context of a safe and healthy environment.
Goals, plans, and decisions are formulated.
The OHN participates in health, safety, environmental, and management activities in solving problems, setting policy, and planning programs and services for clients.
Conflict management and engagement is promoted.
Standards and applicable codes of conduct that govern behavior among peers and colleagues are followed to create a work environment that promotes cooperation, respect, and trust.
The OHN engages in teamwork and team-building processes.
Additional criteria for the Advanced Practice Registered Nurse (APRN):
The APRN as a licensed independent practitioner participates as a team leader and/or member in providing health and medical care and interacting with professional colleagues in providing comprehensive care.
Standard X. Research
The OHN uses research findings in practice and contributes to the scientific base in occupational and environmental health nursing to improve practice and advance the profession.
Practice reflects the integration of currently validated research findings.
Research activities are participated in at levels appropriate to the individual’s education and experience, such as:
- identifying researchable problems;
- preparing proposals for support of research projects;
- participating in the data collection process;
- protecting the rights of research participants;
- critically reviewing and evaluating reported research;
- using research findings in the development of policies, procedures, and practice guidelines;
- sharing research findings and activities; and
- collaborating with other disciplines in the development of research studies and the dissemination of research findings.
Standard XI. Ethics
The OHN uses an ethical framework for decision-making in practice.
Practice is guided by the AAOHN Code of Ethics and Interpretive Statements (AAOHN Code of Ethics and Interpretive Statements, 2009).
Confidentiality of health information is maintained in accordance with professional codes, statutes, and regulations.
The rights of client(s) and the occupational and environmental health nurse are protected.
Care is delivered to client(s) that is respectful of self-determination, capabilities for self-care, and diverse personal attributes.
The OHN acts as an advocate to promote client’s(s’) self-determination and to preserve autonomy, dignity, and rights.
Resources to facilitate ethical decision-making and resolve ethical dilemmas are utilized.
Instances of illegal, inappropriate, or unethical behavior that can endanger or jeopardize the best interests of the client or situation are acted upon appropriately.
Case Management: Process of coordinating an individual client’s total healthcare services, following disease, illness, or injury, to achieve optimum quality care delivered in a cost-effective manner (AAOHN, 2004; Strasser, AAOHN Journal, May 2010; Gleason, AAOHN Journal, May 2009; Brown, AAOHN Journal, June 2009; Brown, Haag, and Kalina, AAOHN Journal, March 2009).
Client: Recipient of health and safety services. For the OHN this may include individual worker, workers’ families/significant others, worker populations, community groups, and employers (AAOHN, 2009; Lukes and Fioritto, AAOHN Journal, April, 2009).
Confidentiality: A legal responsibility and professional obligation to ensure public trust and prevent unauthorized and inappropriate disclosure of personal health information (PHI) that should be maintained in accordance with professional codes, laws, and regulations (AAOHN/CMSA, 2003). The protection of client confidentiality is a professional tenet emphatically endorsed by AAOHN (AAOHN, 2004).
Credentialing: A complex process intended to define levels of practice and associated knowledge, skills, abilities, and competencies (AAOHN Core Curriculum, 2006; Alleyne, AAOHN Journal, September 2009; Budde, AAOHN Journal, January 2009). Credentialing processes for OHNs include licensure and certification.
Criteria: Relevant, measurable indicators of the standards of practice and professional performance (ANA, 2010).
Diagnosis: Derived from assessment data to guide and establish priorities for choosing appropriate evaluations and interventions, developing plan of care, and facilitating the determination of expected outcomes (AAOHN, 2003).
Documentation: Written communication that care was provided and written communication of information that is the basis of the legal occupational health record (AAOHN Core Curriculum, 2006), as well as compliance with governmental recordkeeping requirements (Thompson, AAOHN Journal, December 2010).
Environment: Totality of surrounding conditions including physical, socio-cultural, organizational, economic, political, and interpersonal dimensions or properties that influence an individual or community (AAOHN Core Curriculum, 2006).
Environmental Health: Promotes health and quality of life by preventing or controlling those diseases or deaths that result from interactions between people and their environments (Beitz, AAOHN Journal, August 2010).
Hazard Analysis: Procedures used to assess workplace contaminants and associated worker exposures relating to probability of occurrence, severity of consequences, and vulnerability of workers; using planned strategies and foresight to ensure that the most productive and thorough evaluation of contaminants in the workplace is performed (OSHA, 2005; Tompkins, AAOHN Journal, April 2009).
Independent Nursing Actions: Guided by scope of professional standards of practice, ethical judgment, and occupational and environmental health nursing standards and competencies, nurses make independent decisions and actions to achieve desired client outcomes. These outcomes are based on diagnoses and achieved through interventions and/or strategies implemented by the nurse.
Levels of Prevention: Three levels of prevention have been conceptualized by Leavell and Clark, using principles of epidemiology (AAOHN Core Curriculum, 2006), which allows occupational healthcare providers to target prevention activities and provide better healthcare:Primary PreventionAimed at eliminating or reducing the risk of injury, illness, and/or exposure through specific actions, which includes immunizations, stress management, smoking avoidance, work site walk-through, and use of personal protective equipment.Secondary PreventionDirected at early case finding and diagnosis of injury, illness, and/or exposure to institute prompt intervention, i.e., screening programs, pre-placement and periodic examinations, and health surveillance (Fritsch, Montpellier, Kussman, AAOHN Journal, February 2009).Tertiary PreventionDirected at rehabilitation and restoration to maximum health potential, which includes disability case management, early return to work, and chronic illness monitoring (Salazar, 2001). Aimed at eliminating or reducing the risk of injury, illness, and/or exposure through specific actions, which includes immunizations, stress management, smoking avoidance, work site walk-through, and use of personal protective equipment. Directed at early case finding and diagnosis of injury, illness, and/or exposure to institute prompt intervention, i.e., screening programs, pre-placement and periodic examinations, and health surveillance (Fritsch, Montpellier, Kussman, AAOHN Journal, February 2009). Directed at rehabilitation and restoration to maximum health potential, which includes disability case management, early return to work, and chronic illness monitoring (Salazar, 2001).
Medical Screening: A method for detecting disease or body dysfunction before an individual would normally seek medical care. Screening tests are usually administered to individuals without current symptoms, but who may be at high risk for certain adverse health outcomes. (http://www.osha.gov/SLTC/medicalsurveillance/index.html#screening)
Medical Surveillance: The analysis of health information to look for problems that may be occurring in the workplace that require targeted prevention. (http://www.osha.gov/SLTC/medicalsurveillance/index.html#screening)
Occupational Health Surveillance: The process of monitoring or tracking the health status of worker populations to gather data on the effects of workplace exposures and using the data to prevent illness and injury (AAOHN, 2004; OSHA, 2004; NIOSH, 2010).
Occupational Injury or Illness: An event or exposure in the work environment that either caused or contributed to the resulting condition or significantly aggravated a pre-existing injury or illness (unless exception in 1904.5) (OSHA, 2001).
Plan: A comprehensive outline of clinical objectives, goals, and actions designed to meet the client’s needs and attain expected outcomes. The plan should be action-oriented and time-specific (Lukes, AAOHN Journal, January 2010).
Quality Improvement: An interdisciplinary process designed to raise the standards of the delivery of preventive, diagnostic, therapeutic, and rehabilitative measures in order to maintain, restore, or improve health outcomes of individuals and populations (IOM, 2006).
Resource: Information, personnel, funds, and equipment necessary to achieve desired outcomes or goals in occupational and environmental health services (Amann, AAOHN Journal, January 2003).
Strategic Planning: Set of organizational processes for identifying the desired future of the organization and developing decision guidelines and creating a map for how an organization will achieve its objectives and goals (Varkey, Bennett, PEJ, March–April 2010; Strasser, AAOHN Journal, 2002).