Chapter 3

Expanding fields of community and public health nursing practice

Learning Objectives:

1. Describe Public Health as a field of practice;

2. Enumerate the standards of Public Health practice;

3. Discuss the nature and scope of Occupational Health Nursing;

4. Explain the value of School Health Nursing for both students and personnel;

and

5. Identify emerging fields of community and public health nursing.

Public health nursing

The terms community health nursing and public health nursing are often used

synonymously or interchangeably but their meanings continue to evolve. In past

debates and discussions, definitions of "community health nursing and "public health

nursing" have indicated similar yet distinctive ideologies, visions, or philosophies of

nursing. Public health nursing has frequently been described as the synthesis of

public health and nursing practice. Freeman (1963) provided a classic definition of

public health nursing:

Public health nursing may be defined as a field of professional practice in nursing and

in public health in which technical nursing interpersonal, analytical, and organizational

affect the community. These skills are applied in concert with those of other persons

engaged in health care, through comprehensive nursing care of families and other
groups and through measures for evaluation or control of threats to health, for health

education of the public, and for mobilization of the public for health action.

It was seen as a subspecialty nursing practice generally delivered within "official" or

governmental agencies. In contrast, "community health nursing" was considered to be a

broader and more general specialty area that encompassed many additional

subspecialties (e g. school nursing, occupational health nursing, forensic nursing, home

health).

In 1980, the American Nurses Association (ANA) defined community health nursing as

"the synthesis of nursing practice and public health practice applied to promoting and

preserving the health of populations"

The ANA (2013) has revised the standards of practice for this specialty area. In the

updated standards, the designation was again "public health nursing," and the ANA

used the definition presented by the American Public Health Association (APHA)

Committee on Public Health Nursing (1996). Thus, public health nursing is defined as

"the practice of promoting and protecting the health of populations using knowledge

from nursing, social, and public health sciences.

STANDARDS OF PUBLIC HEALTH NURSING PRACTICE

Standards 1. Assessment

The public health nurse collects comprehensive data pertinent to the health status of
population.

Standard 2. Population Diagnosis and Priorities

The health nurse analyses the assessment data to determine the population diagnoses

and

priorities.

Standard 3. Outcomes Identification

The public health nurse identifies expected outcomes for a plan that is based on

population diagnoses and priorities.

Standard 4. Planning

The public health nurse develops a plan that reflects best practices by identifying

strategies, action plans and alternatives to attain expected outcomes.

Standard 5. Implementation

The public health nurse implements the identified plan by partnering with others.

Standard 5 A. Coordination

The public health nurse coordinates programs, services, and other activities to

implement the identified plan.

Standard 5B. Health Education and Health Promotion

The public health nurse employs multiple strategies to promote health, prevent

disease, and ensure a safe environment for populations.

Standard 5C Consultation

The public health nurse provides consultation to various community groups and

officials to facilitate the implementation of [programs and services

Standard 5D. Regulatory Activities

The public health nurse identifies, interprets, and implements public health laws,

regulations, and policies.

Standard 6 Evaluation

The public health nurse evaluates the health status of the population.

Occupational Health Nursing

the role of the occupational health nurse in workplace health management, a new and

exciting concept that is designed to improve the management of health and health

related problems in the workplace (1). Specialist occupational health nurses can play a

major role in protecting and improving the health of the working population in Europe as

part of this strategy. Occupational health nurses can also make a major contribution to

the sustainable development, improved competitiveness, job security and increased

profitability in enterprises and communities by addressing those factors which are

related to the
health of the working population. By helping to reduce ill health occupational health

nurses can contribute to the increased profitability and performance of organizations

and reduce health care costs. Occupational health nurses can also help to reduce the

externalization of costs onto the taxpayer, by preventing disability and social exclusion,

and by improving rehabilitation services at work. By protecting and promoting the health

of the working population, and by promoting social inclusion, occupational health nurses

can also make a significant contribution towards building social capital,

Evolution of occupational health nursing in the Philippines

Occupational health nursing in the Philippines traces its roots to Mrs. Magdalena

Valenzuela of the Department of Health (DOH). She instituted the Industrial Nursing

Unit (INU) of the Philippine Nurses Association (PNA) on November Il, 1950. Ms. Peria

Gorres of the Philippine Manufacturing Company (PMG,) served as the first

chairperson. On August 19, 1964, Ms. Anita Santos of Jardine Davies was elected as

first president. She organized several continuing education programs and strived for the

passing of the constitution and by-laws governing the association, which was approved

on November 12, 1966. It paved way to the modification in name of the organization to

Occupational Health Nurses Association of the Philippines (OHNAP), On June 5-6,

1970 the first annual convention was held. In 1978, the constitution registered with the

Securities and Exchange Commission on September 25, 1979. As a result of the

amendments, an article in the bylaws was created to organize a Specialty Board for

Certified Occupational Health Nurses title to be conferred to its qualified affiliates.

Occupational health strategies: assessment and control of hazards in the workplace

The way by which the occupational health team could classify occupational health

concerns in the workplace is to identify (1) health hazards and (2) safety hazards.

Health hazards are the elements in the work environment that can cause work-related

disease to the worker. Safety hazards are the unsafe conditions or unsafe acts that

significantly increase the risk of worker to be injured. The occupational health team

begins with risk anticipation and assessment by creating a job-safety analysis. This

could be done through reviews of records, process and equipment reviews, chemical

inventories, interviews, focused group discussions, surveys, observation, and walk-

through methods. In this process, the hazards present, those who are exposed, and the

degree of individual exposures are identified, the occupational health team may

categorize identified health hazards in the workplace as follows:

1. Administrative control refers to the development and implementation of policies,

standards, trainings, job design, and the like. For example, a workplace where a

substantial level of noise is involved may need to implement job rotation policies to be

able to assure that no worker is exposed to the threshold limit (i.e., 85 decibels per 8-

hour shift) in any given work day.

2. Engineering refers to the adaptation of physical, chemical, or technological

improvements to limit the exposure of workers to hazards of the workplace. Noise-

emitting machines can be isolated with sound-proof walls, and dangerous tough

materials. Toxic chemicals could be substituted with alternatives, and their handling

could be automated as well.

3. Material provision refers to providing the workers with supplies or supplements

that can decrease their exposure or susceptibility to occupational hazards (see Table

3.3). Personal protective equipment (PPE), immunization, and vitamin

4. Supplementation are some examples of these. Health care and laboratory

workers could be provided with masks, eye shields. And

1. Occupational and environmental health nurses provide health care in the work

environment with regard for human dignity and client rights, unrestricted by

considerations of social or economic status, personal attributes or the nature of the

health status. The profession of occupational and environmental

health nursing is dedicated to the promotion, protection and preservation of the life and

health of every client.

Occupational and environmental health nurses render non-prejudicial and

nondiscriminatory care to clients. Within the specialty of occupational and environmental

health nursing, clients may be defined as the employee, the employer and the

community. Therefore, the occupational and environmental health nurse has a unique

role in protecting the integrity of the workplace and the work environment.

Occupational and environmental health nurses have an obligation to treat clients fairly,

respecting their dignity and worth. While recognizing the existence of a vast diversity of

cultural beliefs and values in society, occupational and environmental health nurses
demonstrate respect for these beliefs and values inherent in their clients and

themselves and plan health care services for and with that client accordingly.

Occupational and environmental health nurses respect their clients' rights to autonomy.

Clients are

encouraged to participate in planning their own preventive and restorative health care,

and occupational and environmental health nurses are truthful in providing clients with

necessary information to make an informed judgment. While respecting their clients'

interests and well-being, nurses examine the short term and long term outcomes of the

decision-making process. As client advocates, occupational and environmental health

nurses have the responsibility to be knowledgeable about their clients' rights. These

rights include acceptance or refusal of care and are acknowledged by professional

nurses.

When personal convictions of occupational and environmental health nurses prohibit

participation in providing health services or when clients refuse care, the nurses may

not be exempt from protecting their clients' health and safety. Occupational and

environmental health nurses avoid abandonment and refer clients to available,

alternative sources of care.

2. Occupational and environmental health nurses promote interdisciplinary collaboration

with other professionals and community agencies to meet the health needs of the client.

Occupational and environmental health nurses are members of the occupational and

environmental health and safety team. Occupational and environmental health nurses
function both interdependently and independently in promoting the welfare of clients.

Interdependent practice requires an interdisciplinary approach to nursing practice,

allowing the occupational and environmental health nurse to work with members of

other health and safety professions in the provision of care. Providing health services to

clients requires a commitment to collaborative planning with other health professionals

and

members of the occupational and environmental health team within the organization.

Collaboration in the broader health perspective takes place as occupational and

environmental health nurses make referrals to appropriate community resources and

seek assistance and expertise from other recognized health professionals in the

provision of services. Occupational and environmental health nurses function within the

scope of nursing practice and delegate responsibility to members

of the health and safety team as necessary. Occupational and environmental health

nurses have an obligation to promote adequate distribution of health care and nursing

resources to meet clients' needs. Occupational and environmental health nurses are

responsible to management as employees. As professionals, occupational and

environmental health nurses recognize situations in which the

interests of management and workers may conflict.

As professionals, occupational and environmental

health nurses have a responsibility to observe professional codes and uphold practice

standards. Occupational and environmental health nurses demonstrate fairness in

conflict resolution. The promotion of health and safety and prevention of injury and
illness at the worksite require occupational and environmental health nursing

representation and participation in the decision-making process within institutional and

political arenas. Occupational and environmental health nurses are encouraged to

become and remain participant in decision-making processes that define or pertain to

occupational and environmental health nursing functions or activities.

3. Occupational and environmental health nurses strive to safeguard employees' rights

to privacy by protecting confidential information and releasing information only upon

written consent of the employee or as required or permitted by law.

Occupational and environmental health nurses have an obligation to maintain the trust

bestowed upon them by clients and to protect their clients' rights to privacy. Public trust

is ensured by maintaining the confidentiality of health information through prevention of

unauthorized access. Occupational and environmental health nurses act with intent to

safeguard the employees' rights. Written policies and procedures should guide the

access, release, transmittal and storage of health information, including

computerized records.

Occupational and environmental health nurses are encouraged to use current

professional literature and

resources for guidance. Occupational and environmental health nurses are

knowledgeable about and adhere to the organizational, local, state, federal and

international laws, regulations, guidelines and policies governing access to confidential

information. Employees are then protected from unauthorized and indiscriminate access
and disclosure of health and personal information. Confidentiality is crucial to the

effectiveness of the occupational and environmental health program.

4. Occupational and environmental health nurses, through the provision of care, strive

to safeguard clients from unethical and illegal actions.

Occupational and environmental health nurses are dedicated to providing quality,

competent and professional services to their clients. Occupational and environmental

health nurses are representatives of the profession and demonstrate competent, ethical

and professional conduct and accountability. The profession's primary commitment is to

the health, safety and welfare of clients. Occupational and environmental health nurses

strive to protect their clients and the profession from incompetent professionals and

individuals who misrepresent themselves and the profession. Any individual or

individuals who exhibit incompetence or engage in unethical or illegal activities should

be reported to licensing, accrediting or certifying authorities, as may be appropriate.

Occupational and environmental health nurses should participate in the development of

policies to promote competent, ethical and legal nursing practice. Occupational and

environmental health nurses have a commitment to comply with the laws and

regulations that govern the workplace in an effort to provide workers with a safe and

healthful workplace.

5. Occupational and environmental health nurses, licensed to provide health care

services, accept obligations to society as professional and responsible members of the

community. As licensed health care professionals, occupational and environmental

health nurses have an obligation to their clients, employers, communities, society and

profession to demonstrate credibility and competence. Occupational and environmental

health nurses are responsible citizens in the community adhering to all laws and

statutes including those governing occupational and environmental health practice. As

professionals, occupational and environmental health nurses respect their clients' and

society's rights to know and to receive factual information about potential and actual job

and environmental hazards. Occupational and environmental health nurses are

knowledgeable of community issues and dilemmas affecting health, safety and the

welfare of society and participate in appropriate resolution when able.

6. Occupational and environmental health nurses maintain individual competence in

nursing practice, based on scientific knowledge, and recognize and accept responsibility

for individual judgments and actions, while complying with appropriate laws and

regulations that impact the del/very of occupational and environmental health services.

Occupational and environmental health nursing is dedicated to promoting competent

professional practice.

Occupational and environmental health nurses have the responsibility to strive for

excellence and maintain a level of knowledge, judgment, technical skills and

professional values necessary for delivering health services. Individual professional

licensure provides for protection of the public to ensure that basic professional

competencies have been achieved. Occupational and environmental health nurses

utilize professional and educational activities to improve professional practice.

Occupational and environmental health nurses may engage in professional, educational

and quality improvement activities, such as peer review. Occupational and

environmental health nurses acknowledge the importance of continued and advanced

educational activities beyond the basic level of nursing education.

As professionals, occupational and environmental health nurses have a personal and

professional responsibility to maintain competence in practice. All occupational and

environmental health nurses are professionally and morally accountable for their actions

and compliance with nurse practice acts, standards of practice and other laws and

regulations governing occupational health practice. In a situation where occupational

and environmental health nurses do not have the necessary skills or knowledge or are

unable to render services personally, the nurses have a moral responsibility to refer

the client to appropriate services.

7. Occupational and environmental health nurses participate in activities that contribute

to the ongoing development of the profession's body of knowledge while protecting the

rights of clients.

Research is an integral part of occupational and environmental health nursing practice,

and may be undertaken as part of a formal research study or as worksite(s)-specific

research. Research provides new information to improve and validate the tenets

underlying the profession's scope of practice. This validation can be accomplished by

designing studies, testing theories to guide nursing practice, utilizing and applying

research findings or participating in the research process. Occupational and

environmental health nursing, as an applied discipline, engages in scholarly inquiry to

build upon the body of knowledge that serves as the foundation for practice.
Occupational and environmental health nurses must strive to create and expand this

body of knowledge, both empirically and theoretically, through research activities.

Research activities are usually approved by appropriate bodies, such as institutional

review boards. Occupational and environmental health nurse researchers

should respect and protect the autonomy, rights and privacy of the subjects. One

mechanism to ensure this respect and protect subjects is by voluntary informed

consent. Occupational and environmental health nurses have moral obligations to self,

their clients, the profession and society to conduct sound ethical research. Occupational

and environmental health nurses have the responsibility to communicate and

disseminate research findings to other occupational and environmental health nurses

and professionals and to appropriately utilize research findings within their practice.

Occupational and environmental health nurses also contribute to the growth of the

profession's body of

knowledge through development, implementation and evaluation of new programs

within the practice of occupational and health nursing, and the publication of their work

and results for other professionals.

School health nursing

School-aged children and adolescents face increasingly difficult challenges related to

health. Many of today's health challenges are different from those of the past and

include behaviors and risks linked to the majority of the leading causes of death, such

as heart disease, injuries, and cancer. The use of tobacco, alcohol, and drugs; poor

nutritional habits; inadequate phvsical activity; irresponsible sexual behavior; violence;

suicide; and reckless driving are examples of behaviors that often begin during youth

and increase the risk for serious health problems.

Education and health are interrelated. As earlv as 1950, the World Health Organization

(WHO) Expert Committee on School Health Services noted that, "to learn effectively,

children need good health." Studies have shown that nutritional deficiencies and poor

health in school-aged children are among the most common causes of low school

enrolment, absenteeism, poor school performance, and early dropout. On the other

hand, regular attendance in school is one of the essential means of improving health.

Education that provides children with both basic academic skills and specific

knowledge, skills, and attitudes related to health is vital. This aspect of education has

lifelong effects (WHO, 1997).

In the Philippines, around 1.2 million children go to preschools, 13.7 million to

elementary schools, and 6.8 million to high schools (NSCB, 2013). This creates a

unique opportunity for the school nurse to make a positive impact on the nation's youth.

There are more teachers than health professionals in the country. Additionally, the

school health structure does not provide for one nurse per school. Generally, the school

nurse visits four to six schools per month, with each visit lasting for 3 days or more,

depending on the type of school, location, and population. Revisits may be done within

the month for follow-up purposes. This means that the nurse spends at least 3 days of

each month in a particular school.

For the rest of the month, teachers, who also serve as school health guardians, provide

primary care as necessary, such as detection of obvious health problems and

administration of first aid. Thus, the school nurse is responsible for planning and

conducting training programs for teachers on health and nutrition (DECS- I-INC, 1997).

During school visits, school nurses see students for a variety of complaints. Increasing

numbers of children are being seen in the school setting because they lack a source of

regular medical care. Through the education of students and teachers, counseling,

advocacy, and direct care across all levels of prevention, the nurse can improve the

immediate and long-term health of this population.

In 2006, an estimated 12.8 million children aged below 15 years (44% of all the children

from this age group) were living in families that did not meet basic living requirements

based on their income (PIDS and UNICEF, 2007). Poverty is associated with decreased

or inferior health care and has been linked to serious health problems that result in an

increase in absenteeism and failure in school. The school nurse and, in the absence of

the school nurse, the well-prepared school teacher, serving as school health guardian,

can effectively manage minor complaints and illnesses, helping these children to return

to or remain in class.

There is a need for mental and physical health services for students of all ages in an

effort to improve both academic performance and sense of well-being. This section

provides an overview of school health and the role of the nurse in the provision of health

services and health education. An in-depth look at the components of a successful

school health program related to the major problems of today's youth is likewise

included in this section.

The evolution of school health services has brought about the development of a more

comprehensive school health program with the entire school community considered as

the client. This resulted to the inclusion of services for school personnel.

Historical development of school health services

The definition of school health and what a school health program should be have

evolved markedly in the past 50 years. Traditionally, school health programs were

defined as covering:

1. School health services,

2. School health education, and

3. A healthy school environment to include both physical and psychosocial aspects

of environment (WHO, 1997).

The interrelationships, however, among these elements as well as the manner in which

they can reinforce each other were not given emphasis, either in theory or in practice

(WHO, 1997). In the Philippines, the first school health program required by law

consisted mostly ofschool health services with the passage of Republic Act 124 in 1947.

Entitled as "An Act to Provide for Medical Inspection ofChildren Enrolled in Private

Schools, Colleges and Universities in the Philippines," this law stated that it was the

duty of the school heads of private schools with a total enrolment of 300 or more to
provide for a part- or full-time physician for the annual medical examination of pupils

and students. The physicians were to render reports of their school health activities at

the end of every quarter of each school year to the Director of Health. The physicians

were placed under the direct supervision of the Bureau of health, the forerunner of the

DOH (Conge* of the Philippines, 1947).

With the changing roles and responsibilities of schools came a redefinition of school

health programs in the 1980s. "the evolving roles of the school nurse and the school

health team in response to the needs of school children and the other members of the

school community resulted in the expansion of the school health program to eight

components. In addition to the first three components mentioned earlier. five more

components have been included, namely (WHO, 1997):

1. Health promotion for school personnel,

2. School-community projects and outreach,

3. Nutrition and food safety,

4. Physical education and recreation, and

5. Mental health, counseling, and social supports.

This new definition emphasized the need for an organized approach, implemented

through comprehensive, holistic strategies. This is the basis for "health-promoting

schools' (WHO, 1997). School nursing covers the entire scope of the eight components

of school health programs. The National Association of School Nurses (in the United

States) defines it as a specialized practice of professional nursing that advances the

well-being, academic success, and lifelong achievement of students. To that end,

school nurses facilitate positive student responses to normal development; promote

health and safety; intervene with actual and potential health problems; provide case

management services: and actively collaborate with others to build student and family

capacity for adaptation. self-management, self-advocacy, and learning (National

Association of School Nurses, 2000).

In the Philippines, a holistic approach to strengthen health and nutrition among school

children is the concept embodied by the Redesigned Approach in School Health

Nursing (RASHN), officially adopted through the Department of Education, Culture. and

Sports (DECS) Memorandum No. 37.

RASHN is based on the philosophy that the academic performance of the pupils and

the instrudional outcomes are determined by the quality of health of the school

population and the communitv where they come from (DECS 1997).

The Department of Education (DepEd) Order 43, s. 2011 on the subject Strengthening

the School Health and Nutrition Programs for the achievement of the Education for All

(EFA) and Millennium Development Goals (MDGs) seeks to strengthen the School

Health and Nutrition Program (SHNP) through a seamless alignment of SHNP activities

with other key school programs, thus the title Integrated School Health and Nutrition

Program (ISHNP). It further states that the ISHNP is designed to maintain and improve

the health of school children by preventing diseases and by promoting health-related

knowledge, skills, and practices (DepEd, 2011).