CE ARTICLE
SECTION EDITOR: FRANCES CHILDRE, MS, RNC, ANP, COHN-S
Defining the Scope of
Occupational Health
Services
EFFECTIVE POLICY AND PROCEDURE
DEVELOPMENT
ike other departments in most organizations, Occu-
L pational Health Services (OHS) units are required to
document proof of quality for services rendered.
The scope of services is defined in the policies and proce-
dures. The foundation for a quality program should be
reflected in the philosophy of the OHS department and
written into the policies and procedures. Brown (1984)
stated the "smooth administration of the health unit is
dependent on the occupational health nurse's having
thought about and committed to writing the philosophy,
policies, and procedures of the unit." When written docu-
ments state the intent of the service and describe the
actions to be taken to meet the intent, uniform approaches
can be applied and are expected from the practitioner(s).
The development of policies and procedures is beneficial
when defining and directing the type of services to be pro-
vided. The ground work is laid so that indicators and mea-
ABOUT THE AUTHOR:
Ms. Ebaugh is Director, Infection Control
Occupational Health Department, DeKalb
Medical Center, Decatur, GA.
NOVEMBER 1998, VOL. 46, NO. 11
by Helen Ebaugh, RN, GIG
surement methods can be developed to validate the quality
of those services.
It is indisputable among occupational health profes-
sionals that written policies, procedures, and protocols that
reflect and guide the day to day function and activities of
the OHS are required. "The need for developing policies
and procedures becomes apparent as one examines the
complexities of the occupational health service" (Brown,
1984). The way in which an OHS responds to regulatory
requirements, medical/health surveillance issues, and
champions health promotion influences the quality of the
service. Effective responses can be demonstrated through
the use of dynamic polices and procedures. However, in
writing policies and procedures there is frequent confusion
and debate about the definitions of policy, procedure, prac-
tice protocols, guidelines, and standards as they pertain to
the OHS arena (see Table 1). The terms sometimes are
used interchangeably which may contribute to the confu-
sion.
It is easier for the author of the documents, as well as
the reader, when a standardized format is used for written
polices and procedures. Once the content formatting struc-
ture is developed, the production of documents is simpli-
fied. For the reader, knowing the structure of the proce-
dures facilitates finding the necessary information in the
document in a more efficient manner.
Formats for writing statements or policies are not
alway s standardized within the organization, company,
547
 CE ARTICLE
TABLE 1
Definitions
• Policy: a governing plan for accomplishing goals
and objectives (Marriner-Tomey, 1996).
• Procedure: chronological sequence of steps within
a process (Marriner-Tomey, 1996).
• Practice protocol: written parameters that provide
legal authorization for medical aspects of nursing
or nurse practitioner practice (AAOHN, 1997).
• Guideline: systematically developed statement to
assist practitioner with decisions about appropriate
health care for specific conditions (AAOHN , 1997).
• Standard: agreed on criteria used to provide
guidance in the operation of health care of other
facilities to ensure quality performance by the
personnel (Como, 1990).
or OHS department. If the organization has a standardized
format for documents, OHS policies and procedures can
be written to fit the structure. The terminology used should
be based on the organization's mission and values state-
ments, as well as the business orientation of the organiza-
tion, i.e. financial institution, health care system, manufac-
turing, etc. Using the terminology understood by person-
nel outside of the OHS department assists the reader, who
may be unfamiliar with health care terms, to better under-
stand the intent of the document. This is especially impor-
tant for policies as they are usually written for a broader
target group than procedures.
Following some basic fundamental s produces a stan-
dardized set of documents . A primary goal of these docu-
ments is to state the intent and purpose of the OHS, as well
as guide and direct the day to day operation. Policies and
procedures that identify, define, and direct the work of the
department provide a basic tool for performance manage-
ment. Additionally, when the structure and responsibilities
of the OHS are clearly defined in writing, it is easier for
organization management to understand the scope of ser-
vices and provide support for those services. For depart-
ments and employees who interact with or access the ser-
vices of OHS, a written program aids in a clearer under-
standing of roles and responsibilities for all involved.
POLICIES
Policies are usually established by the organization's
upper management for the purpose of guiding decision
making throughout all levels of management. However,
548
depending on the type of organization, polices specific to
the OHS may be needed. For example, a manufacturing
facility may not routinely have policies for the delivery of
health care. Yet, if an onsite OHS unit exists or there is a
contract with a specific provider for work related injuries,
a specific policy related to these functions is advisable. In
the health care setting, OHS policies may be established
through the collaborative efforts of nursing, other occupa-
tional health professional staff, and medical staff to define
the intent of the policy.
"Fundamentally, the policies are guides to thinking in
decision making. Their task is to ... ensure that a decision
will contribute to the attainment of objectives and desired
plans" (Fallon, 1993). Writing policies allows for more
critical thinking about the intent of the statement or docu-
ment. Once written, the policy provides clarity and the
opportunity for misinterpretation is decreased.
Policies and procedures are frequently seen as the
same but it is important to know the difference. Written
policies state how goals will be achieved. They define the
course and scope of activities for the OHS and guide deci-
sions and actions. Policies should be consistent and under-
standable so present and future OHS managers and nurses
can make independent decisions that are interpreted and
applied fairly.
Policies need to be flexible enough to allow for appli-
cation in similar areas. This avoids the need to develop
separate policies for all goals and functions related to that
particular area. For example, an organizational policy
related to the budgetary process is used by all departments.
The OHS procedures in response to that policy are specif-
ic to how the OHS meets the policy's intent. Operational
policies are documents that can be changed if the need
arises. This frequently occurs when regulatory require-
ments are updated or changed. Therefore , it is important to
review policies periodically to insure they provide accurate
guidance to OHS personnel. For example, when the Cen-
ters for Disease Control and Prevention (CDC) and the
Occupational Safety and Health Administration (OSHA)
developed CDC recommendation s and OSHA Standards
for the implementation of Universal Precautions to control
the transmission of bloodbome pathogens to health care
workers, a conceptual change was necessary and new poli-
cies directing practice were required.
Policies need to be simply stated using as few words
as possible. A policy statement preceding a procedure
defines who should follow the document and states the
overall intent of the procedure. A policy for annual health
screens might read:
Employees are required to complete an annual assess
AAOHN JOURNAL
 CE ARTICLE
ment which includes a health history update, an
immunization status review and a tuberculosis expo-
sure screen.
PROCEDURES
Procedures are specific, step by step guides for
accomplishing a task. Procedures do not allow for inter-
pretation. They standardize equipment and process and
are written to achieve a high level of regularity in task
performance. "Good procedures can result in time and
labor savings" (Marriner-Tomey, 1996). OHS procedures
usually do not affect the entire organization and are spe-
cific to the occupational health setting.
Written procedures have many benefits for the OHS.
They provide a set of steps to be followed to complete a
task. Operational procedures clearly state the functions of
the services and who performs the task. Once written and
reviewed by individuals following the procedures, appro-
priate management staff, and other stakeholders, the pro-
cedures should be clearly communicated to all individuals
impacted by the document. Procedures always need to be
readily accessible either in a manual or via computer
access. The procedure manual serves as a reference guide
for staff and is functional in the orientation process, as well
as in staff development and performance review.
Written procedures include:
• The purpose, responsibilities for the persons perform-
ing the task,
• Documentation requirements,
• Precautions required while preparing and performing
the task, and
• Other considerations, such as location and disposal of
materials.
Adding the guiding reference or reason for the procedure
such as legal implications also may be beneficial.
Clearly stated procedures eliminate discrepancies in
service delivery. Once written, it is important to conduct a
review of the document by several of the users to assure
there are no inaccuracies or unclear statements. Making
changes to the written document are continued until all
steps are clearly stated.
A process for periodic review and evaluation is a vital
part of the development of written policies and procedures.
The review process should include an inventory of tasks
performed by reviewing the table of contents. Procedures
no longer relevant to the practice need to be removed. It is
important to revise modified procedures and add new pro-
cedures as practice changes occur. Once they have been
approved for use, any alterations to documents should be
dated and the updated procedures communicated to the
appropriate individuals.
NOVEMBER 1998. VOL. 46. NO. 11
Following the organization's requirements for
approval and implementation of policies and procedures is
crucial. Depending on the type of institution, OHS policies
and procedures may need to be approved by an adminis-
trative body (e.g., Human Resources, Environmental
Health and Safety) or a committee (e.g., Infection Control)
with oversight for OHS.
Historical recordkeeping of revisions, additions, and
deletion of policies and procedures provides not only legal
protection but also an accurate history of practice and busi-
ness improvements. Following the organization's require-
ments for record retention as well as those outlined by reg-
ulatory bodies which govern OHS, i.e., OSHA, is essential.
DOCUMENT DEVELOPMENT
When writing policies and procedures, the author
assumes nothing and provides clear directions in a chrono-
logical format. Using standardized format saves time when
writing a procedure (see Table 2). It also clarifies the steps
to be followed. Below is a list of components that may be
included in a written operational policy and procedure.
Additionally, some skills or tasks may not have procedures
written for them if individuals performing the skill are
assumed to have mastery of it via education. For instance,
if all direct care providers are registered nurses, a proce-
dure for taking blood pressure may be redundant.
Name of the Procedure
Specifically stating the name of the procedure so that
the user can easily identify it is vital. Some subjects or
areas may have multiple procedures. In these cases, it may
be beneficial to label all documents with a subtitle or a sec-
ond part of a title describing its intent. For example, topics
guiding the management of tuberculosis may have the
name "Tuberculosis: Management of the Infected Health
Care Worker," "Tuberculosis: Post Offer Screens," etc.
Policy Statement
Policies are intended to remain as guidelines for
behavior over an extended period of time. When writing a
policy statement, it may be helpful to think about the over-
all intent of what is to be accomplished. It is important to
avoid being influenced by present practices and biases.
Focusing on the broad goal and keeping in mind policies
are to be flexible in their applicability to other documents
is helpful. Flexibility can be compromised by including
procedural statements in this section. For example, a poli-
cy statement related to the prevention of transmission of
varicella zoster may state:
Prevention and control of varicella zoster will be
549
 CE ARTICLE

Purpose/Objective
The purpose statement or objective briefly explains
TABLE 2 the reason for the policy and procedure. In some basic pro-
Organization Name cedures this may not be necessary as the purpose is self
evident. The purpose or objec tive is the rationale for the
Occupational Health document. A purpose statement or objective for the work
Service restriction of an employee exposed to an infectious disease
reads:

Name of Procedure: Name the task; can also Restriction of work assignment for the susceptible
include a procedure number for cross reference health care worker from the 10th to the 21st date after
and referral. exposure to chicken pox is recommended by the CDC
to prevent possible transmission of the varicella virus.
Policy Statement: Simple statement defining what
is to be achieved; define the overall intent of the
procedure. Materials/Equipment/Supplies
Purpose/Objective: State the reason for the All items required to accomplish the task, along with
procedure; rationale. their location, need to be delineated. Equipment lists are
Materials/Equipment/Supplies: List all supplies, included in procedures with a clinical focus, such as
equipment needed to conduct the procedure; can removal of sutures, drawing lab work, audiometric testing,
also include where equipment or supplies are or providing post exposure follow up. Such a list also may
located. be included in a clerical procedure which defines comput-
er data entry for tracking of injuries and illnesses or to doc-
Responsibility: State who is to do what as it
relates to the procedure. ument immun ization histories. This section assists the
OHS employee or an employee performing an unfamiliar
Procedure: List in chronological order what is task to locate all the necessary supplies or inform ation
required to accomplish the task. needed to successfully complete the procedure. For exam-
Steps: ple, the list of required items for OHS follow up of a blood
1. and body fluid exposure includes all the required forms to
2. be completed as well as the type and number of blood
3. tubes used when collecting the blood specimen for base-
or line testing. The clerical component of exposure mana ge-
Steps Key Points ment includes entry of this occurrence into the trackin g
1. 1. system for future follow up and statistical analysis.
2. 2.
3. 3. Responsibility
Documentation: State what is to be documented , Defining each role when more than one departm ent or
who documents it and where to document. service has responsibility for portions of the procedure is
References: List documents that guided the essential. For example, if a laboratory service is responsi-
development of the procedure. ble for picking up specimens and sending the results back
to the OHS, this needs to be stated in the procedure. The
ApprovaVReview Dates: List date document was delivery of pharm aceuticals to OHS is anothe r area in
developed, approval body and any subsequent
which role definition s and responsibilities are clarified
review, revision, and approval dates.
within the procedure as these services are provided by an
outside source. Clear role definitions provide both protec-
accomplished through screening all health care work- tion and guidanc e in the performance of certain tasks.
ers who have direct contact with patients on the Oncol- They also reduce redund ancy and duplication of work as
ogy Units and Pediatric Services for immunity to the
varicella zoster virus. well as conflicts .

This statement leaves no room for interpretation as to Procedural Steps

who is included. The procedure states how this is accom- In a step by step format, it is helpful to list what needs
plished . to be done to complete the procedure or accomplish the

550 AAOHN JOURNAL

 CE ARTICLE
TABLE 3
Abbreviated Narrative Format With Key Points
Steps
1. Collect sphygmomanometer. Select correct size
cuff. Average adult size 12-14 cm; large adult size
18 to 20 cm.
2. Place client in comfortable position .
3. Expose arm , roll sleeve well above elbow.
4. Etc.
task. This may be accomplished in a narrative format
defining each step in a full sentence or in an abbreviated
narrative format separating the key steps from the key
points. Following are examples of the two formats written
for blood pressure monitoring.
Narrative Format
I. Gather the sphygmomanometer and stethoscope.
2. Place the client in a comfortable siting position.
3. Expose arm, rolling sleeve well above elbow.
4. Etc.
Abbreviated Narrative Format With Key
Points
The abbreviated narrative format with corresponding
key points is seen in Table 3.
Several approaches may be used to determin e the
steps. If the author is familiar with the procedure , writing
down each step as the task is mentally completed is help-
ful. On the other hand, it may be necessary to simulate
the task using a procedure scenario. Another method is to
observe the procedure and write each step as it is accom-
plished .
It is important to document the steps in chronologi-
cal order as they are determined. Stating each step in
action verb phrases so each step is a clear command is
essential. Each item in the procedure is grammatically a
command: place, raise, fill, remove, record , calcul ate,
and state (Griffith, 1984). When using the abbreviated
narrative format with key points, it is helpful to add to
each step any qualifier that facilitates efficiency with the
person performing the procedure. Procedures are not
intended as teaching tools.
After the procedure is written, reviewing each step to
NOVEMBER 1998, VOL. 46, NO. 11
Key Points
1. If cuff size is too narrow, pressure reading will be
abnormally high. If it is too wide, reading will be falsely
low.
2. It helps decrease client anxiety, which may
influence blood pressure measurement.
3. Assure rolled sleeve does not constrict arm, as this
will alter the correct reading.
4. Etc.
determ ine if it is clearly stated is crucial. One approach is
to have another individual or group of individuals famil-
iar with the procedure review the document for clarity. It
is important to remember when writing a procedure the
person using it may not be familiar with the task to be
performed.
Documentation
Every procedure should include a section on docu-
mentation content and responsibility for documentation.
Specific forms requiring completion are also listed in this
section and may be attached to the procedure document
as a quick reference guide. A procedure on immunization
might include a copy of an immuniz ation record used to
document immuni zations over a time period. An example
of a statement to be included in this section is:
Complete the Immun ization Record to include type
of immun ization , lot number, expiration date, site of
injection , and signature of person administering the
vaccine.
References
Government, accreditation, or regulatory agency
requirements (e.g., Federal Register, CDC recommenda-
tions) which direct the development of policies and pro-
cedures need to be listed as source references in the writ-
ten document. Adding this section may save time and
research at a later date when the document is updated or
reviewed. As document s are reviewed and revised, new
reference documents should be added as appropriate.
Approval Dates and Approving Body
The development date of the original document, as
551
 CE
Defining the Scope of
Occupational Health
Services
Effective Policy and
Procedure Development
Ebaugh, H.
AAOHN Journal 1998; 46(11),547-552.
The development of policies and proce-
1. dures define and direct the type of services
provided by the OHS unit.
Written policies and procedures lay the
2. groundwork for the development of indica-
tors so the quality of the services provided
by OHS can be measured and validated.
A standardized format for written policies
3. and procedures facilitates the development
process.
Policies define the course and scope of
4. activities and guide decisions and actions.
Procedures are a step guide for complet-
ing a task.
well as any subsequent review and revision dates, should
be included and retained in the document. Health care
system documents are required to be reviewed routinely.
This is dictated by different licensing and regulatory
agencies depending on the type of institution. OHS in
other settings should establish an internal policy for the
routine review of polices and procedures. This assures
consistent performance standards and offers opportuni-
ties for continuous improvement.
Having a prescribed review date is not essential.
Anytime a procedure is changed, the written document
should be updated. Keeping the documents current is a
necessary legal requirement and must be built into the
overall management plan for the OHS.
The name of the approval department, body, or com-
mittee are included in this section. When revisions are
made, the changes should be taken to the approval source
552
ARTICLE
and current dates added to the document. Following is an
example:
Developed: August 1994
Reviewed: July 1996
Revised: February 1998
Approved: Document Review Committee
September 13, 1994; March 14,1998
It is important to develop procedures when new
product or practice modes are introduced. When new pro-
cedures are developed in response to changes in practice,
and revisions are made for the same reason, the routine
review process is automatically achieved.
Keeping the policy and procedure manual updated
can be accomplished by assigning specific sections to
designated staff persons for quarterly review. Whatever
the process for development, review, and revision, writ-
ten policies and procedures are beneficial as a manage-
ment tool, an educational reference, and as a statement of
the scope and responsibilities of the OHS department.
It appears that every department or unit in every
organization is required to validate what they are doing,
how they are doing it, and why it is important. Written
policies and procedures establish a baseline for the col-
lection of information to monitor and measure the type,
quantity, and quality of work accomplished by OHS.
Choosing the procedures most frequently performed by
OHS (annual health screens, audiometric surveillance) or
that involve additional cost to perform (work related
injuries or illnesses) provide a solid beginning to defining
the occupational health program. Developing a written
policy and procedure manual is a basic step to establish-
ing a continuous quality improvement program for the
OHS.
REFERENCES
AAOHN. (1997). AAOHN advisory: Developing clinical guidelines of
protocols for practice. AAOHN Journal, 45(10), 476A-B.
Brown, K.C. (1984). Development of philosophy, policies, and proce-
dures for an occupational health nursing service. AAOHN Update
Series, 2-6.
Como, D. (Ed.). (1990). Mosby's medical, nursing, and allied health
dictionary. St. Louis: C.v. Mosby Company.
Fallon, WK. (1983). General management. In: W.K. Fallon (Ed.). AMA
management handbook (pp. 1-51). New York: American Manage-
ment Association.
Griffith, J., & Ignatavacicius, D. (1984). Procedure development a sim-
plified approach. The Journal of Nursing Administration, /4(9), 27-
32.
Marriner-Tomey, A. (1996). Organizational culture. In: A. Marriner-
Tomey (Ed.). Nursing management and leadership (pp. 151-165).
St. Louis: C'V, Mosby.
AAOHN JOURNAL

Defining the Scope of Occupational Health Services:
Effective Policy and Procedure Development
This issue of the AAOHN JOURNAL
contains a Continuing Education Module
on "Defining the Scope of Occupational
Health Services: Effective Policy and
Procedure Development." 1.0 contact
hour of continuing education credit will
be awarded by AAOHN upon successful
completion of the posttest and evalua-
tion .
A certificate will be awarded and the
scored test will be returned when the
following requirements are met by the
participant: 1) The completed answer
sheet is received at AAOHN on or
before October 31, 1999; (2) A score of
70% is achieved by the participant; (3)
The answer sheet is accompanied by a
$10 processing fee. Expect up to 6
weeks for delivery of the certificate.
Upon completion of this lesson, the
occupational health nurse will be able
to:
1. Discuss the importance of written
policy and procedure documents for
occupational health nursing practice.
2. Compare and contrast nursing
policies and procedures.
3. Describe the components of a
written operational policy and procedure .
AAOHN is accredited as a provider
of continuing education in nursing by
the American Nurses Credentialing
Center's Commission on Accreditation.
Alabama provider number ABNP0063.
California provider number CEP9283.
Louisiana provider number LSBN3 .
Contact hour credits received for
successful completion of the posttest
and evaluation may be used for relicen -
sure, certification, or re-certification.
Directions : Circle the letter of the best
answer on the answer sheet provided.
(Note: you may submit a photocopy for
processing. )
1. A governing plan for accomplish-
ing goals and objectives is known
as a:
A. Philosophy.
B. Procedure.
C. Policy.
D. Standard.
NOVEMBER 1998, VOL. 46, NO. 11
CE MOD U L E
2. In the occupational health set-
ting, the nurse's legal authoriza-
tion for medical aspects of nursing
or nurse practitioner practice is
provided by a written:
A. Policy.
B. Practice protocol.
C. Guideline.
D. Standard.
3. A nurse is a member of a man-
agement team charged to review
organizational policies and devel-
op any needed written policies for
a new occupational health service
in a manufacturing organization. A
priority action is to:
A. Develop a unique format for occu-
pational health service policy docu-
ments.
B. Include step by step procedures
for occupational health nursing prac-
tice.
C. Use terminology specific to occu-
pational health nursing practice.
D. Use terminology consistent with
the plant's mission and value state-
ments.
4. During orientation, a nurse man-
ager refers a new nurse to a writ-
ten to review the purpose,
responsibilities, and step by step
process of performing a task.
A. Procedure.
B. Guideline.
C. Standard.
D. Policy.
5. Which of the following is most
likely to promote standardized
documentation of occupational
health nursing practice in the
occupational health service?
A. Procedures.
B. Policies.
C. Guidelines.
D. Standards.
6. When developing documents for
practice, the nurse recognizes
that:
A. All nursing tasks must be outlined
in a written procedure.
B. Procedural statements are meant
to be flexible.
C. It is beneficial to use a standard-
ized format for procedures.
D. Policy statements change fre-
quently.
7. " The use of universal precau-
tions by all health care workers is
recommended by the CDC to pre-
vent the transmission of blood
borne pathogens" is an example of
a:
A. Policy statement.
B. Purpose.
C. Practice protocol.
D. Operational procedure.
8. After a body fluid exposure, a
new nurse would find a list of nec-
essary equipment in which of the
following resources?
A. Procedure.
B. Policy.
C. Objective.
D. Standard.
9. The nurse expects to find "key
points" in this section of a written
policy and procedure:
A. Policy statement.
B. Purpose.
C. Procedural steps.
D. Documentation.
10. The nurse is aware that written
procedure documents should be
updated:
A. Bimonthly.
B. Semiannually.
C. Annually.
D. When a procedure is changed.
553
 ANSWER SHEET
Continuing Education Module

Defining the Scope of Occupational Health Services:

Effective Policy and Procedure Development

November 1998
(Goal:To gain ideas and strategies to enhance personal and
professional growth in occupational and environmental health nursing.)

Mark one answer only!

(You may submit a photocopy of the answer sheet for processing.)

1. ABC D 6. ABC D
2. ABC D 7. ABC D
3. ABC D 8. ABC D
4. ABC D 9. ABC D
5. ABC D 10. ABC D

EVALUATION (must be completed to obtain credit)

Please use the scale below to evaluate this continuing education module.

4 - Toa great 3 - Tosome 2 -To little 1 -To no

extent extent extent extent
1. As a result of completing this module, I am able to:
A.Discuss the importance of written policy and procedure docu-
ments for occupational health nursing practice. 4 3 2
B. Compare and contrast nursing policies and procedures. 4 3 2
C. Describe the components of a written operational policy and pro-
cedure. 4 3 2
2. The objectives were relevant to the overall goal of this independent
study module. 4 3 2
3. The teaching/learning resources were effective for the content. 4 3 2
4. How much time (in minutes) was required to read this module and
take the test? 50 60 70 80

Please print or type: (this information will be used to prepare your certificate of completion for the module).
DEADLINE: OCTOBER 31, 1999

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554 AAOHN JOURNAL