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Occupational and Environmental Ethics and Professionalism

by Bonnie Rogers, DrPH, COHN-S, LNCC, FAAN

abstract This article provides an overview of ethical issues related to the practice of occupational and nursing and possible strategies for resolution. Also, professionalism related to professional growth and advancing the specialty is discussed.

ccupational and environmental health nursing’s including the changing and work force; work basic includes a population-focused and organizational factors such as downsizing, increased O(i.e., work force) approach to protecting worker work demands, and significant stress; the introduction of health, preventing and , conducting health new work processes, new biological agents, and increased surveillance, and providing a safe and healthful work use of potentially hazardous agents (i.e., nanoparticles), environment. Contemporary occupational and environ- with a concomitant increase in in the work en- nursing emphasizes , vironment; technological advances and increased regula- evidence-based practice, interdisciplinary collaboration, tory mandates; emphasis on integrated ; and improved , and program and devel- an increase in complex ethical health issues at the work- opment. Environmental health, deeply rooted in nursing’s site coupled with rising health care costs and workers’ heritage, is integral to the specialty practice (Pope, Sny- compensation claims. Consequently, interprofessional der, & Mood, 1995). approaches to address work force health problems must Many factors have influenced the evolution of oc- be emphasized. Occupational and environmental health cupational and environmental health nursing practice, nurses work in a variety of settings (e.g., pharmaceutical companies, furniture , , oil refin- eries, cosmetic and meat packing companies, construc- ABOUT THE AUTHOR Dr. Rogers is Director, NC Occupational Safety and Health and tion sites, government and insurance agencies, apparel and Center and OHN Program, School of , Univer- finishing)—wherever a work force needs occupational sity of North Carolina at Chapel Hill. health services. Given the changing of the The author received an honorarium from the American Association of Oc- cupational Health Nurses, Inc., to write this article. U.S. population (i.e., aging and ethnically diverse), health Address correspondence to Bonnie Rogers, DrPH, COHN-S, LNCC, care professionals will provide a wider array of services FAAN, University of North Carolina at Chapel Hill, 1700 Airport Road and need additional occupational health resources to meet CB#7502, Chapel Hill, NC 27599-7502. E-mail: [email protected]. Received: December 19, 2011; Accepted: February 23, 2012; Posted: demands (Rogers et al., 2011). Occupational and environ- March 23, 2012. mental health nurses can meet these challenges. doi:10.3928/21650799-20120316-51 This article provides an overview of ethical issues

WORKPLACE HEALTH & SAFETY • Vol. 60, No. 4, 2012 177 occupational health and safety as these values sometimes Sidebar 1 compete. Nurses are obligated to act in the best interest of AAOHN Code of Ethics the worker and provide effective leadership skills in ethi- cal health care. In this role, occupational and environmen- tal health nurses not only bring expertise to occupational 1. Occupational and environmental health nurses pro- health dilemmas but also structure the issues so sound and vide health, wellness, safety, and other related services deliberate decisions are made using a reasoned approach. to clients with regard for dignity and rights, un- The AAOHN Code of Ethics details five principal state- restricted by consideration of social or economic status, ments for ethical practice and behavior (Sidebar 1). The personal attributes, or the of the health status. Code of Ethics should be used as a policy document and 2. Occupational and environmental health nurses, as shared with to effect better understanding of licensed health care professionals, accept obligations occupational and environmental health nursing practice. to as professional and responsible members of the . Ethical Issues and Practice Ethical issues in occupational health settings are of- 3. Occupational and environmental health nurses strive ten subtle and insidious rather than overt (Rogers, 1988). to safeguard clients’ rights to privacy by protecting Based on research, issues related to balancing costs and confidential information and releasing information only benefits, privacy of employee health information, truth as required or permitted by . telling, worker notification and , worker 4. Occupational and environmental health nurses health screening, by both employees and promote collaboration with other health professionals, health care providers, mandatory , workplace community agencies, and stakeholders to meet the discrimination, professional competence and unethical health, wellness, safety, and other related needs of the or illegal acts (e.g., fraudulent credentials), and whistle- client. blowing are challenges occupational health profession- als face in an effort to protect and improve worker health 5. Occupational and environmental health nurses main- (Rogers, 2001, 2003). In addition, , cultural tain competence in nursing practice, based differences, and work force diversity present ethical com- on scientific knowledge, and recognize and accept re- plexities related to effective of information sponsibility for individual judgments and actions, while necessary to protect workers from hazardous exposures. complying with appropriate and regulations. In corporate environments where the primary mission is to Note. From American Association of Occupational Health produce successful products while ensuring corporate sur- Nurses, Inc. (2009). vival and profitability, conflicts may be created if health and safety issues compromise the profit goal (Rest, 2010). Fry (2000) states that the nurse, as a moral agent, related to the practice of occupational and environmental is concerned with values, choices, priorities, and duties health nursing and possible strategies for resolution, and for the “good” of the individual, society, and the profes- a discussion of professionalism related to professional sion. In the delivery of occupational and environmental growth and advancing the specialty. health nursing services, nurses provide comprehensive professional health care to , groups, and work Code of Ethics forces, respecting human dignity and self-worth while Occupational and environmental health nursing prac- promoting client . Occupational and envi- tice is regulated by state nurse practice acts and guided ronmental health nurses have the primary responsibility by standards of occupational and environmental health to advocate for worker health and safety while honor- nursing practice (American Association of Occupational ing ethical, cultural, spiritual, and corporate beliefs. For Health Nurses, Inc. [AAOHN], 1999). The occupational many industries, health services may be of secondary im- and environmental health nurse must be knowledgeable portance, inasmuch as health care providers do not gener- about laws and regulations that govern the occupational ate income, but rather cost companies money. Nurses can health and safety of workers (e.g., Occupational Safety assist management to recognize the human benefits of and Health Act, Americans with Act, Record- occupational health programs, which promote employee keeping Standard, Communication Standard), mental and physical well-being and result in improved and recommend and implement programs responsive to productivity and quality. mandated health and safety requirements. Within a values framework, occupational and envi- The occupational and environmental health nurse’s ronmental health nurses practice autonomously, maintain framework for practice is guided by ethical treatment of self-integrity, and demonstrate leadership in decision workers as documented in the AAOHN Code of Ethics making. In most occupational health settings, occupa- (AAOHN, 2009). Many situations in the work environ- tional and environmental health nurses manage occu- ment create ethical dilemmas, including confidentiality pational health units and provide direct health services. of employee health records, hazardous exposures to vul- Thus, nurses have dual responsibilities and act as agents nerable , and conflicting duties. Nurses must of the company, but, more importantly, as advocates for recognize both personal and corporate values related to workers. Occupational and environmental health nurses

178 Copyright © American Association of Occupational Health Nurses, Inc. are involved in many workplace issues having direct ef- fects on the health and well-being of individual workers Sidebar 2 and the work force. For example, issues related to access Tenets to Support Occupational Health to health records may present conflicts if the principle of confidentiality is not shared by others (i.e., company and Safety management). When conflicts arise, occupational and en- vironmental health nurses must decide to act with cour- 1. Worker rights and treatment related to principles of age, sometimes at their own (Rest, 2010). Nurses self-determination and non-discrimination including must adhere to professional standards and codes that diversity, and the receipt of quality health care while guide and direct safe and ethical care for which they are protecting employee confidentiality is respected. accountable. Management, occupational and environ- 2. Promotion and protection of health throughout the mental health nurses, and other health care professionals work community are obligations of all parties. must respect each others’ roles and confront issues that threaten worker health and safety. Differences between 3. Occupational health and safety professionals’ deci- professions must be discussed and resolved. The tenets in sions, such as holding health information confidential, Sidebar 2 can provide guidance. are honored. Beauchamp and Childress (2008) described the most 4. The benefits of the occupational health service to the widely observed ethical principles of autonomy, nonma- worker population and company, with the appropriate leficence, beneficence, and justice, which have wide ap- level of resources, are supported. plication in occupational health settings (Rogers, 2003). Autonomy, characterized by self-determination, relates to 5. The competence and continuing professional devel- issues such as informed consent, confidentiality and right opment of the staff, including recognition of legal and to privacy, right to refuse treatment, right to know about ethical considerations and accountability for practice, is potential workplace health hazards, and worker inclusion expected. in decision making. This principle denies paternalism 6. Collaborative multidisciplinary relationships that sup- (i.e., when one claims to know what is best for another) port and enhance worker health and safety, including in decision making and thereby precludes health profes- the relationship of the occupational health service to sionals or others from making decisions for employees the community, are essential. without their input and consent. Potential dilemmas include the use of hazard pay for dangerous jobs; access to or denial of exposure informa- tion and long-term consequences by employers; access to tions (i.e., wellness, screening, and health surveillance medical records by management personnel, which may programs) exemplify this principle. Examples include the result in denial of promotion, loss of job, or other puni- installation of control devices such as needle tive or coercive behaviors; and the maintenance of confi- or sharps containers in patient rooms or clinic areas, the dentiality for a substance-abusing employee who handles use of non-latex gloves when latex is not needed, the de- heavy equipment that can harm other workers. Of signifi- velopment of a back program for work- cant concern is the use of predictive or genetic screening ers with back problems or previous injury, or workplace to identify genetic risk factors in workers and then us- walk-throughs by the occupational and environmental ing that information for employment decisions. Who will health nurse to identify health and safety hazards and rec- have access to this information? Will individuals be de- ommend risk reduction programs. Mandatory screening nied employment or access to select jobs based on these programs and the availability of test results demand cau- data? The potential to violate the right of autonomy is tious evaluation to ensure worker autonomy and protect significant in these situations (National Institute for Oc- confidentiality and right to privacy. For instance, should cupational Safety and Health, 2009). urine screening be required of all or some employ- The second principle, nonmaleficence, is often re- ees, how should data be obtained and stored, and what are ferred to as the “no harm” principle. Foundational to most the repercussions of unreliable testing procedures? professional ethical codes, this precept encompasses the The fourth principle, justice, focuses on treating em- concepts of both harm and avoidance of harm. For ex- ployees fairly, equally, and without discrimination, in- ample, an employee with a known should not cluding providing equal opportunity for disabled workers be placed in a job situation that will further compromise to be hired and promoted, assuring individuals they will hearing, and a pregnant employee should not be exposed not endure discrimination because of a health condition to potential or known teratogens that may jeopardize her (e.g., ) if they are able to perform the job. This health or that of her fetus. The results of preplacement, concept is embodied in the Americans with Disabilities periodic, and mandatory examinations are used to iden- Act. Sexual or alcohol as well as the general health tify work-related hazards and protect the health of em- status of employees may be considered risk informa- ployees. tion with respect to potential discrimination (D’Arruda, Beneficence, the third ethical principle, requires that 2001). Singling out particular individuals or work groups health care professionals act in the best interest of the to perform unpleasant or hazardous jobs also violates this worker. Health promotion and health protection interven- principle.

WORKPLACE HEALTH & SAFETY • Vol. 60, No. 4, 2012 179 know how to lead, corporate management is reasonable, Sidebar 3 the degree and severity of risk is understood, and changes Professionalism and Leadership can be made within a reasonable time frame, leading an organizational change can be an effective, safe approach. In the final analysis, occupational and environmental Professionalism includes providing leadership and health nurses must make their own decisions and live acting in a leadership role. Leadership is provided in with the consequences (Rest, 2010). several ways, including, but not limited to: As health care professionals, nurses must often eval- 1. Influencing and developing policy for occupational uate ethical dilemmas, questioning what ought to be done health and safety programs and initiatives in the work in a health situation from an ethical standpoint. Dilemmas . are difficult problems that have no easy solutions; how- ever, using ethical theories and principles can classify the 2. Influencing governmental legislation and regulation. decision-making process to arrive at resolution. Rogers 3. Influencing and empowering peers to become in- (2003) developed a model for ethical decision making to volved in occupational health and safety issues. guide an organizational change through deliberate and ra- tional decision making. 4. Participating in leadership activities in the work orga- nization, external publics, and professional , Honesty and Ethics in the Professions and advancing the specialty. Each year, the Gallup organization conducts a survey 5. Engaging in leadership election opportunities in rating the honesty and ethical standards of professions. professional societies, voluntary , and The 2010 poll, conducted through telephone interviews government. of a randomly selected national sample of 1,037 adults, found that the top three professions rated high or very high in honesty and ethical standards were nurses (84%), Issues related to health care costs and benefits cut U.S. (73%), and druggists/ (71%). across all ethical principles. Cost containment is never a Health care provided by nurses is of high quality and substitute for quality health care delivered to all employ- consistent with professional codes and standards that re- ees. No employee should receive substandard care. All flect the values of caring, advocacy, and accountability; employees should have equal access to care options with- the public recognizes this. As advocates, nurses speak in the scope of their benefits at the most reasonable cost. for or in support of the best interests of clients, including To resolve ethical problems, occupational and en- populations at risk (Rogers, 2003). vironmental health nurses must recognize both personal and corporate values, and identify when these values Professionalism in Occupational and compete. The consequences of addressing organiza- Environmental Health Nursing tional ethical issues can be unpleasant (e.g., one can be To support the role functions and advance the spe- punished or fined, one’s career can suffer, or one can be cialty of occupational and environmental health nursing, ostracized) (Nielsen, 1989). However, several strategies , competency enhancement, can be employed. For example, clarification of legal re- and professional growth are essential. Occupational and quirements or restrictions such as the Americans with environmental health nurses must maintain a current and Disabilities Act, Bloodborne Standard, Family evolving scope of practice and use ethical judgment re- and Medical Leave Act, or Portability garding practice issues. To accomplish this, occupational and Accountability Act can lead to educational opportu- and environmental health nurses benefit from member- nities for all workers and management regarding required ship in AAOHN, the professional society for nurses en- confidentiality of health information. gaged in the practice of occupational and environmental Occupational and environmental health nurses must health nursing. Among many of its activities, AAOHN build alliances with other health care providers, profes- supports the professional development of occupational sionals, and company leaders to institute an ethical orga- and environmental health nurses. Within this context, nizational change, promoting health care organizational AAOHN defines the scope of practice and sets standards integrity rather than acting individually. This work may and competencies for practice; develops the AAOHN involve whistle-blowing and significant risk, particu- Code of Ethics; promotes and provides continuing edu- larly if company culture demands conformity. However, cation; and develops tools and resources to support oc- working with employees, health care professionals, and cupational and environmental health practice. However, management to create a health care bill of rights for all the primary responsibility for continued competence in employees can build trust within the organization. The an evolving scope of practice and work responsibilities bill of rights should be displayed at key locations within rests with individual occupational and environmental the company and also in the occupational health unit. The health nurses. AAOHN Code of Ethics can also be displayed and given to management as a guide for developing related Mentoring and Leadership to occupational health and safety. Mentoring is an essential component of professional- If occupational and environmental health nurses ism; professional growth and development provide guid-

180 Copyright © American Association of Occupational Health Nurses, Inc. ance and assistance for occupational and environmental health nurses in developing skills and abilities. Role mod- IN SUMMARY eling and mentoring are professional behaviors that assist new occupational and environmental health nurses to de- Occupational and velop a network of colleagues and that provide opportuni- Environmental Health ties to enhance decision-making skills and increase self- confidence and independence. As mentors, occupational Nursing and environmental health nurses benefit from the satis- Ethics and Professionalism faction of knowing that the success of others has been promoted and these individuals will assume positions of Rogers, B. influence and leadership (Sidebar 3). Workplace Health & Safety, 2012; 60(4), 177-181.

Advancing the Profession, Practice, Occupational health professionals face many and Discipline ethical issues in the course of practice. As part of professionalism, nurses are account- 1 able for their own professional development to enhance Occupational and environmental health nurses professional growth and competency and contribute to 2 must be familiar with the ethical principles pro- scientific knowledge to improve practice. Professional viding a foundation for the ethical treatment of development is accomplished through lifelong learning workers. and development of evidence-based practice. Lifelong learning needs are based on self-assessment and initia- The AAOHN Code of Ethics can provide guid- tion of a plan to meet identified needs through academic ance for ethical decision making. and continuing education. Nurses may earn additional 3 academic qualifications and certifications needed for improved job performance or personal and professional achievement. American Association of Occupational Health Nurses, Inc. (2009). Nurses should actively integrate research findings Code of ethics. Pensacola, FL: Author. into practice and identify researchable practice problems Beauchamp, T. C., & Childress, J. E. (2008). Principles of biomedical ethics. New York: Oxford University Press. that can be studied to add new knowledge or improve spe- D’Arruda, K. (2001). Legal update: Application of the ADA to contin- cialty practice. gent workers. AAOHN Journal, 49, 323-324. Fry, S. T. (2000). Ethics in community-oriented nursing practice. In M. Summary Stanhope & J. Lancaster, Community and (pp. 116-137). St. Louis: Mosby. The practice of occupational and environmental Gallup. (2010). Honesty/ethics in professions. Retrieved from www. health nursing is comprehensive. It requires an inter- gallup.com/poll disciplinary knowledge base guided by nursing science. National Institute for Occupational Safety and Health. (2009). Genetics Occupational and environmental health nurses are strong in the workplace (Publication no. 2010-101). Cincinnati, OH: Author. advocates for workers, and approach ethical issues us- Nielsen, R. (1989). Changing unethical organizational behavior. The Academy of Management, 3, 123-130. ing rational decision making guided by ethical principles Pope, A. M., Snyder, M. A., & Mood, L. H. (1995). Nursing, health, & and the AAOHN Code of Ethics. As professionals, oc- environment. Washington, DC: Press. cupational and environmental health nurses benefit from Rest, K. M. (2010). Ethics in occupational and environmental health. In membership in their professional association, AAOHN. B. Levy, D. H. Wegman, S. L. Baron, & R. K. Sokas, Occupational and environmental health: Recognizing and preventing disease and All occupational and environmental health nurses are injury. Philadelphia: Lippincott Williams & Wilkins. obligated to maintain professional competence; many re- Rogers, B. (1988). Ethical dilemmas in occupational health nursing. sources exist to support this obligation. Career and pro- AAOHN Journal, 36, 100-105. fessional growth will be the outcome. Rogers, B. (2001). Why a code of ethics. AAOHN Journal, 49, 11-12. Rogers, B. (2003). Occupational and environmental health nursing: Concepts and practice. St. Louis: Elsevier. References Rogers, B., Marshall, J., Garth, K., Mopkins, D., Remington, J., Siemer- American Association of Occupational Health Nurses, Inc. (1999). ing, K., et al. (2011). Focus on the aging worker. AAOHN Journal, Standards of occupational and environmental health nursing prac- 59(10), 447-459. tice. Pensacola, FL: Author.

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