Claire Maurice G.

Juanero
BSN III-C

A. School Health Nursing

School nurses wear many hats in the school setting. They provide care for minor illnesses and
injuries; give or supervise health care for children with special health care needs; monitor health
screenings; advocate for students; participate in multidisciplinary teams; and counsel students,
families, and school staff. An important role for nurses in all settings is health education. In
nursing education programs, much emphasis is given in the classroom and in the clinical
practice setting about the importance of patients or clients understanding their health care
requisites in order to restore, maintain, or promote health. This information enables them to
make informed decisions, cope more effectively with temporary or long-term alterations in
health, and to assume greater personal responsibility for their health. Most nurses are quite
comfortable delivering information to patients/clients and families on the individual level. One on
one teaching, also known as patient teaching, usually focuses on the specific information
needed by a individual at this particular time. It can be customized to the individual’s situation
and his or her level of understanding, validated during the interaction, and questions answered
during the teaching session. This type of teaching is done by nurses in all settings, including
school nurses in the school health office. From a cost-effectiveness perspective, individual
patient teaching is a time-consuming and expensive nursing intervention. A more cost-effective
method of health education is to target large groups interested in specific topics such as
nutrition and weight loss, groups at risk for certain conditions such as sexually transmitted
diseases, or groups who have a need for specific information such as hand washing or oral
hygiene.

Although some of the steps in preparing teaching for individuals are the same as preparing an
educational program for a group, there are a number of factors that must be considered when
delivering health education to a group. Many baccalaureate nursing education programs
emphasize health education in community health nursing and have content on the process of
developing, implementing, and evaluating educational programs. Practicum students in
community settings, including schools, often develop and implement health education programs
as part of their clinical experience. School nurses need to continually develop their skills as
health educators in the school setting. This not only includes information about topics of interest
that are appropriate for the school-age population, but also encompasses the skills needed in
doing a needs assessment, writing objectives, developing programs, selecting strategies used
in delivering programs, and devising measurement tools needed to determine the outcomes or
effectiveness of health education.

Health education, rooted in the origins of modern nursing, has become one of nursing’s major
roles. Many of the early definitions of nursing emphasized the role of nurses in helping patients
achieve self-care by having the information and skills necessary to restore health, maintain
health, prevent disease, or move to a higher level of wellness. At the beginning of the 20th
century, a major concern of nursing was educating individuals, families, and communities about
the importance of nutrition, cleanliness, and preventing the spread of communicable disease. As
the knowledge about diseases and their treatment increased, nurses moved from the
community where health education was a major focus to hospitals where the emphasis was on
treating illness and delivering patient teaching to individuals and families. As we move into the
21st century, the importance of health education is once again evident as further gains to be
made in the health of Americans will be in the area of lifestyle modification, which will benefit
many, rather than highly technical and expensive treatments that benefit a few. Working to
prevent the chronic conditions that affect the health of many Americans, such as obesity,
diabetes, hypertension, cardiovascular disease, osteoporosis, and cancer, is more cost-effective
than treating these diseases once they are established. Because many of the health behaviors
that contribute to these conditions begin and are reinforced during childhood, nurses who work
with children and families have an opportunity to promote healthy lifestyles by providing health
education in the schools.

HEALTH EDUCATION: A ROLE FOR SCHOOL NURSES?

Many school nurses wonder about their role as health educators in schools. A discussion about
teaching health on the School Nurse Listserv during May motivated me to write this editorial.
Some school nurses did not believe that health teaching in the classroom is a nursing role—
they viewed health education in the classroom as a role for teachers. Many wondered if they
had the time to assume this time-consuming role, whereas others were not sure they had the
skills needed to plan, implement, and evaluate health education, to say nothing of managing a
large number of students in the classroom setting. In addition, some stated salary issues or
reimbursement for overload needed to be resolved before they would take on this additional
responsibility. On the other hand, there were school nurses who stated that health education is
an important role for school nurses, giving them the opportunity to see students in a more
natural setting, rather than only during a health crisis. These nurses also used these
opportunities to have students see them in a different role, increasing their visibility in the
school. Classroom contact also gave students who rarely or never visit the health office an
opportunity to become acquainted with the nurse and make them more comfortable with the
nurse in the event they wanted to ask health-related questions at a later time. These nurses
stated they had the educational background and experiences that gave them a more holistic
perspective on the health topics presented.

Standards of Practice

The National Association of School Nurses Standards for Professional School Nursing

Practice (NASN, 1998) includes a standard related to health education. “Standard XI. Health
Education” lists eight measurement criteria specifying the role of the school nurse as a health
educator in the school setting (Table 1). The standard states, “The school nurse assists
students, families, the school staff, and the community to achieve optimal levels of wellness
through appropriately designed and delivered health education” (p. 20). It is clear from this
standard that health education is within the scope of practice of the school nurse and is an
expectation for those whose practice is consistent with the standards outlined for the specialty
of school nursing.

THE HEALTH EDUCATION PROCESS

The nursing intervention Health Education is defined as “developing and providing instruction
and learning experiences to facilitate voluntary adaptation of behavior conducive to health in
individuals, families, groups, or communities” (Iowa Intervention Project, 2000). This definition
was adapted from the classic definition of health education by Green (Green & Johnson, 1983),
who also emphasized using a variety of strategies to achieve the goal of healthy behaviors.
The Nursing Interventions Classification (NIC) lists activities needed to implement health
education, from the identification of high risk populations and describing learner characteristics
to the planning, implementation, and evaluating of health education programs. This process is
similar to the familiar nursing process. These activities provide a framework for school nurses as
they embark on health education in the school setting.

Health education is a higher level nursing skill that requires education to efficiently and
effectively accomplish goals. Many nurses tend to teach as they were taught without thinking
about the theoretical base underpinning the educational process or taking adequate time to plan
engaging presentations that will enhance learning. It is important to consider that learning takes
place in three domains, and each needs to be considered when developing health education
programs.

The Domains of Learning

Cognitive Domain

The cognitive domain relates to the knowledge or information that learners need to know about
the topic (Bastable, 1997). There are six levels of learning in the cognitive domain. The first is
knowledge, or information about the topic. For example, it is important to know that the food
pyramid is a guide to food selection in a healthy diet. The second level is comprehension, or
understanding, of the information presented. Students need to know what the various
components of the food pyramid mean and why they are important to good health. Being able to
apply this information is the third level of learning. Knowledge about nutrition is not very useful
unless it can be applied to daily life in a practical way. Students need to know how to make
healthy nutritional selections in different situations—at school, at home, at a fast food
restaurant, or when selecting snacks. Emphasis on application is essential if there is to be any
practical relevance to the content presented. The fourth level of cognitive learning, for more
advanced learners, is the ability to analyze the information. In this instance, students would be
able to look at a typical diet recorded in a food diary and analyze the diet in relation to the food
pyramid. The fifth level, synthesis, indicates that the learners can take apart the information and
put it back together in a new and creative way. By using a food diary, students could analyze
the components of the diet and then plan or create a menu that was consistent with the daily
recommendations on the food pyramid. The final stage is evaluation, or being able to determine
the adequacy of the diet on a more global level and making recommendations for modifications
based on numerous factors considered during the evaluation process.

Too often nurses view health education as the giving or dispensing of information. There is the
belief that knowledge is power, and knowledge will have a dramatic effect on the target
audience of learners. Although knowledge is necessary, it is not sufficient to achieve the goal of
health education—healthy behaviors. For example, we know that adolescents have
considerable knowledge about the transmission of HIV and the risk of unintended pregnancy,
yet they do not personalize the risk or engage in behaviors that would protect them from the
potential consequences of unprotected sexual activity. On a more personal level, I often ask
undergraduate or graduate students in my health education classes if they know that regular
exercise is an important health promotion behavior. All agree about the importance of exercise,
yet when asked if they act on that knowledge, few report actually engaging in vigorous exercise
on a regular basis every week. I then pose the same question about getting adequate sleep and
eating breakfast every morning. This gives students a new appreciation that knowledge alone
does not ensure healthy behaviors. Ask yourself, do you act on all the health information you
have? Yet we expect that giving information to students and families will change their behavior.

Affective Domain

The next and very important question is: How can we bridge the gap between knowledge and
behavior? We need to consider the next domain of learning—the affective domain. The affective
domain relates to values and beliefs (Bastable, 1997). In order to act on information, the
individual must believe that the content is important and personally relevant. The information
also needs to be congruent with personal, cultural, and religious beliefs. Students who value
athletic performance may be motivated to change their nutritional practices. Steps of learning in
the affective domain include being receptive to new information; being responsive to the
information; attaching a value to the information; and finally internalizing, or valuing, the
information. Once an individual values the health information, it is more likely to be acted on or
become a part of the health-related behavior of that person.

Psychomotor Domain

Finally, in addition to having and valuing health information, psychomotor skills are necessary to
carry out the new behaviors. Learning in the psychomotor domain teaches the skills needed to
perform healthy behaviors (Bastable, 1997). Knowledge is often isolated from practical skills.
Learners may need skills in reading nutritional labels, shopping for foods with the desired
nutrients, and actually preparing healthy meals and snacks. These skills are acquired through
strategies such as demonstration and actual hands-on practice of the desired skill. It is essential
to consider each of the domains—cognitive, affective, and psychomotor—when planning health
education to ensure that students not only have the desired information, but also have
developed an appreciation for the desired behavior and possess the skills to achieve it.

Assessing the Need for Health Education

Doing a needs assessment is the first step in the development process. We may know risk
factors of a particular population or age group, have an idea of problems frequently seen in our
schools, or have an idea of what we think is important. However, a needs assessment will
gather information from students, parents, staff, or community members who can provide a
wider perspective and data about needs prevalent in the school population. Information for a
needs assessment can be gathered informally through feedback from a variety of individuals
and groups or more formally through questionnaires, data from health records, and community
statistics. From the data gathered during the needs assessment, a nursing diagnosis, such as
risk for infection or risk for injury, can be made (North American Nursing Diagnosis Association
[NANDA], 2001). This diagnosis will provide direction for health education and assure that the
time, effort, and money spent will target specific needs. Many times, numerous needs, all
seemingly important, are identified. The challenge is in being realistic about what can be
accomplished and prioritizing the needs identified. Important questions to ask include the
following: What is the most pressing need? What is the most realistic to achieve? What do you
have the skills and resources to do well? What is acceptable to the target audience? What is
acceptable to the community? The last two questions are particularly important when planning
health education related to sexuality.

Identifying the Target Population

The next step is identifying the target population, whether it be kindergartners or adolescents,
and the characteristics of this population. Characteristics may be general in nature, such as
developmental abilities or behavioral attributes of a certain age, or more specific, relating to
cultural and family factors or risk factors in a specific school population. These factors will help
guide in planning the outcome goals and the strategies chosen to meet these goals.

Formulating Goals and Objectives

After a topic has been identified, it is time to articulate a goal statement that answers the
question: What is it you are seeking to achieve? This should be a clear, concise statement that
is general in nature. For instance, the goal may be that elementary students wash their hands
after using the restroom and before lunchtime. Another goal might be that girls in a special
education class understand menstrual hygiene. More specific objectives are then written that
delineate the components of the program. Objectives should specify who is to exhibit the
desired behavior (the target audience of the health education); what behavior is expected at the
completion of the program; and the criteria for minimal performance standards. It is essential to
make objectives realistic, attainable, and measurable.

Planning for Health Education

Once the topic, the target audience, and the learner characteristics have been identified and the
goals and objectives formulated, it is time to plan the program. Considerations include the time
frame. This may be determined by the time allotted for a specific class or the developmental
level of the learners. Another important consideration is the topic and the proposed strategies.
When time is limited, as it usually seems to be, there is a temptation to want to cover a lot of
content in a short period of time. This leads to information overload or the “little bit of everything,
not much of anything” syndrome. It is better to select a few main points and make those points
memorable and practical.

Determine what resources are available for handouts, audiovisuals, or materials to be used in
practicing psychomotor skills, such as toothbrushes or feminine hygiene products. Advance
planning provides time to write for information or products needed. The skills of the school nurse
are important in the development of programs—some are creative at developing hands-on
activities; others have excellent computer skills used to develop signs, handouts, or games;
whereas others are good at the use of humor to hold the attention of the learners. Know your
gift and use it in health education programs. On the other hand, work at developing new skills
that will enhance your effectiveness as a health educator.
In addition to Health Education, the Nursing Interventions Classification (NIC) (Iowa Intervention
Project, 2000) has a number of other nursing interventions appropriate for the school setting
such as “Teaching: Sexuality,” “Teaching: Group,” “Sports Injury Prevention,” and “Substance
Use Prevention.” These NIC interventions list suggested activities specific to the intervention;
other activities can be developed to customize the intervention to the target population.

Outcome Measurement

An essential part of the planning process is determining if the program goals and objectives
have been met. Too often health education classes or programs are delivered with no thought
about evaluation. In this era of accountability, health professionals and teachers alike are being
asked to show in a very concrete manner the effectiveness of the efforts (Denehy, 2000).
Unfortunately, most nurses have not been taught or have not developed the skills needed to
perform this essential component of the nursing process. Carefully worded objectives provide
the framework on which to construct an evaluation tool. Data collected, whether from a quiz,
interview, or behavioral observation, needs to be directly related to the objectives. A real
challenge is in having baseline data, such as the knowledge or behavior status before the
intervention. Without this data, it is impossible to determine if the education made any
difference. Gathering this data takes planning and time, but provides the information needed to
justify the continuation of resource allocation for health education. The guiding principle here is
that anything worth doing is worth evaluating.

Another consideration in evaluating the effectiveness of health education is when to measure

outcomes. Certainly outcome measures administered soon after the completion of a class or
program are likely to show the most change. However, many of the goals for health education
involve long-term outcomes, such as classes designed to prevent tobacco use. The ultimate
goal of such programs is to have students choose to be smoke free not just the day after the
program, but for life. When, then, is the appropriate time to measure the effectiveness of the
program? One day, 1 week, 1 month, 1 year, or 5 years after the intervention?

The Nursing Outcomes Classification (NOC) (Iowa Outcomes Project, 2000) has a number of

outcomes that would be appropriate to measure the effectiveness of health education. These
include “Knowledge: Health Behaviors,” “Knowledge: Personal Safety,” “Health Beliefs,” and
“Health Promoting Behavior.” Each of these outcomes has a list of indicators related to the
specific outcome and a five-point scale used to measure the effectiveness of nursing
interventions. Indicators relative to the outcome can be selected from the list available, or new
indicators can be developed to measure the effectiveness of the specific health education class.
The knowledge-related outcomes measure outcomes in the cognitive domain, whereas “Health
Beliefs” relates to the affective domain, and “Health Promoting Behavior” is appropriate for the
psychomotor domain. Use of NOC outcomes gives the school nurse a readily available tool to
measure the outcomes of health education.

Learning Strategies

Selection of teaching strategies is crucial to the success of any educational endeavor. As Green
and Johnson (1983) emphasize in their discussion on health education, a combination of
strategies is needed. Knowledge of the learning domains assists in the selection of strategies.
When the goal is to present information in the cognitive domain, appropriate strategies may
include lecture, slides, videotapes, pictures, and handouts. When developing or selecting
handouts, a readability index will make sure that the material is appropriate for the target
audience. For presentations that plan to instill a value for a health-related behavior, appropriate
strategies for the affective domain include discussion, role playing, examples, and value-
clarification exercises. Manipulation of materials is essential for learning psychomotor skills
necessary to perform health-related behaviors. Strategies may include a demonstration of
techniques, allowing students to practice the behavior, and then return the demonstration.
Because most health education topics include learning in all three domains, the use of multiple
strategies not only promotes learning in each domain, but also helps maintain the attention of
the learner.

The Intervention

The most important part of the process is actually implementing the health education
intervention. However, the success of health education depends on careful planning. The
intervention is actually the shortest and most challenging part of the process, yet it is most
rewarding for the school nurse. It is a time when all the skills and planning come together to
educate children on a wide variety of health-related topics. School nurses bring extensive
knowledge and experience to the educational setting. They bring a unique and holistic
perspective to the topic and a level of expertise that no one else in the school setting has.
Participation in health education gives the school nurse a opportunity to share this knowledge
and to increase his or her visibility and credibility in the school setting. It also establishes a
unique bond with students who will see the nurse as a resource person on health-related
matters.

When doing health-related presentations, start strong, use easy-to-understand language,

engage the learners in dialogue or activities, give examples, and end strong. It is important to
remember the three Rs of learning: repetition, repetition, repetition. This is one way to
accentuate important points. Accentuate the positive, rather than pointing out the negative
consequences in health education presentations. Avoid the use of scare techniques, assuming,
for example, that knowing the dire consequences of smoking or reckless driving will discourage
students from engaging in these risky behaviors. Studies have shown that presenting immediate
advantages of not smoking, such as better breath, greater physical endurance, or more money
to spend on clothes or CDs, are more salient that presenting the harmful or long-term effects of
smoking (Wilson, Purdon, & Wallston, 1988).

Outcome Evaluation

The final step in the health education process is to measure the effectiveness of the class or
program. The method and timing of program evaluation was determined during the planning
stage. It is important to consider other types of evaluation. One is formative evaluation that is
ongoing during the implementation of the intervention. The nurse may notice that there is
outside noise that is interfering with attention, which can be eliminated by shutting the door, or
that the arrangement of student seating is not conducive to the hands-on activities, which can
be corrected by reorganizing a few desks. There may be other things that are noted during the
presentation that cannot be altered, but may be changed if the class is to be offered again, such
as the time of day, the selection of groups for activities, or the need for additional help with
special education students. Noting these factors immediately after the intervention will enhance
the effectiveness of subsequent health education endeavors. Another type of evaluation is
process evaluation that examines factors such as the choice of strategies, the appropriateness
of the content to the target audience, or the effectiveness of the marketing for after school or
parent education programs.

B. Occupational Health Nursing

What is Occupational Health Nursing?

Occupational health nursing is a field within the nursing discipline that involves developing
business health and safety programs or observing workers who have been injured on-the-job. If
you are interested in starting a career in nursing, it is important to be aware of all of the various
types of opportunities that exist. You can work in healthcare as a nursing professional without
working in a clinical setting at a doctor’s office, clinic or hospital. Read on and learn more about
this interdisciplinary field of health care so that you know whether or not this is the right
occupation for you.

What Do Occupational Health Nurses Do?

Occupational health nurses (OHNs) are specialists who practice in industrial and community
settings to help improve the health and safety of workers and other community groups. The role
of an OHN can be extremely diverse and specific responsibilities will depend upon where an
OHN is employed. Some of the most common roles and responsibilities of OHNs include:

 Observation of workers doing their job tasks to assess health statuses

 Development of innovative health and safety programs
 Management of work-related diseases
 Disaster and emergency planning
 Environmental health planning
 Assistance with rehabilitation
 Coordination of employee treatments and referrals
 Emergency care to injured employees who are on-the-clock
 Counseling employees and families when injured
 Conducting research and working with community organizations and health educators
 Working with executives to lower costs of disability claims or other related costs

What Settings Will OHNs Be Found in?

You can work in a broad array of settings when you are a professional occupational health
nurse. You may work in a classroom as an educator or researcher, or in a boardroom as a
corporate director. It is also common to find OHN professionals in clinic settings as a case
manager, nurse practitioner, or clinician. Some OHN’s are self-employed and work in business
settings as consultants who manage several clients at once.

How Do You Become an Occupational Health Nurse?

Before you can become an OHN, you need to complete a nursing program or earn your
Bachelor of Science in Nursing. After you possess your BSN degree, you can then take the
National Council Licensure Exam to get licensed in your state. Once you are an licensed
Registered Nurse, you must complete an Occupational Health Nursing program so that you can
sit for the certification exam through the American Board for Occupational Health Nurses. In
order to earn the mark of prestige that is a certification, you will need to complete a certificate
program and then complete 3000 hours in the field.

The demand for highly trained and experienced Occupational Health Nurses is on the rise as
employers search for ways to cut costs and to keep up with employment laws. If you would like
to work in a specialty area that is flourishing, you should consider the advantages of becoming a
Certified Occupational Health Nurse. Be sure to find out what types of training programs you
can complete to earn your certificate. Once you find Occupational Health Nursing programs, you
can map out the path that you will take to gain experience and get certified.