OCCUPATIONAL HEALTH AND SAFETY

I. INTRODUCTION
Occupational health Is the health science which is related to human work
work-place, and work environment. Occupational health is entirely preventive
medicine. The chief objective of occupational health is the safety of workers in all
occupations from injuries and diseases and to improve their health ' status.
Occupational health science gives priority to the welfare of the workers. Through
health protection and promotion, the efficiency of workers can be improved, thus
more work and production can be achieved, absenteeism can be checked and better
relationship can be established between workers and management. According to joint
committee of WHO and IL0 (1950), occupational health in all occupations should be
care and improve the physical, mental and social well-being of workers ,prevent
hindrances to health including those which occur due to work place, protect the
workers engaged in occupations and provide them a healthy environment. For
occupational health besides medical science, knowledge of mechanics, applied
physics and chemistry. hygiene, physiology, psychology etc. are also required.
II. DEFINITION

OCCUPATIONAL HEALTH
Occupational health should aim at the promotion and maintenance of the
highest degree of physical, mental and social well-being of workers in all occupations;
the prevention among workers of departures from health caused by their working
conditions; the protection of workers in their employment from risks resulting from
factors adverse to health; the placing and maintenance of the worker in an
occupational environment adapted to his physiological and psychological equipment,
and, to summarize, the adaptation of work to man and of each man to his job
(K. Park)
OCCUPATIONAL HAZARD
An occupational hazard is a hazard experienced in the workplace.
(Wikipedia)

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III. OCCUPATIONAL ENVIRONMENT

By “occupational environment” is meant the cum external conditions and

influences which prevail at the pl of work and which have a bearing on the health of
the working population. The industrial worker today is placed in a highly complicated
environment which is getting more complicated as man is becoming more ingenious.
Basically, there are three types of interaction in a working environment:
a) Man and physical, chemical and biological agents
b) Man and machine
c) Man and man.
MAN AND PHYSICAL, CHEMICAL AND BIOLOGICAL AGENTS
1. Physical agents: The physical factors in the working environment which may be
adverse to health are heat, cold, humidity, air movement, heat radiation, light,
noise, vibrations and ionizing radiation. The factors act in different ways on the
health and efficiency of the workers, singly or in different combinations. The
amount of working and breathing space, toilet, washing and bathing facilities are
also important factors in an occupational environment.
2. Chemical agents: These comprise a large number of chemicals, toxic dusts and
gases which are potential hazards to the health of the workers. Some chemical
agents cause disabling respiratory illnesses, some cause injury to skin and some
may have a deleterious effect on the blood and other organs of the body.
3. Biological agents: The workers may be exposed to viral. rickettsial, bacterial
and parasitic agents which may result from close contact with animals or their
products, contaminated water, soil or food.
MAN AND MACHINE
An industry or factory implies the use of machines driven by power with
emphasis on mass production. The unguarded machines, protruding and moving parts,
poor installation of the plant, lack of safety measures are the causes of
accidents which is a major problem in industries. Working for long hours in
unphysiological postures is the cause of fatigue, backache, diseases of joints and
muscles and impairment of the worker’s health and efficiency.

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 MAN AND MAN
There are numerous psychosocial factors which operate at the place of work.
These are the human relationships amongst workers themselves on the one hand, and
those in authority over them on the other. Examples of psychosocial factors include
the type and rhythm of work, work stability, service conditions, job satisfaction,
leadership style, security, workers participation, communication, system of payment,
welfare conditions, degree of responsibility, trade union activities, incentives and a
host of similar other factors, all entering the field of human relationships. In modern
occupational health, the emphasis is upon the people, the conditions in which they live
and work, their hopes and fears and their attitudes towards their job, their fellow-
workers and employers.
The occupational environment of the worker cannot be considered apart from
his domestic environment. Both are complementary to each other. The worker takes
his worries home, and brings to his work disturbances which arise in his domestic
environment. Stress at work may disturb his sleep, just as stress at home may affect
his work. Severe prolonged stress, no matter where it has been aroused, may produce
serious physical or mental symptoms which do not allow man to work efficiently.
According to ecological approach, occupational health represents a dynamic
equilibrium or adjustment between the industrial worker and his occupational
environment
IV. OCCUPATIONAL HAZARDS
An industrial worker may be exposed to five types of hazards, depending upon
his occupation:
a) Physical hazards
b) Chemical hazards
c) Biological hazards
d) Mechanical hazards
e) Psychosocial hazards
a) Physical hazards
1. HEAT AND COLD: The common physical hazard in most industries is heat. The
direct effects of heat exposure are bums, heat exhaustion, heat stroke and heat

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 cramps; the indirect effects are decreased efficiency, increased fatigue and enhanced
accident rates. Many industries have local “hot spots”- ovens and furnaces, which
radiate heat. Radiant heat is the main problem in foundry, glass and steel industries,
while heat stagnation is the principal problem in jute and cotton textile industry High
temperatures are also found in mines for instance in the Kolar Gold Mines of Mysore
which is the second deepest mine of the world (11,000 feet), temperatures as high as
65 deg. C are recorded. Physical work under such conditions is very stressful and
impairs the health and efficiency of the workers. For gainful work involving
sustained and repeated effort, a reasonable temperature must be maintained in each
work room. The Indian Factories Act has not laid down any specific temperature
standard. However, the work of Rao (1952, 1953) and Mookerjee et a1. (1953)
indicate that a corrected effective temperature of 69 to 80 deg. F (20°C to 27°C) is
the comfort zone in this country and temperatures above 80 deg. F (27°C) cause
discomfort.
Important hazards associated with cold work are chilblains, erythrocynosis
immersion foot, and frostbite as a result of cutaneous vasoconstriction. General
hypothermia is not unusual.
2. LIGHT: The workers may be exposed to the risk of poor illumination or excessive
brightness. The acute effects of poor illumination are eye strain, headache, eye pain,
lachrymation, congestion around the cornea and eye fatigue. The chronic effects on
health include “miner’s nystagmus”. Exposure to excessive brightness or “glare” is
associated with discomfort, annoyance and visual fatigue. Intense direct glare may
also result in blurring of vision and lead to accidents. There should be sufficient and
suitable lighting, natural or artificial, wherever persons are working.
3. NOISE: Noise is a health hazard in many industries. The effects of noise are of two
types:
i. Auditory effects which consist of temporary or permanent hearing loss
ii. Non auditory effects which consist of nervousness, fatigue, interference with
communication by speech, decreased efficiency and annoyance. The degree
of injury from exposure to noise depends upon a number of factors such as

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 intensity and frequency range, duration of exposure and individual
susceptibility.
4. VIBRATION: Vibration, especially in the frequency range 10 to 500 Hz, may be
encountered in work with pneumatic tools such as drills and hammers. Vibration
usually affects the hands and arms. After some months or years of exposure, the fine
blood vessels of the fingers may become increasingly sensitive to spasm (white
fingers). Exposure to vibration may also produce injuries of the joints of the hands,
elbows and shoulders
5. ULTRAVIOLET RADIATION: Occupational exposure to ultraviolet radiation
occurs mainly in arc welding. Such radiation mainly affects the eyes, causing intense
conjunctivitis and keratitis (welder’s flash). Symptoms are redness of the eyes and
pain, these usually disappear in a few days with no permanent effect on the vision or
on the deeper structures of the eye
6. IONIZING RADIATION: Ionizing radiation 19 finding increasing application in
medicine and industry, e.g., X-rays and radioactive isotopes. Important radio-isotopes
are cobalt 60 and phosphorus 32. Certain tissues such as bone marrow are more
sensitive than others and from a genetic standpoint, there are special hazards when
the gonads are exposed. The radiation hazards comprise genetic changes,
malformation, cancer, leukaemia, depilation, ulceration, sterility and in extreme cases
death. The International Commission of Radiological Protection has set the
maximum permissible level of occupational exposure at 5 rem per year to the whole
body.
b) Chemical hazards
There is hardly any industry which does not make use of chemicals. The
chemical hazards are on the increase with the introduction of newer and complex
chemicals. Chemical agents act in three ways: local action, inhalation and ingestion.
The ill-effects produced depend upon the duration of exposure, the quantum of
exposure and individual susceptibility.
1. LOCAL ACTION: Some chemicals cause dermatitis, eczema, ulcers and even
cancer by primary irritant action; some cause dermatitis by an allergic action.
Some chemicals, particularly the aromatic nitro and amino compounds such as

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 TNT and aniline are absorbed through the skin and cause systemic effects.
Occupational dermatitis is a big problem in industry. Rao and Banerji (1952) were
the first to draw attention in India to the prevalence of occupational dermatitis due
to machine oil, rubber, X-rays, caustic alkalies and lime.
2. INHALATION:
(i) DUSTS : Dust: are finely divided solid particles with size ranging from 0.1
to 150 microns. They are released into the atmosphere during crushing,
grinding, abrading, loading and unloading operations. Dusts are produced in
a number of industries- mines, foundry, quarry, pottery, textile, wood or
stone working industries. Dust particles larger than 10 microns settle down
from the air rapidly, while the smaller ones remain suspended indefinitely.
Particles smaller than 5 microns are directly inhaled into the lungs and are
retained there. This fraction of the dust is called ‘respirable dust”, and is
mainly responsible for pneumoconiosis. Dusts have been classified into
inorganic and organic dusts; soluble and insoluble dusts. The inorganic dusts
are silica, mica, coal, asbestos dust, etc.; the organic dusts are cotton, jute
and the like. The soluble dusts dissolve slowly, enter the systemic
circulation and are eventually eliminated by body metabolism. The insoluble
dusts remain, more or less, permanently in the lungs. They are mainly the
cause of pneumoconiosis. The most common dust diseases in this country
are silicosis and anthracosis,
(ii) GASES : Exposure to gases is a common hazard in industries. Gases are
sometimes classified as simple gases (e.g., oxygen, hydrogen), asphyxiating
gases (e.g. carbon monoxide, cyanide gas, sulphur dioxide, chlorine) and
anesthetic gases (e.g., chloroform, ether, trichlorethylene). Carbon
monoxide hazard is frequently reported in coal-gas manufacturing plants
and steel industry,
(iii) METALS AND THEIR COMPOUNDS: A large number of metals, and
their compounds are used throughout the industry. The chief mode of entry
of some of them is by inhalation as dust or fumes. The industrial physician
should be aware of the toxic effects of lead, antimony, arsenic, beryllium,

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 cadmium, cobalt, manganese, mercury, phosphorus, chromium, zinc and
others. The ill effects depend upon the duration of exposure and the dose or
concentration of exposure. Unlike the pneumoconiosis most chemical
intoxications respond favorably to cessation, exposure and medical
treatment.
3. INGESTION: Occupational diseases may also result from ingestion of chemical
substances such as lead, mercury, arsenic, zinc, chromium, cadmium, phosphorus
etc. Usually these substances are swallowed in minute amounts through
contaminated hands, food or cigarettes. Much of the ingested material is excreted
through faeces and only a small proportion may reach the general blood
circulation.
c) Biological hazards
Workers may be exposed to infective and parasitic agents at the place of work.
The occupational diseases in this category are brucellosis, leptospirosis, anthrax,
hydatidosis, psittacosis, tetanus, encephalitis, fungal infections, schistosomiasis and a
host of others. Persons working among animal products (e.g., hair, wool, hides) and
agricultural workers are specially exposed to biological hazards
.
d) Mechanical hazards
The mechanical hazards in industry centre round machinery, protruding and
moving parts and the like. About 10 percent of accidents in industry are said to be
due to mechanical causes. .
e) Psychosocial hazards
The psychosocial hazards arise from the workers failure to adapt to an alien
psychosocial environment. Frustration, lack of job satisfaction, insecurity, poor
human relationships, emotional tension are some of the psychosocial factors which
may undermine both physical and mental health of the workers. The capacity to
adapt to different working environments is influenced by many factors such as
education, cultural background, family life, social habits, and what the worker
expects from employment.
The health effects can be classified in two main categories

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 (a) Psychological and behavioral changes including hostility aggressiveness,
anxiety, depression, tardiness, alcoholism, drug abuse, sickness,
absenteeism
(b) Psychosomatic ill health : including fatigue, headache, pain in the
shoulders, neck and back; propensity to peptic ulcer hypertension, heart
disease and rapid aging.
Reports from various parts of the world indicate tha physical factors (heat,
noise, poor lighting) also play a major role in adding to or precipitating mental
disorders among workers. The increasing stress on automation, electronic
operations and nuclear energy may introduce new psychosocial health problems in
industry. Psychosocial hazards are therefore, assuming more importance than
physical or chemical hazards.
V. PREVENTION OF OCCUPATIONAL DISEASES
The various measures for the prevention of occupational diseases may be
grouped under three heads; medical, engineering and statutory or legislative.
1. MEDICAL MEASURES
i. Pre- placement examination
Pre-placement examination Is the foundation of an efficient occupational health
service. It is done at the time of employment and includes the worker’s medical,
family, occupational and social history; a thorough physical examination and a battery
of biological and radiological examinations, e.g., chest X-ray, electro-cardiogram,
vision testing, urine and blood examination, special tests for endemic disease. A fresh
recruit may either be totally rejected or given a job suited to his physical and mental
abilities. The purpose of preplacement examination is to place the right man in the
right job, so that the worker can perform his duties efficiently without detriment to his
health. This is ergonomics. The following is a list of some occupations in which it is
risky to employ men suffering from certain diseases.
Hazard Undesirable conditions
1 Lead Anaemia, hypertension, nephritis, peptic ulcer
2 Dyes Asthma; skin, bladder and kidney diseases; precancerous
lesions

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 3 Solvents Liver and kidney disease, dermatitis. alcoholism
4 Silica Healed or active tuberculosis of lungs, chronic lung disease
5 Radium and Signs of ill-health, especially any blood disease.
x-rays

Pre-placement examination will also serve as a useful bench-mark for future

comparison. It may be mentioned that in most countries, many workers start
employment without the benefit of a pre-employment medical examination. This is
particularly true of workers in small-scale industries and mines and those engaged in
construction and agricultural work in the developing countries.

2. Periodical examination
Many diseases of occupational origin require months or even years for their
development. Their slow development, very often, leads to their non-recognition in
the early stages and this is harmful to the worker. This is the reason why a periodical
medical check-up of workers is very necessary when they handle toxic or poisonous
substances.
The frequency and content of periodical medical examinations will depend
upon the type of occupational exposure. Ordinarily workers are examined once a year.
But in certain occupational exposures (e.g., lead, toxic dyes, radium) monthly
examinations are indicated. Sometimes, even daily examinations may be needed such
as when irritant chemicals like dichromates are handled. The periodical examinations
may be supplemented, where necessary by biological and radiological examinations.
Particular care should be given to workers returning from medical leave, to assess the
nature and degree of any disability and to assess suitability or otherwise of returning
to the same job.
3. Medical and health care services
The medical care of occupational diseases is a basic function of an
occupational health service. In India, the Employees State Insurance Scheme provides
medical care not only for the worker but also his family. Within the factory, first aid
services should be made available. Properly applied first aid can reduce suffering and

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 disability and hasten recovery. Immunization is another accepted function of an
occupational health service
4. Notification
National Laws and Regulations (Factories Act, 1976; Mines Act, 1952; Dock
Labourers Act, 1948; etc.) require the notification of cases and suspected cases of
occupational disease. in the Factories Act, a list of 22 diseases is included while in the
Mines Act 3 diseases and in the Dock Regulations 8 diseases are listed. These diseases
are recognized internationally for the purpose of workmen’s compensation. The main
purpose of notification in industry is to initiate measures for prevention and protection
and ensuring their effective application; and to investigate the working conditions and
other circumstances which have caused or suspected to have caused occupational
diseases
5. . Supervision of working environment
Periodic inspection of working environment provides information of primary
importance in the prevention of occupational disabilities. The physician should pay
frequent visits to the factory in order to acquaint himself with the various aspects of
the working environment such as temperature, lighting, ventilation, humidity, noise,
cubic space, air pollution and sanitation which have an important bearing on the health
and welfare of the workers. He should be acquainted with the raw materials, processes
and products manufactured. He should also study the various aspects of occupational
physiology such as occurrence of fatigue, night-work, shift-work, weight carried by
the workers and render advice to the factory management on all matters connected
with the health and welfare of the workers. For studies of this kind the physician
should enlist the cooperation of safety engineers, industrial hygienists and
psychologists.
6. Maintenance and analysis of records
Proper records are essential for the planning, development and efficient
operation of an occupational health service. The worker’s health record and
occupational disability record must be maintained. Their compilation and review
should enable the service to watch over the health of the workers, to assess the hazards
inherent in certain types of work and to devise or improve preventive measures.

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7. Health education and counseling
Ideally, health education should start before the worker enters the factory. All
the risks involved in the industry in which he is employed and the measures to be
taken for personal protection should be explained to him. The correct use of protective
devices like masks and gloves should also be explained. Simple rules of hygiene -hand
washing, paring the nails, bodily cleanliness and cleanliness of clothes, should be
impressed upon him. He should be frequently reminded about the dangers in industry
through the media of health education such as charts, posters and hand bills. The
purpose of health education is to assist the worker in his process of adjustment to the
working, home and community environment.
2.ENGINEERING MEASURES
1. Design of building
Measures for the prevention of occupational diseases should commence in the
blue-print stage. The type of floor, walls, height, ceiling, roof, doors and windows,
cubic space are all matters which should receive attention in the original plan of
the building which is put up by the industrial architect. Once the building is
constructed, it would be difficult to introduce alterations without much trouble and
expense.
2. Good housekeeplng
Good housekeeping is a term often applied to Industry, and means much the
same as when used domestically. It covers general cleanliness, ventilation,
lighting, washing, food arrangements and general maintenance. Good
housekeeping is a fundamental requirement for the control or elimination of
Occupational hazards. It also contributes to efficiency and morale in industry. The
walls, ceilings, and passages should be white-washed at least once a year. The dust
which settles down on the floor, ledges, beams, machinery and other stationery
objects should be promptly removed by vacuum cleaners or by wetting agents.
Masks, gloves, aprons and other protective equipment should be kept clean and in
a state of good repair. To prevent accidents, the right thing should be in the right
place. Not only the inside, but the outside of the plant should also be kept clean
and tidy.

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 3. General ventilation
There should be good general ventilation in factories. It has been recommended
that in every room of a factory, ventilating openings shall be provided in the
proportion of 5 sq. feet for each worker employed in such room, and the openings
shall be such as to admit a continued supply of fresh air. In rooms where dust is
generated there should be an efficient exhaust ventilation system. Good general
ventilation decreases the airborne hazards to the workers, especially hazards from
dusts and gases. The Indian Factories Act has prescribed a minimum of 500 cu. ft.
of air space for each worker.

4. Mechanization
The plant should be mechanized to the fullest possible extent to reduce the
hazard of contact with harmful substances. Dermatitis can be prevented if hand-
mixing is replaced by mechanical devices. Acids can be conveyed from one place to
another through pipes. There may be other similar situations where mechanization can
be substituted to hand operation.
5. Substitution
By substitution is meant the replacement of a harmful material by a armless one,
or one of lesser toxicity. A classical example is the substitution of white phosphorus
by phosphorus sesquisulphide tn the match industry, which resulted in the elimination
of necrosis of jaw (Phossy jaw). Zinc or iron paints can be used in place of harmful
lead paints; silver salts can be used in place of mercury salts; acetone can be used in
place of benzene. But substitution is not always possible in industry. Where possible,
it should be used to the fullest possible extent.
6. Dusts
Dusts can be controlled at the point of origin by water sprays, e.g., wet drilling
of rock. Inclusion of a little moisture in the materials will make the processes of
grinding, sieving and mixing comparatively dust-free. Wet methods should be tried to
combat dust before more elaborate and expensive methods are adopted.
7. Enclosure

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 Enclosing the harmful materials and processes will prevent the escape of dust
and fumes into the factory atmosphere. For example, grinding machinery can be
completely enclosed. Such enclosed units are generally combined with exhaust
ventilation.
8. Isolation
Sometimes it may be necessary to isolate the offensive
process In a separate building so that workers not directly connected with the
operation are saved from exposure, Isolation may not be only in space, but also in the
fourth dimension of time. Certain operations can be done at night in the absence of the
usual staff.

9. Local exhaust ventilation

By providing local exhaust ventilation dusts, fumes and other injurious
substances can be trapped and extracted “at source" before they escape into the factory
atmosphere. The heart of the local exhaust ventilation is the hood which is placed as
near as possible to the point of origin of the dust or fume or other impurity. Dusts,
gases and fumes are drawn into the hood by suction and are conveyed through ducts
into collecting units. In this way, the breathing zone of workers may be kept free of
dangerous dust and poisonous fumes.
10. Protective devices
Respirators and gas masks are among the oldest devices used to protect
workers against air-borne contaminants and they are still used for that purpose.
There are two classes of respirators :
(i) those which remove contaminants from air,
(ii) those to which fresh air is supplied.
The workers should know what kinds to use, and when and how to use.
Respiratory devices should not be used as substitute for other control methods. The
other protective devices comprise ear plugs, ear muffs, helmets, safety shoes, aprons,
gloves, gum boots, barrier creams, screens and goggles. The worker should be
instructed in the correct use of protective devices.
11. Environmental monitoring

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 An important aspect of occupational health programme is environmental
monitoring. It is concerned with periodical environmental surveys, especially
sampling the factory atmosphere to determine whether the dusts and gases escaping
into the atmosphere are within the limits of permissible concentration. The use of
“permissible limits” has played an important part in reducing occupational exposure to
toxic substances. Thermal environment, ventilation, lighting would also have to be
monitored. Such monitoring should be done by joint collaboration of doctors and
engineers.
12. Statistical monitoring
Statistical monitoring comprises review at regular intervals of collected data on
health and environmental exposure of occupational groups. The main objective of
these reviews is to evaluate the adequacy of preventive measures and
occupational health criteria, including permissible exposure levels.
13. Research
Research in occupational health offers fertile ground for study which can
provide a better understanding of the industrial health problems. There are two kinds
of research pure research and research for the improvement of, or in connection with
a manufactured product. Both are important. Study of the permissible limits of
exposure to dusts and toxic fumes, occupational cancer, accident prevention,
industrial fatigue and vocational psychology are some aspects of research in
occupational health.
3. LEGISLATION
Society has an obligation to protect the health of the worker engaged in diverse
occupations. It has grown out of the realisation that the worker is more important
than the machine which he operates. The worker cannot be permitted to endanger
his life and limb in an occupation, while the employ" makes a fortune. Factory
laws. therefore. have been framed In every country to govern the condition. In
Industry and to safeguard the health and welfare of the worker. The most impmtant
factory laws in India today are:
(1) The Factories Act. 1948
(2) The Employees' State Insurance Act. 1948

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 There are other specialized Acts adapted to the particular circumstances of the
industry. E.g. the Mine. Act, the Plantation Act, the Minimum Wages Act, the
Maternity Benefit Act etc. All these Acts lay down certain standards to which
the employer must comply to ensure health and safety to workers.

The Factories Act, 1948

The first Indian Factories Act dates as far back as 1881. The Act was revised
and amended several times, the latest being the Factories (Amendment) Act, 1987.
A brief description of the Act is given below:
The Act defines factory as an establishment employing 10 or more workers
where power is used, and 20 or more workers where power is not used. There is no
distinction between perennial and seasonal factories. The 1976 amendment
modifies the definition of the term ‘worker’ so as to include within its meaning
contract labour employed in the manufacturing process. The Act applies to the
whole of India except the State of Jammu and Kashmir. The State Governments are
authorized to appoint besides the Chief Inspector of Factories as many Additional
Chief Inspectors, Joint Chief Inspectors, Deputy Chief Inspectors and Inspector: as
they think fit to enforce the provisions of the law.
The Employees State Insurance Act, 1948
The ESI Act passed in 1948 (amended in 1975, 1984 and 1989) is an important
measure of social security and health insurance in this country. It provides for
certain cash and medical benefits to industrial employees in case of sickness,
maternity and employment injury. The Act extends to the whole of India. The ESI
Act of 1948 covered all power-using factories other than seasonal factories wherein
20 or more persons were employed (excluding mines, railways and defence
establishments). The provisions of the ESI (Amendment) Act of 1975 were
extended to the following new classes of establishments :
a) Small power-using factories employing 10 to 19 persons, and non-power-using
factories employing 20 or more persons
b) Shops;
c) Hotels and restaurants;

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 d) Cinemas and theatres;
e) Road-motor transport establishments; and
f) Newspaper establishments with effect from 1.10.2006
The Act covers all employees manual, clerical, supervisory and technical
getting up to Rs.10,000 per month. The provisions of the Act can be extended
to any other agricultural or commercial establishment.
VI. IMPORTANCE OF OCCUPATIONAL HEALTH IN HOSPITALS
Hospitals are large, organizationally complex system driven institutions
employing large numbers of workers from different professional streams. They are
also potentially hazardous workplaces and expose their workers to a wide range of
physical, chemical, biological, ergonomical and psychological hazards. Thus
Occupational Health and Safety issues relating to the personal safety and protection of
its workers is a very important Environmental Health concern for hospitals.
a) Personal (Staff) Protection- Physical Hazards
Radiation Exposure
There is a wide range of radiation hazards related to medical imaging (x rays,
nuclear scans utilizing radioactive isotopes) and radiation oncology which utilizes
ionizing radiation from a variety of sources to treat a range of malignant tumors.
These sources include
i. sealed sources containing radioactive material such as isotopes of radium,
cobalt and strontium, and
ii. linear accelerators emitting short wave length gamma waves.
Licensing users of this technology is strictly controlled
i. appropriate training, certification and credentialing of users
ii. demonstrated implementation of safety precautions related to storage, use and
shielding of non target personnel
iii. regular inspection, maintenance and certification of equipment by the
Department of Physics within Queensland Health, and
iv. ongoing monitoring of radiation exposure of staff using the equipment.
Back injury

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 Hospital staff and particularly nurses are prone to back injury from the need to
lift and roll immobilized or disabled patients for toilet, washing, dressing and pressure
care. Hospitals are now required to give training on back care to all new staff. This
training combined with the use of wards persons to assist nurses and the use of
hydraulic lifting devices has decreased the risk of back injury considerably
Burns due to Steam Sterilizing
Larger hospitals now have Central Sterilizing Departments utilizing
appropriately trained, dedicated staff, that are familiar with and follow set policy and
procedure. This type of specialized set up minimizes risk of physical injury from hot
equipment. However, smaller peripheral steam sterilizers are still required in some
departments such as the Operating Theatres.
Where possible many smaller satellite hospitals now use the Central Sterilizing
Department of their larger referral Base Hospital for their sterilization needs.
Laser Burns
Lasers are now frequently used in Operating Theatres and appropriate
protective equipment must be used, especially eye protection to prevent retinal burns.
The use of this equipment is covered by set protocols.
Electrical Defibrillators
Use of this equipment is restricted to those staff who have undergone
competency based training and certification.
Personal Violence
Risk of injury from personal violence is an important hazard in Emergency
Departments who at times deal with mad, bad or intoxicated patients. Similarly,
Psychiatric Units who have to look after the psychotically disturbed are also at risk.
Again, staff education and set policy and procedure needs to be in place for dealing
with aggressive patients. Personal security alarms, a system for rapidly mobilizing
ancillary staff, and a set approach to safely restraining, immobilizing and sedating
violent patients are all important components.
b) Personal (Staff) Protection- Chemical Hazards
Toxic chemicals is use in hospitals include
i. Industrial cleaners used by contracted cleaning staff.

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 ii. Chemical stertiizers, in particular gluteraldehyde used for the sterilization of
endoscopes and other equipment that cannot be steam sterilized.
iii. Tissue preservatives such as formaldehyde used to store and preserve body
tissue prior to histopathology.
iv. Chemical reagents used in the hospital pathology laboratory.
v. Cytotoxic drugs requiring preparation prior to parenteral administration to
cancer patients.
vi. Processing chemicals for X-ray film development.
vii. Anesthetic gases in the Operating Theatre.
The hierarchy of principles for controlling chemical hazards are well documented and
utilized within hospitals
i. Elimination (use an alternative process or strategy eg. disposables).
ii. Substitution (use the least toxic chemical that will do the job).
iii. Isolation (keep the relevant chemical in one isolated area if possible).
iv. Enclosure (e.g. gluteraldehyde fume cupboard, preparation enclosure for
cytotoxics, closed circuit anesthetic machines with scavenging of exhaust
gases)
v. Ventilation (X-ray processors).
vi. Personal protection (gloves, goggles. plastic gowns etc. where appropriate).
vii. Personal hygiene (hand washing after use).
viii. General cleanliness (clean up spills. appropriate storage, etc.).
Again, relevant staff must have appropriate training and education in the use of any of
these chemicals, and must be informed of any dangers including those of low risk.
c) Personal (Staff) Protection- Biological Hazards

Management of biological hazards should be comprehensively covered in the

hospital's Infection Control Manual. with the policies and procedures developed and
monitored by an Infection Control Committee chaired by an Infection Control Nurse.
There are 3 imponant modes of disease transmission from patients to staff:
1. Airborne and droplet aerosol exposure includes viral upper respiratory tract
infections. measles and TB. Preventative measures include
i. Keeping distance (>1m) from frontal coughing as much as possible

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 ii. Wash hands after every patient contact and especially avoid rubbing eyes
before washing
iii. High liltration face masks (where applicable generally not practical in the
outpatient setting)
iv. Isolate inpatients in a negative air pressure room.
2. Skin contact exposure includes Staphylococcus aureus and Varicella. Prevention

requires protective gown and gloves.

3. Exposure to infectious fluids via broken skin, eyes, mucous membranes, and

parenteral exposure includes hepatitis B. hepatitis C. and HIV from all body fluids
except sweat, as well as gastroenteritis and hepatitis A from fecal fluid. Preventive
measures include universal precautions (gloves. gown. goggles and mask) and
appropriate management of sharps. spills, and contaminated waste.
If acute exposure to a biological hazard does occur, staff members need to be aware
of relevant policies and procedures for appropriate management of the exposure. This
will include:
i. Appropriate washing for mouth, eyes or skin exposure
ii. First aid for penetrating sharps injury
iii. Prophylaxis for high risk exposure
iv. Testing of the source if possible
v. Testing and follow up of exposed staff
vi. Incident reporting.
d) Personal (Staff) Protection-Psychological Hazards
Hospitals are stressful places for sick and injured patients and their families.
However they can also be stressful for staff due to such factors as:
Shift work, on call duty, fatigue and “burn out”.
i. High workload and demand.
ii. High or unrealistic patient expectations.
iii. Verbal abuse or threats from disgruntled or intoxicated patients.
iv. High or unrealistic expectations from supervisors and management.
v. Problematic interpersonal work relationships.
vi. Frustrations due to limited resources, especially staffing levels.

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vii. Poor organizational climate with low staff morale.
Hospitals are part of a high demand, high expectation service industry and are
heavily reliant on staff for the friendly, safe, effective and efficient delivery of
services. To optimize productivity and attitude of staff, senior management must be
committed to ensuring a conducive organizational climate with high staff morale.
Clear priorities and direction, realistic performance goals and workloads, commitment
to continuing education and quality assurance, reception to staff feedback, and support
with counseling services for stressed staff are all important components.
Patient Protection
Nosocomial Infection Control
Minimizing adverse outcomes of health care for inpatients is of prime
importance to hospitals and a major focus of Quality Assurance activities. A very
significant indicator of quality care is the nosocomial infection rate.
The hospital’s Infection Control Nurse and Infection Control Committee are
ooncemed with the prevention, surveillance and control of nosocomial infections. The
Infection Control Program should be documented in the hospital’s Infection Control
Manual, which outlines the principles, strategies, policy and procedures for infection
control in the hospital. All staff needs to be familiar with its contents.
Regular feedback on surveillance of nosocomial infection rates will help motivates
staff to remain vigilant.
Patient Safety
Injury prevention for patients may require some of the otlowing interventions
when appropriate
i. Diligence in keeping bed rails up particularly for those patients with an altered
conscious state from medication or illness.
ii. Bathroom / toilet aids particularly for the elderly or disabled.
iii. Nurse and physiotherapy assisted mobilization during recovery.
iv. Walking aids for the disabled, and during recovery.
v. Occupational therapy home assessment for home aids.
vi. Community nurse visits for bathing etc. following discharge
Evacuation Plans for Internal Emergencies

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 Various internal emergencies including fure, explosion and bomb threat may
require evacuation of all or parts of the hospital. Well-documented and rehearsed
evacuation plans are required to ensure the safe evacuation of disabled, immobilized
or otherwise helpless patients. In critical care areas this will include manual back up
for life support systems.
Food Safety
Hospital kitchens prepare meals for inpatients and in many cases prepare meals for the
staff canteen. It is obviously imperative that food storage, handling and preparation
is done to the highest standards and poses no risk to already sick or compromised
patients.
VII. ROLE OF NURSE MANAGER IN OCCUPATIONAL HEALTH
Occupational health nurses, as the largest single group of health care
professionals involved in delivering health care at the workplace, have responded to
these new challenges. She/he will work as a nurse manger in occupational health.
They have raised the standards of their professional education and training,
modernized and expanded their role.
By keeping the above conditions in mind, the nurse manger has to play four major
roles in occupational health programmes as follows:
i. Professional role
ii. Environmental role
iii. Managerial role
iv. Educational role
Professional role
An occupational health nurse (OHN) assesses workers for evidence of both
occupational and non-occupational injuries and illnesses. Often the initial screening is
done by the plant foreman in an industry or a supervisor in another organization.
These personnel are usually in close contact with the workers. After referral from
these sources, the OHN begins a more thorough assessment. Knowledge of
occupational processes and their toxic effects as well as the chronic and acute diseases
and injuries affecting this age group is helpful in this assessment. Nurses are interested

21
in preventing diseases resulting from occupational hazards and in early diagnosis for
workers showing signs and symptoms of deviation from the normal.
Occupational health nurses plan with physician for periodic physical
examination and follow-up of exposed workers. Nurses may also give emergency care
based upon written orders for emergency nursing within their job description and
limitations of professional nursing practice. Following this care, they will find
placement for the workers as indicated in the standard orders and policies, and will
notify the appropriate people such as the physician and management. At the same time
they will use epidemiologic concept in viewing this illness or injury as it relates to the
worker and the environment to determine if injury and illness of other workers can be
prevented.
Nurses also select, train and supervise auxiliary nursing personnel to be used in
selected aspects of occupational health nursing programme. In addition they work
closely with plant foreman and supervisors, teaching them the knowledge they require
to prevent diseases and injuries to case finding.
Environmental Role
An occupational environment is the sum of external conditions, influence
which prevail at the place, of work and which have a bearing on the health of the
working population. For example in industry the worker has three types of interaction
in a working environment.
i. Man and physical, chemical and biological agents e.g., Physical: Heat, cold,
radiation, etc.
Chemical: toxic dust and gases
Biological: viral, bacteriological, rickettsial, etc.
ii. Man and machine e. g., operating machines.
iii. Man and Man, e. g., human relation
Occupational health nurses periodically assess the environment and all the
facilities in the organization to maintain a healthy working environment and to detect
and appraise health hazards. In addition to chemical substances, physical state of the
environment, mechanical factors and infectious agents, nurses also assess the optimal
conditions for work, such as lighting, ventilation, temperature and humidity and

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cleanliness of all areas in the organization to prevent contamination. This assessment
in conjunction with the knowledge of plant processes, modes of transmission of
causative agents, and conditions for optimal work output gives baseline for
recommendations to those in management for preventive and corrective measures.
To provide safe environment in the occupational setting particularly in
industrial setting, the Bhore committee recommended following measures to improve
occupational health in India.
1. Working hours should be reduced to 45 hours per week and 8 hours of work
only per day with midday rest for an hour and night duty to be limited to a
fortnight.
2. Periodic inspection of the plant (industry) is to supervise the ventilation,
cleanliness, dust gases, heat, light, drinking water, toilet facilities and sanitary
arrangements.
3. Periodic medical check-up of the workers to detect any signs of sickness.
4. Precautions should be taken to prevent accident by the worker and also by the
management, e.g., supply and advise to wear protective devices such as goggles,
apron and gloves and take precautions while handling machines to avoid related
hazards.
5. There should be adequate lighting and ventilation just to avoid related hazards
like eye defects, accidents minor ailments, e.g., by providing proper lighting and
air conditioning.
6. There should be proper washing facilities to maintain cleanliness and prevent
infection.
7. The workers should be taught to gain knowledge about rules for safety,
prevention of health hazards and need for regular medical check-up.
8. The workers should be provided with proper house, eg., a single person should
have a room 10' x 12' x 10' in size with verandah 8' x 8' and for married person
two rooms of such size, a kitchen and a toilet need to be provided.
9. The industries are required to provide canteen facilities when there are more
than 250 employees with reasonable cost. It is expected that the canteen should

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 adopt proper sanitary measure, to avoid gastrointestinal infection and
infestation. It helps to prevent malnutrition.
10. The industries are expected to provide health care facilities to the workers for
early diagnosis, treatment, prevention and rehabilitation.
11. The environmental sanitation requires to be established to order to prevent and
control the communicable diseases, e.g., water supply, food, toilet facilities,
adequate floor surface, ventilation and disposal of wastage and garbage system.
12. Women workers should have the privilege of 3 months maternity leave.
13. Creches should be provided where more than 50 women are employed in the
industry.
14. First aid training should be given to workers.
15. Proper measures to be taken for promotion of mental health and prevent mental
illness.
16. Health education is an integral part of total health programme.
Managerial Role
Occupational health nurses also work closely with management They may
report unsafe and hazardous Conditions, the health condition of employees
necessitating a change in area of employment or health conditions of workers
requiring medical attention and a leave from work. They work closely with
management. They may report unsafe and hazardous conditions, the health condition
of employees necessitating a change in area of employment, or health conditions of
workers requiring medical attention and a leave from work.
Industry is an open system where there are exchanges between industry and the
community. Workers bring their attitudes, knowledge, skills and personal problems
to the work setting and these may influence that work productivity. In addition, they
bring the illness and some of these, such as acute communicable diseases, may affect
others in the organisation. Thus there is a need for nurses to use the nursing process
in relation to home and work problems to improve the health and productivity of the
workers. In addition, there is an exchange between the organisation (economic
subsystem) and other community resources (social, health or welfare sub-system).

24
 Nurses establish relationship with the community. This may involve
interpreting the health needs of the workers. It may also involve setting up a referral
system to arrange care for workers and their families or it may involve compiling
data on absenteeism owing to illness to be used in calculating illness rates for the
community. Nurses may also work closely with nursing programmes and health
agencies to provide learning experiences for students and others interested in
occupational health nursing. Occupational health nurses also take part in planning,
formulation and implementation of policies related to the health and welfare of the
workers and their organizations.
Educational Role
With regard to provide education to worker, occupational health nurse is
expected to play a vital role, according to the circumstances such as advisor,
counselor, educator, environmentalist, hygienist, interpreter (law), leader,
rehabilitator, researcher, safety expert, student and supervisor.
To sum up, the objectives of occupational health services are concerned with:
i. The effects of work on health.
ii. Monitoring of the environment and development of control method.
iii. Identification and advice on hazards.
iv. Periodic examination related to identified risk
v. Interpretation of the law (e.g., factory, commercial, professional)
vi. Health supervision of welfare facilities.
vii. Epidemiological, sickness absence
viii. Disaster planning.
ix. The effects of health on work.
x. Examination relative to job demands, e.g. preemployment and special
hazards.
xi. Rehabilitation and resettlement.
xii. Care for special groups, eg: disabled, the young pregnant women.
xiii. Health advice to employees/patients.
To help in achieving these objectives, the occupational health nurse will be
involved in the following functions:

25
 i. Health supervision at the place of work.
ii. Health education.
iii. Occupational safety.
iv. Environmental monitoring.
v. Counselling.
vi. The organization of an emergency treatment service for accident and illness at
work.
vii. Provision of a routine treatment service.
viii. Rehabilitation and resettlement.
ix. Administration of occupational health unit including its developments.
x. Co-operation with outside agencies.

In addition to the above, another five major practice roles exist in occupational
nursing. The occupational health nurse may fulfill several, often interrelated and
complimentary, roles in workplace health management including:
1. Clinician
2. Specialist
3. Manager
4. Co-ondinator
5. Adviser
6. Health educator
7. Counsellor
8. Researcher
1. CLINICIAN
a) Primary prevention-The occupational health nurse is skilled in primary
prevention of injury or disease. The nurse may identify the need for, assess and
plan interventions to, for example modify working environments, systems of
work or change working practices in order to reduce the risk of
hazardous exposure.
b) Emergency care- The occupational health nurse is a Registered Nurse with a
great deal of clinical experience and expertise in dealing with sick or injured

26
 people. The nurse should provide initial emergency care at workers injured at
work transfer of the injured worker to hospital and emergency services.
Occupational health nurses employed in mines, on oil rigs. In the desert regions
are more responsible for this work
c) Treatment services- In some countries occupational health services provide
curative and treatment services to the working population, In other countries
such activities are restricted.
d) Nursing diagnosis - Occupational health nurses are skilled in assessing client's
health care needs establish a nursing diagnosis and formulating appropriate
nursing care plans in conjunction with the patient or client groups to meet those
needs. Nurses can then implement and evaluate nursing interventions designed to
achieve the care objectives. The nurse has a prominent role in assessing the
needs of individuals and groups and has the ability to analyze, interpret, plan and
implement strategies to achieve specific goals.
e) Individual and group care plan- The nurse can act on the individual, group,
enterprise or community level.
f) General Health advice and health assessment- The occupational health nurse
will be able to give advice on a wide range of health issues, and particularly on
their relationship to working ability, health and safety at work or where
modifications to the job or working environment can be made to take account of
the changing health status of employees.
2. SPECIALIST
i. Occupational health policy, and practice development, implementation
and evaluation : The specialist occupational health nurse may be involved,
with senior management in the enterprise, in developing the workplace health
policy and strategy including aspects of occupational health, workplace health
promotion and environmental health management.
ii. Occupational health assessment: Occupational health nurses can play an
essential role in health assessment for fitness to work, pre employment or pre
placement examinations, periodic health examinations and individual health
assessments for lifestyle risk factors.

27
 iii. Health surveillance: Where workers are exposed to a degree of residual risk of
exposure and health surveillance is required by law the occupational health
nurse will be involved in undertaking routine health surveillance procedures,
periodic health assessment and in evaluating the results from such screening
processes. The nurse will need a high degree of clinical skill when undertaking
health surveillance and maintain a high degree of alertness to any abnormal
findings.
iv. Sickness absence management : Occupational health nurses can contribute by
helping managers to manage sickness absence more effectively. The nurse may
be involved in helping to train line managers and supervisors in how to best use
the occupational health services.
v. Rehabilitation : Planned rehabilitation strategies, can help to ensure safe
return to work for employees who have been absent from work due to ill health
or injury. The occupational health nurse is often the key person in the
rehabilitation programme who will, with the manager and individual employee,
complete a risk assessment, devise the rehabilitation programme, monitor
progress and communicate with the individual, the occupational health
physician and the line manager.
vi. Maintenance of work ability : The occupational health nurse may develop
pro-active strategies to help the workforce maintain or restore their work
ability.
vii. Health and safety
viii. Hazard identification: The occupational health nurse often has close contact
with the workers and is aware of changes to the working environment. Because
of the nurses expertise in health and in the effects of work on health they are in
a good position to be involved in hazard identification.
ix. Risk assessment: Legislation is increasingly being driven by a risk
management approach. Occupational health nurses are trained in risk
assessment and risk management strategies depending upon their level of
expertise.

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3. MANAGER
i. Management: In some cases the occupational health nurse may act as the
manager of the multidisciplinary occupational health team, directing and
coordinating the work of other occupational health professionals. The OH
nurse manager may have management responsibility for the whole of the
occupational health team, or the nursing staff or management responsibility
for specific programmes.
ii. Administration: The occupational health nurse can have a role in
administration. Maintaining medical and nursing records. monitoring
expenditure, staffing levels and skill mix within the department, and may
have responsibility for managing staff involved in administration.
iii. Budget planning: Where the senior occupational health nurse is the budget
holder for the occupational health department they will be involved in
securing resources and managing the financial assets of the department. The
budget holder will also be responsible for monitoring and reporting within
the organization on the use of resourses.
iv. Marketing
v. Quality assurance
vi. Professional audit
vii. Continuing professional development
4. CO-ORDINATOR
Occupational health team: The occupational health nurse, acting as a
coordinator, can draw together all of the professionals involved in the occupational
health team. In many instances the nurse will be the only member of the team who
is permanently employed by the institution.
Worker education and training: The occupational health nurse has a role in
worker education. This may be within existing training programmes or those
programmes that are developed specifically by occupational health nurses to, for
example, inform, educate and train workers in how to protect themselves from
occupational hazards, workplace preventable diseases or to raise awareness of the
importance of healthy practices.

29
 Environmental health management :The occupational health nurse can advise
the enterprise on simple measures to reduce the use of natural resources, minimise
the production of waste, promote re-cycling and ensure environmental health.
5. ADVISER
To management and staff on Issues related to workplace health management:
Occupational health nurses act as advisers to management and stair on the
development of workplace health policies and practices, and can fulfil an advisory
role by participating in, for example, health and safety committee meetings, health
promotion meetings, and may be called upon to provide independent advice to
managers or workers who have specific concerns over health related risks.
As a conduit to other external health or social agencies: Occupational health
nurses act in an advisory role when seeing individuals who may have problems
that, whilst not directly related to work may affect future work attendance or
performance.
6. HEALTH EDUCATOR
Workplace Health promotion -Health education as one of the key prerequisites
of workplace health promotion is an integral aspect of the occupational health
nurses' role. In some countries the nurse is required to support activities aimed at
adoption of healthy lifestyles within on-going health promotion process, as well as
participate in health and safety activities. Occupational health nurses can carry out
a needs assessment for health promotion.
7. COUNSELLOR
Counselling and reflective listening skills -Where the nurse has been trained in
using counselling or reflective listening skills they may utilize these skills in
delivering care to individuals or groups.
Problem solving skills Due to the close working relationship which occupational
health nurses have wit!1 the working population, and because of the nurses r
non position of trust, occupational health nurses are often approached for advice
on personal problems.
8. RESEARCHER

30
 Research skills- Nurses are becoming increasingly familiar with both quantitative
and qualitative research methodologies, and can apply these in occupational health
nursing practice. In the main, occupational health nurses working at the enterprise
level, are more likely to use simple survey techniques, or semistructured
interviews, and to use descriptive statistical techniques in their presentation of the
data.
Evidence based practice- Occupational health nurses are skilled in searching the
literature, reviewing the evidence available, which may be in the form of practice
guidelines or protocols, and applying these guidance documents in a practical
situation. Occupational health nurses should be well skilled in presenting the
evidence, identifying gaps in current knowledge.
Epidemiology The most widely used and accepted form of investigation into
occupational related ill health and disease is based on large-scale epidemiological
studies.
VIII. SUMMARY
So far we discussed about occupational health and safety. First we discussed about
introduction, definition, occupational environment, occupational hazards, prevention
of occupational diseases, importance of occupational health in hospitals and finally we
saw about role of nurse manager in occupational health.
IX. CONCLUSION
Occupational diseases should not be neglected and should give proper attention
at time. It is the main role of a nurse to work as an educator, manger and protector in
the field of occupation. Early detection and timely management can control
occupational diseases. It is important that the management of safety is systematic and
core safety elements are integrated so that OHS risks can be controlled effectively in a
large and complex working environment. Governmental bodies are interested in
monitoring and regulating hospital services to ensure that minimal standards of safety
and quality of care are being delivered.
X. RESEARCH ABSTRACT.
Cheng LI, University of Campinas, Brazil.Occupational Safety and Health
Guidelines for the Retail Industry

31
 Occupational health centered among the service sector, retail development is
expanding dramatically in most countries, especially in these developing economies,
for example, nearly 20 per cent accounted for the regional GDP in ASEAN. This
growth not only contributes towards the development of economy but also creates
employment opportunities. For instance, 19 per cent in Brunei Darussalam, 18 in
Indonesia, 17 in Malaysia and 16 per cent of Thailand employment share are taken up
by the retail industry.

Occupational Safety and Health (OSH) is an important part of the workplace

environment. Both the worker and the employer have a responsibility to keep the
workplace a safe environment. Yet comparative mapping of several national profiles
of OSH legislation has revealed current standards of OSH for the retail sector to be
seriously inadequate or even absent. However, the public face of safety and health is
often restricted to incidents when fatal accidents or serious incidents occur, it is also
important to remember that OSH includes such aspects as the general wellbeing of all
workers. Taking the retail workers as example, every year many people suffer long-
term injuries at the workplace, subsequently affecting their lives and their ability to
work. Furthermore, the retail environment necessitates some unique OSH conditions
to be taken into consideration.

This research will determine the legal and practical provisions for OSH in the retail
industry in various countries and retail establishments. These have been classified
according to the various OSH risks, are to serve as guidelines for the implementation
of specific legislation by governments, specific regulation by retail stores, as well as
further campaigns and training by trade unions.

XI. BIBLIOGRAPHY
1. K.Park, Textbook of Preventive and Social Medicine.20ed.Bhanot publications
2. Basavanthappa B T. Nursing Education.1sted.New Delhi: Jaypee Brothers Medical
Publishers;2003.
3. Deepak.k,sarath chandran .C,Mithun Kumar.B.P.A comprehensive Text book on
Nursing Mangement.Emmess publication;2013.

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4. Kesav Swarnakar.A Text book for Community Health Nursing,Bhanot
Publications.
5. DC Joshi,Mamta Joshi.Hospital Administration. I edition. New Delhi Jaypee
Brothers Medical Publishers 2009.
6. Basavanthappa B T.Community Health Nursing;second edition, Jaypee Brothers
Medical Publishers;2008

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