Better by degree?

ANNE HARRISS

OH nursing is a distinct specialism within the family of nursing. Educational programmes for OH nurses, originally known as industrial nurses, have a long history. The Royal College of Nursing offered the first industrial nursing course around 70 years ago. This course was replaced by the OH Nursing Certificate (OHNC), validated by the Royal College of Nursing (RCN), and the OHNC was in turn replaced by the Diploma in OH Nursing (DOHN) validated by the national boards including the ENB. The past decade has seen a rapid development in the programmes offered to prepare these specialist practitioners to meet the needs of the 21st century. This has, in part, resulted from the changes in pre-registration nurse education.

Pre-registration nurse education is now delivered at diploma level as a minimum; nurses now qualify with a diploma in higher education (or equivalent) or, indeed, with graduate status. In the long term, nursing is likely to become an all-graduate profession, which will raise the professional status of nursing.

Specialist practitioner status is essential if OH nursing is to move forward as a profession in its own right. There has been extensive discussion, among OH nurses, particularly on the JISC mail site*, about the status of practitioners holding the previous qualifications of OHNC and DOHN.

These courses were the only ones which conferred ‘qualified occupational health nurse’ status when they were offered and as such the UKCC recognised that holders of such qualifications should also have the right to specialist practitioner status.

In common with many other practitioners, I believe the title ‘occupational health nurse’ should be protected and only those nurses who have completed a programme conferring specialist practitioner status should be eligible to call themselves an occupational health nurse. This may, in reality never occur. However, there was a move towards this when the third part of the Nursing and Midwifery Council (NMC) register opened in August 2004. Specialist practitioners will become Registered Specialist Community Public Health Nurses. (Further details are available on the NMC website.)

Such specialist registration is a cause for celebration, however, it has to be admitted that a number of tasks undertaken in the OH setting do not need to be performed by nurses qualified to degree level. Degree-level programmes are designed to enable their graduates to undertake a role in four broad domains: clinical practice; care and programme management; practice development; and leadership. Clearly not everyone who practices in the OH setting will be required to fulfil roles in these areas and many will not feel able to do so. There will always be a place for nurses who do not hold a degree in this discipline to work in the OH setting.

A specialist OH nurse is a valuable and costly resource. A skilled specialist practitioner will rapidly become demotivated and de-skilled if their skills are not used appropriately. A well-balanced skill-mix within the team, which may include non-specialist members, is in the interest of employer and practitioner alike. Caution is advised as the OH nurse must be seen to be adding value to the organisation; if they do not there is always the possibility that their employer may look on the non-specialist as a much cheaper alternative.

OH nurse education is frequently criticised by the profession as not meeting the needs of practitioners and therefore by implication not meeting the needs of employers. The curriculum content of OH courses is driven by the requirements of the statutory body. Some educators believe that meeting the requirements of that body, their own educational institutions and the needs of practitioners and employers has been a difficult balancing act.

In conclusion, there will be interesting times ahead for OH nursing. The inclusion of OHNs on the third part of the register acknowledges their specialist public health role. Although there is a place within an OH team for differing skill mixes, the icing on the cake would be for the title Occupational Health Nurse to become protected.

CYNTHIA ATWELL

In Occupational Health ,June 2004, Anne Harriss discussed the issues regarding the ‘theory-practice gap’ and stressed the importance of preparing practitioners to be ‘critical thinkers and knowledgeable doers – knowing how to undertake an occupational health skill as well as appreciating why they are doing it’. But how well is our present system of education achieving this?

Research carried out by Bamford and Warder in 2001 found that occupational health nurses (OHNs) working in the NHS wanted training opportunities which were offered on an ‘incremental basis’, not all at specialist practitioner level.1 They identified skill gaps in management, the application of health, safety and employment law, and in practical skills with particular reference to the workplace.

If everyone working in OH nursing must be qualified to graduate level then the profession will lose a number of very competent people, with skills gained through experience and other education programmes. ‘Specialist practitioner status’ should not just be based on qualifications, but assessed on the competence of an individual to operate at a specific level.

Qualifications are only the beginning, however. Once qualified, the nurse then needs to gain experience, skills and competence to undertake the role of an OHN. A study carried out by Jasper in 1994 discusses the concept of ‘expert’ as used in nursing.2 This found that the word ‘expert’ had many definitions to different people. This included ‘experienced person'; ‘specialist'; and ‘able to reflect on what they are doing’. Qualifications came very low on the list.

The nursing profession appears to be obsessed with degrees. But surely it is not the degree, but how skilled and competent the practitioner is at fulfilling the role of OHN?

The RCN, in its Competency Framework for Occupational Health Nursing sets out a graded skills matrix. OHNs will be able to assess their competence levels within this framework. The recent NMC consultation document on Standards for Specialist Community Public Health Nursing (SCPHN) discusses the standards required for entry to this part of the register and OHNs, with a recognised qualification in occupational health are to be included in this part of the register.

When employers seek clarification of the qualifications of OHNs, and they are registered as a SCPHN, then it would be reasonable for the employer to assume that the nurse is competent to operate at a high level and has the necessary skills and experience to support that.
The nurse who is a specialist practitioner should be able to demonstrate a high level of knowledge and skill in the speciality OH: the ability to carry out tasks such as a risk assessment. My personal experience is that this is not always the case, and degree-qualified OHNs are not being given these fundamental skills.

I fully support nurses undertaking degree-level programmes, to improve their overall education and gain knowledge of research, but are we going too far and losing other good competent people to the profession? I think perhaps we are.

There are many nurses working in OH who do not wish to undertake degree programmes for a variety of reasons, but this should not mean they are pushed out. Many of these nurses have a great deal of experience and are highly skilled in the speciality – all of which has been gained ‘on the job’.

If all nurses working in OH are specialist practitioners, then who will undertake the routine work, such as health assessments and surveillance? Should we introduce another type of person to do this, such as a ‘technician’, who is trained to undertake the routine tests and screening? This would equate to the changes in the NHS, where healthcare assistants are carrying out most of the basic nursing care, under the supervision and direction of qualified nurses. A number of companies are now doing this, including Bombardier and Capita Health.

Our survival depends on how we are valued by society and by businesses, the unions and by professional colleagues. We need to develop a stronger understanding of business and ensure we contribute to the overall success of the undertaking.

The whole nursing profession needs evidence to support the assumption that an all-graduate profession will provide a higher standard of care. There is plenty of anecdotal evidence to suggest that this is not the case, with much criticism about falling standards of nursing care within the NHS. Where is the evidence to indicate that degree-qualified OHNs are more competent practitioners?

Although the degree must be the ultimate goal for those aspiring to lead and manage OH services, let us look at different ways of developing the profession without losing competent non-degree nurses.

Anne Harriss is OH course director at London South Bank University. Cynthia Atwell is an OH consultant and visiting teaching fellow, University of Warwick. The opinions expressed are not necessarily the view of any organisations associated with the authors.


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