CPD: Advanced practice – a place at the table for OH nurses?

The role of an expert occupational health nurse is complex and demanding, meaning OHNs are potentially prime candidates to achieve the status of “advanced practice”. However, as Professor Anne Harriss argues, the nursing “credentialing” process is currently stacked against the specialty – and things need to change.

Occupational health (OH) nursing is a unique specialism within the nursing family. Unlike the practice of most nursing colleagues, occupational health nurses (OHNs) work with a predominantly well community and aim to keep them that way.

Many expert OHNs operate strategically, influencing the health and health and safety agenda of employers. They practice autonomously, utilising high-level critical thinking and complex problem-solving skills to devise strategies supporting employees with disabilities and/or long-term health conditions to remain economically active.

The role of an expert OHN is complex and demanding. A proportion of OHNs would be identified by both themselves and their peers as working at an advanced level, as they utilise an expert knowledge base, advanced comprehensive clinical competencies and their practice incorporates complex decision-making skills so will they achieve the status of advanced practice (AP). This status has been conferred on approximately 500 other specialist nurses, including nurse practitioners working in community settings.

NHS Wales (2010, p.10) notes that: “Advanced practice… is not exclusively characterised by the clinical domain but may also include those working in research, education, management/ leadership roles.”

The Department of Health and Social Care (2010) and the Royal College of Nursing (RCN 2018a) recognise that AP is a “level” rather than a “type” of practice.

RCN credentialing approach

A credentialing approach to enable those nurses to demonstrate that they practice at an advanced level has been established by the RCN. Disappointingly, however, from the information available to date no OHNs have been recognised as advanced level practitioners.

The costs to the economy resulting from benefits paid relating to incapacity, disability and injury are in the region of £44bn (Office for National Statistics, 2016). The Department for Work and Pensions (2017) highlights that the annual cost of working age ill health is in the region of £100bn.

Public Health England (2018a, 2018b) point to one in three workers experiencing long-term health conditions, one in 10 having musculoskeletal disorders and one in 8 having mental health conditions.

The Stevenson/Farmer (2017) review of mental health confirmed that poor workplace mental health places a considerable financial burden on employers – in the region of £33-42bn per year.

The Health and Safety Executive (HSE) (2018) has calculated that in 2017-18 stress, anxiety or depression accounted for 57% of all working days lost due to sickness and 44% of all cases of work-related ill health.

Adding value to organisations

Although small in number, the input of OHNs adds value to their organisations and indirectly to society. Highly skilled OHNs can support workers with these conditions to return to, or remain in, work because of the breadth and depth of their understanding of the effects of work on health and health on work and their leadership interventions.

Appropriately qualified, highly skilled OH nursing experts with the leadership skills, required to operate at a strategic level are well able to demonstrate advanced level practice, as encompassed within the standards promoted by bodies such as Health Education England (HEE) (2017).

In illustration, supporting employees with mental health conditions can be particularly complex within OH practice; advanced level practitioners can drive a mental wellness agenda within their workplaces.

Strategies intended to reduce work absences because of these conditions are effective when multi-faceted and early interventions are instigated (Waddell, Burton and Kendall (2008); National Institute for Care and Health Excellence (NICE) 2009; and Pomaki et al 2010).

OHNs may be working with incomplete information (Health Education England (HEE 2017) which is common because of the stigma often associated with mental ill health. Being able to provide effective care in the absence of complete information is integral to AP.

Advanced-level OHN practitioners are highly skilled in the use of a biopsychosocial approach to their comprehensive assessments of the client’s health status in the light of their job requirements.

Once this has been established, they can consider a range of possible options addressing physical or psychological barriers to an effective return to work, as this underpins the strategies they recommend to the employee’s manager in the support of a successful return to work.

Expert practice and problem-solving

Crucial elements include their creative problem-solving skills and multi-disciplinary approaches. This can involve, but is not restricted to, the client’s healthcare providers, including psychiatric services/therapists and may involve reference to their general practitioner.

As Wong (2019) recognises, OH professionals’ specialist knowledge of worker health and the working environment are key to developing strategies facilitating a return to work following long-term sickness absence.

Effective OH management of highly complex cases requires expert practice. Benner’s (1984) work on the expert practitioner, although developed from bedside nursing, can be applied across professions and specialisms, including that of OH nursing. Benner highlights the continuum of the stages through which a nurse progresses from novice to being an expert professional able to deal confidently and competently with complex cases.

Expert practitioners have a deep understanding of all facets of the situation presented to them. Their highly proficient, autonomous practice requires being skilled and able to utilise considerable analytic ability in the management of extremely complex cases.

This level of autonomous practice requires extensive knowledge of the reciprocal effects of health on work and work on health, the management of health and safety and a working knowledge of health and safety and employment legislation.

These OH professionals tread a fine line as impartial advisers to both employer and employee. They frequently respond to multi-faceted conflicts in practice, whilst discharging their responsibilities to both organisation and employee.

For some nurses, having the status of an AP is becoming a reality. Some achieve this through the current RCN (2018a) process of credentialing, a transitional arrangement until 2020. Others complete an AP clinical practice programme delivered at master’s level that meets specific standards suggested by bodies including NHS Scotland, (2010); NHS Wales (2010); HEE (2017).

Sadly, OH nursing seems to be at the back of the queue in gaining this recognition. This may result from the nature of OH practice being poorly understood by those involved in the development of the credentialing process.

The way ahead for OHNs may be for universities to develop educational programmes totally rooted in the principles of AP and incorporating the four pillars of AP: clinical practice, leadership and management, education and research promoted by NHS Scotland, NHS Wales and HEE, as above.

Thus far, some master’s-level university courses for OHNs have been approved by the Nursing and Midwifery Council (NMC) to confer Specialist Community Public Health Nursing (SCPHN) registration on their graduates.

As the process for gaining AP approval can be complex, several institutions have developed high-quality OH-focused courses but have chosen not to seek NMC approval.

Currently no OH nursing courses have been validated to claim they confer “advanced level” status on graduation. Even if there were, this is not yet a legally protected title.

Should title protection come to fruition, it is likely to be initiated by the NMC requiring specific standards to be set for preparatory courses, just as there have been for those conferring SCPHN registration (NMC, 2004).

Until they do, and unless consideration is made that OH nurses do not offer treatment services with no need to prescribe, OH nurses are likely to be left out in the cold. The emphasis on diagnosis and independent prescribing that is integral to the RCN (2018a) credentialing process significantly disadvantages OHNs because of the nature of their role, as shall be shown in the next section.

1) Clinical practice

On commencing their careers, specialist OHNs begin to develop as autonomous, impartial advisers to both clients and employers. With experience, they progress to become senior practitioners some leading the OH provision for large multi-faceted organisations undertaking roles previously the preserve of consultant level OH physicians.

Clinically, they manage highly complex cases remaining accountable for their decision-making whilst practicing within the limits of their own competence and scope of practice.

To ensure compliance with the NMC code, they require a critical understanding of their level of responsibility and utilise high levels of professional judgement in the management of complex cases, often with incomplete information.

Expert OHNs utilise specialist knowledge, assessment skills and experience to undertake effective organisational needs assessments which underpins high-level professional decision making. This requires critically evaluating risk factors and working in partnership with colleagues, managers and external agencies.

They utilise a range of assessment methods including history taking, undertaking and/or interpreting diagnostic tests including audiometry and spirometry. Should any UK OHN identify abnormal spirometry results, for example, they are able to refer on to specialist units, such as London’s Royal Brompton Hospital for further NHS investigation by respiratory specialist physicians. This decision-making is underpinned by expert clinical reasoning.

The only aspect of clinical practice OHNs do not generally involve themselves with is that of independent prescribing. Although this element of clinical practice is not fundamental to the standards published by HEE (2017) it is pre-requisite in the RCN (2018a) credentialing standards, making it a sticking point for OHNs in the context of AP.

2) Leadership

Leadership is integral to AP. Advanced-level OH practitioners lead teams, initiate practice and service development and have the knowledge, skills and personal attributes to provide consultancy across both professional and service boundaries.

They must be prepared to be challenged and constructively challenge others, which may result in them escalating concerns affecting the safety and/or wellbeing of clients and others to appropriate agencies including senior managers, the Health and Safety Executive, the NMC or GMC.

3) Education

This pillar incorporates identifying, reflecting upon and then developing a plan to meet the learning needs of themselves and the team members they manage. It requires them to be recognising the value of supporting team-members to build capacity and capability through work-based, inter-professional learning opportunities.

HEE notes that advanced-level practitioners are educated to master’s level, although this is not currently a requirement for the RCN (2018a) credentialing process.

4) Research

Research is the final pillar and is of particular importance for OH practice because of the current lack of research to underpin evidence-based practice.

APs contribute to, and aim to develop, a unique body of knowledge – enhancing their practice and the support they give their clients/stakeholders.

Their ability to critically appraise and synthesise the outcome of research and then disseminate those findings to a wider audience strengthens the impact of OH provision.

OHNs are well placed to undertake impactful, robust research, providing the evidence that steers clinical practice and OH management. “Research” in this context is not restricted to finding evidence to support clinical practice, it encompasses identifying gaps to underpin current practice. Many OHNs critically evaluate and audit clinical practice, then act on that information.

Although neither were nurses, the review of Waddell and Burton (2001) resulted in the development of the Faculty of Occupational Medicine guidelines for the management of low back pain, the first national OH management guidelines in the UK for this common condition. Similarly, research by OHNs could lead to other guidelines.

Conclusion

This article has explored components integral to AP, demonstrating how some OHNs already practice as APs.

Achieving AP status for OHNs should be on the radar of bodies such as iOH (formerly AOHNP) and the newly established Faculty of Occupational Health Nursing.

Fellowship status is currently under consideration by FOHN, which has the potential to kick-start a process of enhanced professional recognition.

Enlightened universities are likely to develop educational programmes for OHNs with the four pillars of AP at their core. Although I for one am looking forward to the day that AP recognition is given to all OHNs who merit this higher-level designation, slow progress is anticipated unless large numbers of OHNs lobby for this status to become available to them.

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References

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