The nature of work has changed at a rapid pace in the past couple of decades. Many occupational injuries and conditions associated with different types of work have been all but eliminated, so it is rare to see new incidences of farmer’s or brewer’s lung, welders with arc eyes, or workers with chrome ulcers.
But the conditions that seem to be persevering are the ones where the relationship between work and injury or illness is more tenuous.
This means there are still large numbers of new cases of stress and musculoskeletal disorders, which may or may not have been caused or exacerbated by work.
It is also the nature of these increasingly prevalent conditions that by the time they get to occupational health (OH) or specialist healthcare, the condition is likely to have reached a stage where it is less amenable to treatment than if it had been prevented from occurring in the first place, or if an intervention had taken place well before the condition became medicalised.
It is in this environment that the role of the occupational health nurse (OHN) in the workplace needs to be re-examined. Here are some areas where nurses could play an increasingly important role in relation to health at work.
Management and leadership
The training of physicians remains fundamentally about diagnosis and the provision of treatments. Even the most proactive of OH physicians often find they have to justify their role in the workplace by putting a lot of emphasis on dealing with incapacity, sickness absence and ill health retirement.
OHNs, on the other hand, are more attuned to the biopsychosocial model and the preventative role, in the spirit of the International Labour Organisation’s OH services convention, which defines OH services as being ‘entrusted with essentially preventive functions’ (C161 Article 1a).
As an educator, I visit students on placement and sees OHNs in physician-led services, dressed in hospital nurses’ uniforms, working in OH ‘clinics’. In nurse-led services one is more likely to see nurses wearing hard hats and safety boots, out on the shop floor.
The performance of the physician-led clinic is easily measurable, in the numbers of workers referred, and the numbers of completed episodes of care. In other words, in numbers of staff granted ill-health retirement, or passed on to specialists in secondary care.
The OHN, either preventing the inception of work-related disease or injury, or capturing it early before it becomes a management concern, is less likely to be able to provide measurable evidence.
What research should be able to show, however, is that in two comparable organisations, one led by an OH doctor and the other by a nurse, the incidence of work-related ill health is likely to be lower in the OHN-led organisation.
There is still an ivory tower mentality among nurses and doctors in OH about nurse diagnoses: a view that to diagnose is the preserve of doctors.
I was made aware of this following a case where a nurse was disciplined by his physician for writing a provisional diagnosis of work-related contact dermatitis in a referral made to a consultant occupational dermatologist.
The diagnosis was confirmed by the dermatologist as being spot on, but the disciplining was for the fact that the nurse had dared to be so presumptuous as to suggest a diagnosis, which supposedly is enshrined in law as being a doctor’s prerogative.
The Nursing and Midwifery Council code requires nurses to ‘…recognise and work within the limits of [their] competence’ (2008, page 7).
For some nurses, that will include the competence to make a diagnosis, and there needs to be a recognition that an experienced OHN, who has seen large numbers of cases of work-related dermatitis, asthma, or any other condition prevalent in their workplace, could be able to reach a more accurate diagnosis than one made by a GP or physician merely dabbling in occupational health.
As ever, the diagnosis will require confirmation by specialist tests carried out by consultant clinicians. There should be no organisational or professional bar to the OHN working to their competence.
Under the law, there is a requirement for appointed doctors to carry out health surveillance for certain groups of workers, such as those potentially exposed to lead or ionising radiation.
Any medical practitioner can apply to the Health and Safety Executive (HSE) for appointment under the appropriate legislation, and in some cases the HSE provides short courses and/or exams towards registration. Some of these are accessible to OH nurses, but there is no structure in place for OH nurses to attain appointment.
I am aware of situations where experienced OH nurses carry out all the elements of surveillance – interview, physiological measurements, blood tests, and so on – and then have to take the records back to an appointed doctor, who in some cases is a GP with very little contact with the worker or the workplace, for signature. Surely it is time for the law to be changed, and for the HSE to be given powers to grant ‘appointed occupational health adviser’ status to OHNs who, after all, are already carrying out this role.
The average age of the working population is increasing, and there is an increasing prevalence of chronic disease and long-term conditions. Articles about the obesity epidemic, and the accompanying increases in diabetes and heart disease, abound. In this changing environment, there is an increasing requirement for OHNs to take on case management.
Nurses sometimes shy away from case management, saying that it is not compatible with their preventative and public health role. Such OHNs are quite wrong in the way they perceive case management.
It should not be seen as a reactive role, where an employee has become a problem resulting from long periods of sickness absence, and the case manager becomes involved in negotiating a return to work (or dismissal) with the employee, management and health services.
Case management can be a rewarding, proactive role where the OHN works with an employee who has a chronic illness or a disability that could lead to acute episodes requiring hospitalisation or emergency treatment to ensure that the employee learns to manage their condition and anticipate early signs of an impending crisis so that they intervene early and prevent the crisis from occurring.
It can mean the OHN becoming the collaborative link between the case employee and their GP, practice nurse, hospital specialists, social workers, physiotherapists and others (see ‘Case encounters’, Occupational Health, Vol 58, no 9, pp 25-25).
I am not advocating an extension of the OHN role in the way nurses’ roles are frequently extended and developed in the NHS, to enable them to take on tasks normally carried out by junior doctors. What I am advocating is seeking out evidence to support the extension of the nursing role, and the nursing aspects of the service provided to workers by their OH service.
The evidence is out there, but OHNs continue to suffer from a diffidence that is a remnant of the old days when nurses were handmaidens to physicians. In the changing workplace leading up to the 2010s, armed with evidence and the mandate provided by Dame Carol Black’s review and the government’s positive response to it, OHNs should seriously consider the increasingly important contribution that nursing can make towards improving the health of the working population.
Black, C (2008) Working for a Healthier Tomorrow: Dame Carol Black’s review. London: TSO.
Health, Work, Wellbeing (2008) Improving Health and Work: Changing lives. (The government’s response to Dame Carol Black’s review) Cm7492. London: TSO.
Nursing and Midwifery Council (2008) The Code: Standards of conduct, performance and ethics for nurses and midwives. London: NMC.
Next month: the big debate on whether OHNs should be more involved in developing evidence-based practice.
OHNs and evidence-based guidelines
“It would be useful to have a forum or online area to publish dissertations of OH professionals so that they were available to colleagues.”
“Not every decision, action and policy can be based on scientific evidence, given the complexities of the human being and the workplace.”
“The definition of ‘evidence’ should not be limited to scientific, peer-reviewed studies in learned journals.”
“OHNs are too busy to get involved in scientific projects, and lack the funding and facilities.”
“It is difficult for OHNs to conduct primary research and publish in a peer-reviewed journal because the mechanisms necessary for ethical approval are often unavailable.”
“There is scope for researching common OH issues through professional forums and audit networks.”
“The RCN Society of Occupational Health Nursing and the Association of Occupational Health Nurse Practitioners should send representatives to participate in developing guidelines, such as the recent Nice absence management guidelines.”
Adapted from Jiscmail e-mail forum debate on ‘evidence-based practice’