In the past decade national policy has created increasing pressure for collaborative working, according to Lax1. This article evaluates the implications of two specific care delivery policies in Scotland – Nursing for Health: Two Years on2 and Improving Health in Scotland: The Challenge3 – for collaboration between occupational health practitioners and other specialists.
Reducing health inequalities is central to almost all of the Scottish Executive’s health policy. Improving Health in Scotland: The Challenge highlighted the workplace as a main area for focus. There are currently more than two million people in paid employment in Scotland and the workplace offers a prime opportunity for raising awareness of health issues.
An article by Whitehead4 points out that by providing health promotion to employees, occupational health nurses influence families and, therefore, the wider community. The Nursing and Midwifery Council (NMC) standards for specialist public health nurses5 stipulate that collaborative working is needed to be a proficient public health nurse.
The nursing profession seems to have had difficulties in adopting collaboration and often resists it. Wachs6 says healthcare has created a hierarchy among disciplines which has a negative effect on care delivery.
Robertson7 argues that nurses feel threatened by the idea and Hong8 states that communication among OH nurses is lacking.
Nursing for Health refers extensively to collaborative work between the NHS and private sector and within all nursing fields.
None of the examples of successful collaboration given mention occupational health, which appears on only three pages. It does state that NHS trusts need to ensure effective use is being made of OH nurses by collaborating with public health networks, but provides no evidence that this is happening.
The significant role OH has with working age adults is mentioned, but the document admits there is little evidence this has occurred. Examples of potential for future development in this area are given, but these do not mention OH nurses, only collaboration between health visitors and GPs.
The document also suggests OH professionals should provide health promotion within communities that have little contact with the health service. This is an important point but again seems to leave the OH nurse working in isolation.
The policy states that partnership working is key to public health nursing activities in the future but does not outline the potential contribution of OH nurses. If significant health policies like this do not recognise or discuss OH, it would seem to perpetuate the exclusion of this specialism.
Davidson9 advocates that policies should be redesigned to reflect multiple perspectives and this may be one way of encouraging inclusion of occupational health.
Improving Health in Scotland: The Challenge sets out the steps health professionals need to take to improve Scotland’s health inequalities. It focuses on four main areas: early years, teenage transition, workplace and community. It might be assumed that occupational health would play a large part in this document, given the importance placed on the workplace.
However, as in Nursing for Health, occupational health is only referred to specifically three times. These three statements again refer to working in isolation. In contrast, partnership working is mentioned some 30 times throughout the document and is deemed paramount for success.
The policy does, however, acknowledge that occupational health policy is not fully developed or integrated in the UK. Croghan and Johnson10 feel that the public health role of the OH nurse is hindered by this lack of information and lack of collaboration with primary care colleagues.
Many OH professionals work alone and, furthermore, OH is a unique specialism (Mackey11), with nurses working in varied settings, including the private sector and NHS. Franco12 points out that important differences exist between OH professionals and other specialisms. Beach and Watt13 note barriers in communication because OH is not a well understood specialty, with confusion about roles and position in the modern health care system. Harriss14 feels the specialty is often poorly understood.
Beaumont15 recognises that communication between GPs and OH professionals is often poor or non-existent. Sometimes the OH professional is suspected of looking out for the employer’s best interest, as opposed to the employee’s.
Misunderstanding about medical confidentiality and OH needs to be taken into account in plans to give every person a single medical file that all health professionals can access electronically. OH nurses in the private sector would be unlikely to have access to this system. NMC regulations16 (2004) state, that access to medical files should be limited where possible, so as to maintain confidentiality. Informed consent would need to be achieved before instigating such a scheme.
OH nurses have a greater understanding of the employees’ roles and duties and are thus better equipped to make decisions on return to work programmes than the GP (Beaumont15). Garrett17 explains that OH practitioners spend on average 50% more time with employees than physicians. Duffin18 goes as far as saying that the GP sometimes has no idea what a patient’s job entails and signs them off when other avenues could be looked at.
Practice nurses and GPs may also be unaware that some OH nurses carry out blood pressure checks and various health promotion schemes within the workplace that would ease workload for the busy practice. Furthermore, some occupational health departments are able to carry out audiometry and spirometry.
There has been slow progress on giving practice nurses access to OH services and primary care trusts seem to have OH low on the agenda (Moore19).
Even simple issues such as time and varying working hours could be a barrier. Enderby20 lists differing cultures, languages, practices, pressures and full-time, part-time and shift work as issues when trying to collaborate. Furthermore, professionals from different areas may have divided loyalties.
Weiner21 points out that collaborative working makes it particularly difficult for partnerships to assign accountability, delineate authority and develop measurable performance outcomes. Trust is a perennial problem in collaborative working.
Collaboration can be time-consuming and frustrating and is often avoided by over-stretched practitioners (Lax1). Cost-cutting and limited resources can often make implementation of collaborative practice difficult (Whitehead4). However Beaumont15 feels that a collaborative approach can bring about great benefit to individuals, often with little financial outlay.
True collaboration is hard work, resource intensive and time-consuming and unless managed carefully often fails (Jasper22). A most obvious barrier between occupational health and NHS services is the differing agenda of private and public organisations (Croghan & Johnson10).
Heijbel23 uses return-to-work programmes as an example of where collaboration really should be used, stating that OH, GPs and others involved in a long-term illness case should work together on a rehabilitation plan.
Poor formal communication was found to be a barrier to collaboration in a study about interprofessional issues reported by Lax1. Recent public enquiries into poor practice have highlighted the critical nature of communication and co-operation between disciplines (Lathlean & Le May24).
There is a lack of research available in the occupational health setting. On searching the literature, only one study was found on a trial of training collaboration between GPs and occupational health professionals, to influence sick leave of low back pain patients. Unfortunately, this study concluded that collaboration did not have a positive effect (Faber25).
However, Garrett17 explains that collaborative practice can lead to treatment benefits, cost savings and improved safety performance. It should not just focus on health professionals but should also be applied to the relationship between the professional and the client.
The Skills for Health26 document on public health calls for professionals to enable people and communities to increase control of health well being. Kesby27 feels that for integrated care and continuity of service for the client to happen, collaborative practice is necessary.
Mack28 suggests that building lasting relationships between community members is necessary to support individuals making healthy decisions and to help them overcome personal and structural barriers to achieving good health. Brocklehurst29 agrees that health improvement is dependent on collective as well as individual action.
Collaborative working should benefit the potential user. If health professionals work together and have good knowledge of the services each offer, then there should be a faster identification of gaps in service delivery and a decrease in duplication of work. Also, individuals will not have to provide an in-depth medical history to every new health professional they see if there was medical record access for all. Cotton30 sees collaboration as a challenge for OH professionals identify the need to find gaps and overlaps that can have detrimental effects on health and wellbeing.
Practice development issues
Better training is required (Whitehead4) and Wachs6 suggests that collaboration should be taught to undergraduate students. Cheri31 feels that students benefit from multidisciplinary education that fosters collaboration among health care workers. Lax1 believes it is important that interprofessional training and education occurs, to create relationships and promote collaboration. Kenny32 points out that policy recommends professional development in nursing should encompass collaboration with other disciplines.
Clearly, there is consensus that nurses require training on collaborative working. However, a change to education would inevitably result in increased cost and could be difficult to achieve in today’s market.
Lack of understanding of the role of OH needs to be tackled and liaison with primary care workers would help break down barriers (Beaumont and Quinlan33).
Frances and Walsh34 believe that learning to become a collaborative worker is complex. Legislation alone will not increase collaboration (Randolph35). Collaborative working requires access to the electronic information culture, an awareness of all health disciplines and dissemination of findings beyond the profession (Kenny32).
Davidson9 points out that collaboration is needed from all stakeholders from multiple sectors including health care, education and housing. Each professional’s roles and responsibilities would need to be identified and this may lead to conflict. Leadership and change management skills are needed.
Differing duties, responsibilities and divided loyalties would need to be addressed. A study by Mackenbach and Stronks37 in the Netherlands concluded that international exchange and collaboration is necessary to reduce inequalities in health. However, catering for collaboration on an international scale would be difficult and would certainly provide practice development problems.
The results from a pilot study of occupational health professionals replacing GPs in providing MED 3 sick notes show several barriers were met, including perceived loss of confidentiality by employees, suggesting, again, a misunderstanding of the role of OH. Perhaps GPs should be educated about the types of assistance provided by OH (Nicholson37).
The challenges of healthcare are so complex that no single discipline can offer an effective solution (Garrett17). Collaborative working is not a new concept, but progress has been slow, particularly within OH. OH professionals must take steps to overcome barriers and collaborate with others, which would help promote the specialism and understanding of its work. They need to develop skills in innovation, change and leadership.
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