Consultant nurses: the OH conundrum

OH urgently needs to rethink how to add value by diversifying its skills
says Denize Bainbridge. She feels it timely to consider radical changes now,
particularly on the role of consultant nurses, as part of the NMC’s review of
nurse competencies

A few months ago a Nursing Times article ran a feature entitled
‘Cash-strapped primary care trusts blocking new roles’,1 referring to the fact
that primary care trusts (PCTs) prefer ‘traditional nurse roles’ to innovative
nursing roles.

It stated that because PCTs are overspent, the local delivery plans do not
account for "new roles and new responsibilities", but rather have concentrated
on "delivering a good number of GPs and consultants" (doctors).

Where then does this leave the concept of consultant nurse in healthcare
and, more significantly, in occupational health practice? How do we fulfil the
philosophies implicit in the nursing strategy Making A Difference?2 (see

Those occupational health nurses who attended the Royal College of Nursing
(RCN) OH Conference last November in Bournemouth may remember hearing a speech
from the first consultant nurse in occupational health practice, Tammie Daly. I
recall a member of the audience asking: "So, what is your role
precisely?" The six core skills required for consultant nurses are quoted
from K Manley’s A Conceptual Framework For Advanced Practice 2000 as:

– Being able to apply the practice of nursing to a specific client group

– Have leadership and strategic vision

– Being able to use research and evaluation approaches that focus on
day-to-day issues in everyday practice

– To facilitate development, structural and cultural practice change

– To create a learning culture that enables all members of the
interdisciplinary team to learn and develop their potential

– To provide consultancy from a clinical level in relation to individual
patients to organisational level, in terms of the provision of patient-centred

So far, the list covers the competencies expected from a senior nurse –
except that provision of consultancy at a strategic level should perhaps be at
the top of the list and not at the bottom.

Given that we are now in the 21st century and nursing has been within higher
education for some years, the RCN has decided it is time to define or redefine
nursing as: "The use of clinical judgement in the provision of care to
enable people to improve, maintain or recover health, to cope with health
problems and to achieve the best possible quality of life, whatever their
disease, or disability until death."4 Well nothing new there then,
considering Florence Nightingale was doing just that, many years ago.

The question is, have we as a profession really moved on in terms of
education, role and status within OH and, if so, where is the evidence within
the profession for this? What should a consultant nurse be doing in
occupational health practice and how is the role defined?

If we look back at the main reason for creating the consultant nurse posts,
we can see it was to keep nurses within the clinical role in the NHS where they
could be more cost effectively employed by taking on some of the roles of
junior doctors, and in keeping with the principles of the Agenda For Change.4

Professional scope

The plan for the consultant nurse role in this context has proved a major
cost benefit to the NHS, both in terms of reducing waiting lists and in developing
the scope of professional practice.

The variety of roles that have been developed, from diabetic consultant
nurse to a nurse who undertakes surgery on patients with Carpal Tunnel
Syndrome, seems to demonstrate success and progress in line with the government
strategy for nurses.

Within occupational health nursing it is not so easy to demonstrate such
desired benefits, because levels of education, training and job opportunity can
be diametrically opposed, depending on where you work, and the opportunities
you can access.

Increasingly, nurses are in competition for senior management roles in the
private sector, where employers sometimes want to keep nurses in a
‘professional box’, and get non-nurse managers to sell and market occupational
health services.

It is essential, therefore, that nurses take all the opportunities they can
to enhance their business skills, commercial awareness and knowledge of
financial management. Manley writing in The Role of Leadership Organisational
Culture and Consultant Nurse Outcomes5 says: "The role of leadership is
key to bringing about organisational change, as is the use of approaches that
clarify values and highlight the contradiction between espoused culture, and
culture in practice."

Yet it can be difficult for nurses in occupational health to gain a first
degree, let alone to reach the Level Three required for consultancy. A first
degree, which is OH specific, is increasingly hard to find, as is the

Many businesses do not see the point of funding a degree to Masters level
because what they need is an OH nurse who stays in the workplace acting as a
reference point for information and advice on sickness absence management,
health, safety and rehabilitation matters.

With only around 0.05 per cent of qualified nurses working in occupational
health,6 the difficulties accessing training programmes, and recent discussions
as to whether it is necessary to even be a nurse for OH practice, there are
perhaps more pressing issues to be addressed among OH nurses before we begin to
consider a role for ‘consultant nurses’.

The OH profession has a rapidly ageing population and there is often a
dearth of practical expertise from incoming practitioners.

Changes in the world of work and the demise of manufacturing has led to a
need to change our skills base, and this, coupled with the increasing need for
commercial and business knowledge in the workplace, should be seen as a window
of opportunity to refashion the role for future OH nurses. The direction is
laid out before us, but who will pave the way?

The rise in mental ill-health and the national shortage of psychiatric
nurses in the UK is an obvious opportunity for nurses to extend their practice
to promote holistic care.

The Health and Safety Executive is currently addressing the subject of
mental ill-health in the workplace, but are OH training programmes relevant and
will they adapt to address the gaps?

There is a rising demand for occupational hygienists,7 but new graduates are
in a minority in the UK, which should indicate another area of skills

The increase in demand for accurate rehabilitation assessments in the area
of ergonomics is increasingly important in work-related health – another
opportunity to bite the bullet.

An increasing number of people qualified in health education are entering
the health arena who are not nurses. This started with the influx of government
money at the beginning of the Aids ‘epidemic’ in the early 1990s and has
penetrated into occupational health. Some of these graduates are taking top

It is important that we recognise these issues and are alert to changing
patterns of work and demand so we can grow our own leaders who can contribute
with innovative ideas and creative thinking to progress our future
opportunities. OH must not stagnate, but needs to urgently rethink how to add
value to an organisation by diversifying skills and encouraging training
establishments to facilitate radical change.

New skills base

The nature of the OH business is about cost effectively managing health at
work, saving companies and the taxpayer the increasing costs related to
absenteeism, demonstrated in the government Green Paper Pathways to Work,8 and
staving off untoward litigation.

OH must demonstrate the cost benefits of our services in meaningful ways,
and in doing so lay the foundations for a new skills base. I would suggest this
is a top priority before we fly the flag for consultant nurses.

Admittedly, we cannot fall behind the national strategy for nursing,2 but to
go full steam ahead with a title that has no underlying substance will not gain
us the credibility we deserve.

Also, I am not convinced that even the Nursing and Midwifery Council (NMC)
has made the vital distinction between demonstrating the cost effectiveness of
consultants outside the NHS as compared with inside the NHS.

The conundrum lies in trying to reach a balance in defining what the
responsibilities are for a consultant nurse role, and here is where it becomes
controversial. The debate is about the appropriate tasks assigned to a
consultant, which has proved to be vocationally specific in the NHS. The
initial idea was to retain clinicians with experience, awarding them with
position and salary.

Outside the NHS, the reality is that those of us who have embarked on an
academic career and progressed to management level may have minimal clinical

There are those who want to remove themselves from clinical work because
they are more suited to research, lecturing or improving systems of work which
support clinical practice; training and supervision are examples.

Within OH practice there is no real clinical ladder to climb as a
consultant, unless we count areas of specialist expertise. The issues are
around balancing job satisfaction with adding value to the business and as an
academic, not having too many expectations.

Ability to diversify

The International Council of Nurses has given credence to the Level Three
required for the consultant role, but in OH it is left to individual
organisations to fathom who they will recruit as an OH nurse, at what level,
who will be a suitable manager for them, and what it is they will be doing.

Occasionally a nurse may have the opportunity to become involved in business
planning, contract management and financial matters, but in reality this is
unusual. In larger organisations there should be more opportunity to get
involved in ‘the bigger picture’, but much depends on the nature of the company
and whether they have strategies for health in which they can involve their
nurses. Nurses are more often kept in a ‘professional box’ which obstructs
career development. The messages we need to give is that we are multi-skilled
and able to diversify and are not only of value through our clinical skills.

Consider the struggle to involve nurses on the commissioning boards of PCTs.

These are the serious issues we need to be thinking about as we churn out
students adept at business studies in theory, while lacking clinical expertise
for good OH practice. There appears to be a real mismatch between what the
colleges think we need, what we, as individuals, think we need (job
opportunities) and the professional body demanding a masters degree to enable
decent job status with no reason as to why or means of helping us to attain it.

This creates conundrum and a gap in aspirations for nurses in terms of
finding the right job and achieving satisfaction. The job description does not
always reach the parts the college modules did, and well-qualified candidates
applying for posts in OH sometimes have little practical experience to offer,
which leaves them somewhat shaky when dealing with workers and unions.

On the other hand, those who are highly qualified and have a wealth of practical
experience feel trapped in clinical posts that do not stretch their intellect.
There is also a plethora of degree types around, and most OH nurses have
secured the community nurse/OH pathway one. Many nursing degrees also have a
large percentage of practical input – commonly up to 50 per cent – and one
could take the view that this cannot be defined as academic. Many organisations
where OH nurses work do not appreciate that nursing is a degree profession, let
alone want to support Masters degrees.

What is the consultant’s role?

Where then does this leave the consultant role in OH? What should this be in
OH and what educational demands can realistically be met?

Now is the time to be collaborating on these issues when the NMC is
evaluating nurse competencies.

Opportunities in occupational health are not as widespread as in the NHS
because OH doctors and physicians undertake many tasks which the OH nurse
undertakes, albeit at a higher level, and with a medical focus dealing with the
final outcomes of our assessments.

What then is the incentive for OHNs to undertake Masters degrees when most
organisations look for the basic services from OHNs and are reluctant to
sponsor places on degree courses, let alone Masters programmes?

This brings us full circle to the notion that the PCTs want ‘traditional
nurse roles’ and points to the importance of defining what our roles will be in
the future and where we fit in the delivery of OH services. Only we can decide.

Denize Bainbridge, RCN, OH Managers Forum/Steering Committee


1. Nursing Times, 18 March 2003, vol 99 no.11

2. Making a difference; strengthening the nursing, midwifery and health
visiting contribution to health and healthcare summary, Department of Health,

3: A Conceptual Framework For Advanced Practice 2000, K Manley. This paper
works on previous research by Brown 1998

4: NHS National Nurse Leadership Project, DOH ref 2000/0690; DOH Agenda For

5: The role of Organisational Culture and Leadership Outcomes, K Manley.
Consultant nurse roles are crucial to the government strategy Making A
Difference (DOH 1999)

6: Nursing Statistics, C Bannister, RCN, 2000

7: Careers in Occupational Hygiene Prospect Planner CSU

8. Pathways to Work government Green Paper on incapacity benefits; pilot
scheme which assists and empowers those returning to work; April 2003 Centre
for Economics and Social Inclusion, Department of Work and Pensions

Sources of further information

– NHS Plan, Shifting the Balance of Power in the NHS; Rushmoor BC, 2001

– Nursing Journal; Clinical Nurse Specialist 1998, November 12 (6), Goldberg

– Nurse Education Today, 1996, Feb; 16(1)

– Enlightenment, Empowerment and Emancipation – The Case for Critical
Pedagogy in Nursing ; Journal of Clinical Nursing, 1997, May; 6 (3)

Making a difference?

Making a difference; strengthening
the nursing, midwifery and health visiting contribution to health and
healthcare summary, Department of Health, 1999. The document spells out the
Government’s strategy for nursing, midwifery and health visiting in England and

– An explanation of the changes in the context of care for all

– The Government’s intention to recruit more nurses

– Its promise to expand training and development opportunities
for nurses

– Plans to strengthen nurse’s leadership skills with new
careers opportunities and the appointment of nurse consultants

– How the Government intends to extend the remit of nurses to
include, among other things, nurse prescribing

Author’s details

Denize Bainbridge is a graduate and
qualified occupational health nurse. She headed a nurse-lead OH service in
Peterborough Health Authority in the 1990s and has recently worked for almost
seven years as principal nurse co-ordinator for the Royal Mail.

As a member of the OH Managers Forum, she has co-written the
national pamphlet on clinical supervision.

In 1992, she worked for the English National Board as a
qualified careers adviser. Denize is a keen advocate of the NHS Agenda For Change

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