In the UK, it is becoming increasingly difficult to recruit and retain qualified occupational health (OH) nurses. Between 1999 and 2001, it was estimated that only 250 nurses would qualify with a degree/diploma in OH throughout the UK.1
An additional problem, in some areas, is the high cost of living. Brighton – where the trust in which this training programme was carried out is situated – is one of the three most expensive cities in terms of property prices in the UK. According to the Halifax Building Society, Brighton showed the highest rise in house prices (215%) between 1992 and 2002.2
With this in mind, Brighton and Sussex University Hospital (BSUH) Trust’s OH department realised that the solution was to create a training post. While this is not a new approach, it was something that had not been done before by this trust.
The opportunity for developing this idea came when the former Brighton Health Care and Mid Sussex Trusts integrated to form what is now Brighton & Sussex University Hospitals (BSUH).
The need for a larger workforce of competent practitioners and the projected increase in workloads resulting from the expectation to provide services to the local primary care trusts (PCTs), GP and dental services, and to the new medical school in Brighton, was also an important factor for increasing the number of OH nurse advisers.
The post was advertised internally, and a registered general nurse with an A&E background was recruited. While it was recognised that it was desirable for the new recruit to gain an OH diploma, it was also apparent that there was a need to provide the appropriate training for the practical and clinical skills relevant to the department.
Occupational Health Nursing reminds us that OH nurses (OHNs) are now required to undertake a wide range of tasks, some technical in nature.3 Clearly these skills would be learned ‘on the job’, and a competency framework was developed to formalise this approach.
Competence was defined by the UKCC in 1999 as “the skills and ability to practice safely and effectively without the need for direct supervision.”4
Background
The use of a competency framework was decided upon for several reasons:
- It would provide a clear framework for the trainee, to guide them through the practical learning experience and help in the journey towards the achievement of becoming a specialist practitioner
- It would ensure that training was given for all core areas
- It would provide evidence of learning and a written record of skills taught
- There would be manageable-sized competencies to accommodate the different abilities of the learner
- Once assessed as competent for a particular area, the trainee would be able to practice independently
- It would provide the supervisor with a basis on which to structure the development and assessment of the trainee.
Developing the competency framework
To begin with, a brainstorming exercise was carried out to identify what skills and knowledge the trainee would need to be competent enough to practice.
Clearly, these would need to link with the Nursing and Midwifery Council (NMC) guidance for competent specialist practice and the Agenda for Change knowledge and skills framework.5
However, the advantage of this approach is that it can also be used for those who want to work in OH but don’t necessarily want to follow an academic pathway, and would still like to develop competent skills to practice under supervision.
These knowledge and skills included the practical and hands on skills of:
- administration of vaccinations
- workstation assessment
- lung function testing
- audiometry.
The roles that involve assessment and interview techniques are:
- Pre-employment health assessment
- Management and self-referrals
- Management of sharps/splash injuries.
Each of these main ‘subjects’ were then broken down into sub-sections, reflecting the knowledge and skills needed for the competent delivery of the core skills. For example, for the competent administration of vaccinations, the trainee would need to have an understanding of:
- Hepatitis B
- Interpretation of blood results for hepa-titis B
- Tuberculosis and TB skin testing (Heaf testing)
- Action following receipt of Heaf test result
- Administration of other vaccines
- Taking blood
- Management of anaphylaxis.
For each of these parts, an assessment was written. Before the assessment takes place, there would be a period of agreed learning. This may include background reading, the observation of qualified OHNs, study days, and so on.
The assessment for the administration of hepatitis B is shown by way of example (see figure 1).
For roles involving the skills of assessment and interview, a different approach was used. For example, for the assessment of the ability to undertake referrals made by management, it was decided that the trainee would first observe at least 10 interviews undertaken by a senior OH nurse adviser. Evidence of this would be documented.
Following this period of observation, and once confident to do so, the trainee would then, over an unspecified period of time, undertake 10 interviews supervised by a senior OH nurse adviser. There was no scientific basis to the number of interviews, but 10 seemed reasonable. After each of these interviews, a competency assessment is made (see figure 2).
The framework can be adjusted to suit the individual needs of the trainee and more supervised interviews can be undertaken – for example, if a particularly challenging referral is made to the OH department. Once at least 10 supervised interviews have taken place, an overall assessment of competency to undertake unsupervised management referrals is then completed (see figure 3).
Each assessment has a review date and all cases seen unsupervised are discussed for a minimum of six months. Also, regular review meetings are held between the supervisor and the trainee to ensure that the process is working.
One benefit of this approach is that while core competencies are pre-written, the way in which the competency framework is used can be adjusted to suit the individual needs of the trainee. This means the trainee has a written record of how they are progressing through the competencies.
As mentioned before, this framework can be used in a similar fashion to the NVQ approach if an individual did not want to follow the academic pathway.
Conclusion
Within the department, the future needs of the OH service are being looked at for the next 10 years as part of a departmental strategy, and the option of creating a technician’s role is being seriously considered in the light of the difficulties in recruiting nurses into OH.
In many OH departments, some roles traditionally undertaken by OH nurse advisers can be carried out by a technician, providing they have developed the competencies and are supervised. This work is ongoing.
Following consultation, the Royal College of Nursing launched its competency framework for occupational health nursing at the Society of OH nursing Conference in November 2004.6 This document outlines a set of core and specialist competencies as part of the development of national competency standards for nursing in the UK. The OH department at BSUH is in the process of adapting its in-house training to reflect this.
The trainee has now been in post for two years and has almost completed the competency skills package, as well as one-and-a-half years of her OH diploma at the Roben’s Institute in Guildford.
She says: “The framework has been an innovative idea, which has given structure to my clinical development. It has helped to link in with my course and contribute to the development of my portfolio for specialist practice, enabling me to link theory and practice.
“Having this framework has given me clear expectations of my role and a clear insight into the role of the OH adviser within the NHS. It has provided all of the members of the OH team with a structure to facilitate my education and development, and has been a fantastic introduction to OH.”
She added: “All members of this department have been extremely supportive, encouraging and are very approachable. The successful achievement of each aspect of the framework has boosted my confidence and I now have my own case load, which I manage under supervision.”
Jane Olver is the OH nurse manager at Brighton and Sussex University Hospitals NHS Trust. Sarah Zahopoulos is a senior OH nurse adviser, and has co-written and implemented the competency package
References
1. NHS Plus conference, 2000
2. Halifax Building Society, press release, 24 May 2003 (website)
3. Oakley, K (1997) Occupational Health Nursing 2nd edition
4. UKCC, Standards for Specialist Education and Practice, April 2001
5. Agenda for Change, published by the DoH www.dh.gov.uk/PolicyAndGuidance/HumanResourcesAndTraining/ModernisingPay/AgendaForChange/fs/en
6. RCN (2004) Integrated Career & Competency Framework for occupational health nursing. www.rcn.org.uk
FIGURE 1: Assessment for the administration of hepatitis B
1. Explain what hepatitis B is and how it can be contracted at work ………………………………….
……………………………………………………………………………………………………………………………………
2. Describe which employee groups should be offered hepatitis B vaccination …………………..
……………………………………………………………………………………………………………………………………
3. Explain the possible side effects of this vaccine …………………………………………………………..
……………………………………………………………………………………………………………………………………
4. Explain what checks need to be made before a vaccination is given ………………………………
……………………………………………………………………………………………………………………………………
5. Demonstrate how to prepare and administer a vaccination ………………………………………….
……………………………………………………………………………………………………………………………………
6. Explain what information should be given to the individual post-vaccination ………………….
……………………………………………………………………………………………………………………………………
7. Explain how a course of hepatitis B is given and when booster doses should be given ……
……………………………………………………………………………………………………………………………………
8. Explain when titre levels should be checked ……………………………………………………………….
……………………………………………………………………………………………………………………………………
Summary of supervised practice undertaken in preparation for assessment: ………………….
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….
Competent/Not Competent (give reason(s) why and action to be taken): ………………………….
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….
Comments: ………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….
Name and signature of assessor: ………………………………………………………………………………….
Date: ……………………………………………………. Date for Review: …………………………………………
FIGURE 2: Assessment of competency
Date of management/Self-referral interview: ………………………………………………………………..
Initial of client seen: …………………………………………………………………………………………………….
Name of assessing OH nurse adviser: …………………………………………………………………………..
Welcome and assessment Satisfactory / Unsatisfactory
Overall interview Satisfactory / Unsatisfactory (relevance and depth of information gained etc)
Plan of action Satisfactory / Unsatisfactory
Documentation Satisfactory / Unsatisfactory
External correspondence Satisfactory / Unsatisfactory (if any, letter to GP, manager etc)
Overall assessment: …………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….
Signature of OH nurse adviser: ……………………………………………………………………………………..
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FIGURE 3: Assessment for unsupervised management referrals
1. Discuss how a manager should make a referral to OH …………………………………………………
……………………………………………………………………………………………………………………………………
2. Explain the process …………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………
3. Explain what information should be included on the referral ………………………………………..
……………………………………………………………………………………………………………………………………
4. Demonstrate the ability to undertake an interview following a referral ………………………….
……………………………………………………………………………………………………………………………………
5. Demonstrate the ability to record the relevant information in the notes …………………………
……………………………………………………………………………………………………………………………………
6. Explain what information needs to be given to the referring manager …………………………..
……………………………………………………………………………………………………………………………………
7. Discuss how a medical report should be obtained and demonstrate a good understanding of the Access to Medical Reports Act …………………………………………………………………………………
……………………………………………………………………………………………………………………………………
Competent/Not Competent (give reason(s) why and action to be taken): ………………………….
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….
Comments: ………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….
Name and signature of assessor: ………………………………………………………………………………….
Date: ……………………………………………………. Date for Review: …………………………………………
