If occupational health practitioners are to shape the future, they need to understand both the profession’s past and its continuing role in defining and delivering “good” work, argues Professor Anne Harriss. But, in a fast-changing working world, that future may mean OH has to consider changing its name.
Occupational health (OH) nurses are the largest single group of healthcare professionals involved in delivering and managing healthcare at, and within, the workplace.
OH nursing sits firmly within the broad nursing family and has a long history. Central to its focus are the principles of public health, which takes a macro approach to protecting and promoting the health of populations.
About the author
Anne Harriss is emeritus professor in occupational health and president of SOM, the Society of Occupational Medicine
Public health is referred to by Acheson (1988) as, “the art and science of preventing disease, prolonging life and promoting health through the organized efforts of society” (World Health Organization 1948 – preamble).
In the case of OH, it is fundamentally about “the organised efforts” of organisations in workplace health management rather than “society”.
Pioneering work of Phillipa Flowerday
As far back as 1872, interventions that promoted worker health were formally initiated at J&J Colman’s, the Norfolk mustard producing company, when it appointed Phillipa Flowerday as a workplace nurse.
She was tasked with assisting the factory doctor, with her role encompassing promoting the health and wellbeing of the workforce. She spent her mornings in the factory and her afternoons ministering to sick workers in their homes. These were innovative interventions and would have had a significant impact on the health of Colman’s workers, as they would have had little, if any, access to any other formal health care provision.
Flowerday lacked specialist training, but undertook what amounted to “good works”. To that end, Colman’s approach to care delivery was laudable but its emphasis was on providing treatment and welfare services, and was therefore very much reactive.
This contrasts with the proactive approach of contemporary occupational health of today, where the priority is to identify and address the multitude of work-related factors having a negative impact on the health of workers.
The range of hazards to which workers may be exposed, and the possible ill-effects on employee health, are now more fully recognised.
Effective physical and managerial control measures can be instigated. Employers have a legal obligation to put strategies in place to ensure that workers’ health is not damaged by their work. OH nurse specialists pay an important role in this and are engaged in devising and implementing strategies to protect and promote worker health. To be effective, they require a wide range of specialist knowledge and a range of clinical skills.
These (and this list is not exhaustive) include:
- Knowledge of the effects of work on physical and mental health and of health status on work
- Recognition of the pathological effects of agents that may be encountered in the workplace
- Competence in history taking and case management
- An in-depth awareness of the range of hazards to which employees could be exposed
- Cognisance of control measures designed to reduce exposures
- Competence in general health assessments, including those undertaken before or during employment, particularly assessments to confirm fitness to undertake safety critical roles
- Competence in a range of statutory health surveillance appropriate to the setting in which they are employed and the hazards to which employees are exposed
- Skills in facilitating collaborative working with a range of stakeholders including managers, workers and their representatives
- The ability to develop policies that promote or support health, safety and/or wellbeing
- Excellent interpersonal, communication and leadership skills
- Proficiency in devising strategies that promote physical and mental health
- Knowledge of health and safety and employment legislation and how compliance can be achieved
- The ability to undertake a leadership role within workplace health management
Role of the NMC and SCPHN qualifications
OH nurse specialists today are, of course, also registered with the Nursing and Midwifery Council (NMC), either as an adult or mental health nurse.
The NMC requires all registrants to comply with its code (NMC 2015) and ensure their practice is underpinned by a breadth of evidence-based knowledge.
OHNs must an appreciation of work processes undertaken by the organisation that engages them. This requires them to have familiarity of the tasks and sub-tasks involved in undertaking those processes.
They must have the ability to identify the impact of these tasks on worker health. When involved in case management, they rely on their knowledge of the pathophysiology of disease processes and how long-term conditions are managed. An understanding of the application of health and safety and employment legislation is also integral to how they formulate their advice.
Yet none of these elements is incorporated within pre-registration nurse education programmes. As a consequence, specialist post-registration education is required if the practitioner is to remain fully able to fulfil their role.
Some therefore complete NMC-approved courses and become eligible for registration as a Specialist Community Public Health Nurse (SCPHN). Others will hold post-registration qualifications in OH or related disciplines, such as ergonomics or organisational psychology. To be effective, practitioners require a unique skill-set, need to be able to engage with all stakeholders, and must be able to provide impartial advice to both managers and employees, a balancing act that can be challenging.
Interestingly, Richardson and Shia (2013) suggest that the role of the SCPHN is a new one. Although this may be true for other registrants on the SCPHN register working in other settings such as health visitors, school nurses and sexual health nurses, in reality this is not generally the case for OHNs.
Utilising biopsychosocial approaches to workplace health management, playing a part in organisational risk management strategies and remaining cognisant of the impact of poor management on mental health, have all been a focus of the role of the OHN since well before the establishment of the NMC SCPHN register.
Although there is a statutory duty of care of employers to their employees under S2 of the Health and Safety at Work Act 1974 and associated legislation, there is no requirement for employers to provide comprehensive OH services.
Adding value to businesses as well as individuals
Fortunately, many insightful employers do make such provision and not merely as an altruistic strategy. In view of the cost implications of this investment, OH provision will only continue as long as organisations consider that it adds value to their businesses.
These enlightened organisations recognise that promoting the health, safety and wellness of the workforce is good for their business, considering it to be a benefit rather than just a financial drain (European Agency for Safety and Health at Work 2007).
The Society of Occupational Medicine (SOM) regularly commissions evidence-based reports relating to occupational health strategies. Two recent SOM publications: The Value of Occupational Health to Workplace Wellbeing (SOM 2019) – as highlighted in last month’s (March) edition of Occupational Health & Wellbeing – and its earlier report Occupational Health: the value proposition (SOM 2017) examine the value and the impact of occupational health initiatives.
Key conclusions reached within the 2017 report included that:
- the positive contribution of employee health and wellbeing to successful business performance, and the links between the two
- highly effective companies will often have a culture and philosophy that values health
- wellbeing strategies need to encompass the work environment, culture and interpersonal relationships
SOM notes that highly effective employers often successfully embed an ethos of valuing employee health and wellbeing within their organisational culture. This culture, being obvious within their organisational goals, value and mission statements, is reflected within their policies and operating procedures. In short, highly effective companies do not value productivity above the health and welfare of their workforce.
Workplace health promoting interventions include those intended to effect behavioural and other changes designed to enhance the health of the workforce. Nurses working in other public health settings are likely to view health promotion as raising awareness of healthy lifestyles. These will be particularly those focused on physical health, including exercise, dietary intake, smoking behaviour and alcohol consumption.
Influencing organisational and community health
Although these interventions are all relevant to general health, OH nurses are well placed to influence organisational policies and procedures that impact on the health of the workforce specifically and the local community in general. Membership of health and safety and associated committees provides opportunities to raise and discuss issues pertinent to the health of both their workforce specifically and to public health in general.
For example, OH nurses should have an awareness of those work processes that result in emissions to air, water and/or land, as these have the potential to adversely affect community health. This is of course very topical in the light of the recent activities of climate change activists such as Extinction Rebellion and Greta Thunberg.
OH nurses are also well placed to highlight at health and safety committee meetings that workplace health management needs to be about more than just compliance with health and safety legislation.
Membership of health and safety committees provides an ideal opportunity to influence organisational policy development. Within this role, OHNs can emphasise the importance of emphasising health within organisational health and safety management strategies.
Health-promoting initiatives should be integral to these approaches and should not just be restricted to a “fresh fruit and pilates” approach.
Let’s take the example of excessively target-driven institutions that are fast-paced and with a “dog eat dog” culture where it is the norm for staff to work very long hours with inflexible work patterns resulting in a poor life balance.
It is a pointless exercise for such organisations to provide, say, free platters of fresh fruit, lunch-time exercise classes and an impressive list of health and other benefits if they otherwise fail to recognise that their expectations can have significant adverse ill effects on the mental and physical health of their workers.
Health promotion as a component of workplace health management should therefore take account of any psycho-social hazards to which the workforce might be exposed.
One element of workplace health promotion is engaging with national health-promoting campaigns of particular relevance to work settings. A calendar of these events is available online each year. Several are highlighted below:
- National Work Life Week (12-16 October 2020). The aim of this week is to encourage both employers and their employees to consider wellbeing at work and how to effect an appropriate work-life balance. By engaging with this strategy employers are able to demonstrate how their organisation is striving to achieve a flexible, family friendly working culture.
- World Mental Health Day (10 October 2020). This awareness-raising day offers an opportunity to raise awareness of the impact of mental ill-health. This day can then be linked the following month to:
- Anti-Bullying Week (16-20 November 2020). The week provides an opportunity to encourage managers to focus on the range of strategies they could consider employing in order to reduce workplace bullying. Engaging with this initiative has the benefit of raising awareness among both managers and workers that bullying is unacceptable and perpetrators will face disciplinary action. Those experiencing bullying will be better informed as to how they can raise their experiences either with their manager or directly with the human resources function.
These approaches can be used by health professionals to highlight that health is a state of complete physical, mental and social well-being and not merely “the absence of disease or infirmity” (World Health Organization 1946).
Recent studies suggest the benefit of interventions aimed at improving worker health is not restricted to worker health. Two studies, those of Jia and others (2018) and Lundmark and others (2018), found that initiatives intended to change and improve health behaviour often had the additional benefit of changing organisational cultures. This, in turn, then paved the way for other interventions that aimed to improve workplace health and wellbeing.
Inter-relationship between wellbeing, health and ‘good’ work
Many organisations, of course, now recognise the inter-relationship between wellbeing and health, and are now fully integrating wellness into their organisational initiatives.
This approach is core to the 2019 SOM publication The Value of Occupational Health to Workplace Wellbeing, notably that health is not just the absence of disease and wellness does not just relate to having good health. If workplace wellness is to be promoted by and within organisations, managers should be aware of the wider impact of “wellness” in the context of how they manage and treat their staff and how staff treat each other.
In recognition of this, SOM asserts that promoting wellbeing is not just the preserve of health professionals; managers and human resource practitioners have an important role if wellness is to be facilitated in the workplace.
Employers, too, should be cognisant of what constitutes “good” work – and occupational health can be a key enabler in this awareness-raising. SOM highlights five areas employers should consider to be integral if they are to ensuring that work is “good”. These are:
- Management capabilities
- Improving job quality
- Enhancing social relationships at work
- Providing support for workers living with health deficits and/or life challenges
- Workplace health promotion
OH nurses can have a significant impact and influence on all these aspects, particularly workplace health promotion and supporting workers with health deficits or other life challenges.
Although OHNs may not be managers themselves, they can still have an impact, as poor management strategies commonly underpin, or exacerbate, the stress employees experience.
Reference to this impact, diplomatically articulated, can be incorporated within the reports OHNs write in response to a referral, which may of course also impact on social relationships at work and indirectly improve job quality.
Conclusions – is it time for a name change?
In conclusion, the SOM (2019) report asserts that health and wellbeing is not just the preserve of health professionals; they are just part of the picture.
Other stakeholders, including HR professionals, senior and middle managers should all also be involved (Jordan, and others. 2003). Specialist nurses employed in workplaces have an important role to play in terms of driving an organisation’s health agenda.
This leads to a final, important, point to make. As anyone reading this publication will know full well, healthcare delivered in the workplace is termed “occupational health”, with nurses practicing in this setting generally given the job title of “occupational health nurses”.
But has this had its day? In view of the broad and increasingly wide-reaching role of the OHN, as outlined above, and their contribution to driving change, perhaps it is now timely to consider changing the name for this specialty?
This is a debate that has, of course, rumbled on for years. But I’d argue there is a strong case to be made for a more appropriate term for this complex nursing role, that of “organisational health management”.
Furthermore, nurse leaders who are driving practice and organisational change should be able to gain the status of “advanced nursing practitioners”, a status denied to the majority working in workplace health management because of the majority not being independent prescribers (Harriss, 2019).
“Public Health in England: Report of the Committee of Inquiry into the Future Development of the Public Health Function”. Acheson Report (1988), Public health in England. London: HMSO.
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Richardson A, and Shia N (2013). “Preventing suicide with a new risk assessment tool.” Available from : https://www.personneltoday.com/hr/preventing-suicide-with-a-new-risk-assessment-tool/
“Occupational health: the value proposition”, SOM (Society of Occupational Medicine) 2017, London. Available from: https://www.som.org.uk/occupational-health-value-proposition
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“Preamble to the Constitution of the World Health Organization”, World Health Organisation (1948). As adopted by the International Health Conference, New York, 19-22 June 1946; signed on 22 July 1946 by representatives of 61 states (Official Records of the World Health Organisation, no2, p100) and entered into force 7 April 1948.