His column is not called ‘Devil’s Advocate’ for nothing. Consultant occupational health (OH) physician Dr Richard Preece’s comments in Occupational Health’s April issue on the role of OH nurses (or lack of it) in creating an evidence base for the profession have certainly succeeded in sparking fierce debate.
Preece controversially criticised OH nurses for being “neither interested in, nor equipped to deliver” evidence-based practice. He also bemoaned what he saw as a lack of involvement and engagement by nurses in some of the most recent evidence-based research, notably ground-breaking guidance on long-term absence published in March by the National Institute for Health and Clinical Excellence, of which he was a member of the programme development group.
“I see very little to suggest that OH nurses base their practice on evidence,” he argued. “I see next to no primary research published by OH nurses in the UK (even those in academic appointments).”
He concluded: “OH nurses must step up a gear and begin to practise with the specialism and professionalism that their title suggests.”
A flurry of responses
As might be expected, Preece’s opinions prompted a flurry of responses from outraged OH professionals on online forums such as Jiscmail, and a large mail bag to the magazine. His comments were described as a “rant” and as an example of someone who was “hell-bent on destroying the credibility of OH nurses”.
Yet others felt that, while his language could have been more conciliatory, Preece was making a valid point, particularly as the need to work within an evidence-based structure is a key part of the Nursing and Midwifery Council’s code of standards for OH practitioners (see box).
The development of a robust, credible evidence base for occupational health was also at the heart of last year’s review of working health by Dame Carol Black, and in the government’s subsequent response that it would establish a National Centre for Working Age Health and Wellbeing.
Barriers to success
At the very least, Preece’s article has started a worthwhile debate about the barriers that many OH nurses and advisers face in getting work published, including carving out the time and securing the funding to conduct or review research, and even whether the various medical journals tend to be too doctor-focused.
As one Jiscmail contributor put it: “In the past I have planned to try and get work published, but you have to jump through so many hoops I gave up after 18 months of trying! As a wife and mother as well as a full-time OH practitioner, I think time is valuable and I am not prepared to waste it!”
Paul D’Arcy, OH clinical nurse leader at Imperial College Healthcare NHS Trust, argued in the same online thread: “There is a significant shortage of good quality occupational health research in the UK, and this is one of the reasons we get forgotten about.
“I feel embarrassed when I read the Journal of the American Association of Occupational Health Nurses and look at the high quality of nursing research in the US and also at the pride of those undertaking and publishing such research, as there is nothing anywhere near comparable in the UK.
“There seems to be only a small pool of UK OH professionals undertaking primary research or publishing solid evidence-based interventions, some of whom post here regularly. Surely there are more of us who would like to get stuck into researching some of the common OH issues that drive us mad?”
So, is Preece right? And, if so, how can occupational health advisers (OHAs) and nurses (OHNs) become more involved in developing evidence-based practice?
We spoke to leading figures in the profession as well as nurses working on the OH frontline to gauge their views.
There is very little to suggest that OH nurses base their practice on evidence
OH nurses, even those in academia, conduct next to no primary research
There has never been a “study day” to address evidence-based OH nursing practice or research methods
OH nurses are neither interested in evidence-based practice, nor equipped to deliver it
Very few OH nurses were involved in developing, have commented on or have probably even read emerging evidence-based guidelines from NHS Plus’s OH Clinical Effectiveness Unit, the European Union’s OHCEU or the National Institute for Clinical Excellence.
Chris Packham, partner, EnviroDerm Services:
“Nurses often simply do not have the time [to conduct research]; they are too busy. If you have not had the training around research and getting work published it can be a bit daunting, but I think the workload of many nurses is the real issue.
“It is very nice to be able to produce something. Every OH practitioner knows that there may not be scientific evidence for something, but if there is enough anecdotal evidence and enough practical experience of the working environment, then that can be worthwhile too.
“There is anecdotal and experiential evidence out there that is every bit as valid as double-blind, peer-reviewed scientific studies. So I think we need perhaps to rethink what we mean by ‘evidence-based’. Are we limiting it purely to peer-reviewed journals?
“One problem, for example, that occurs when attempting to conduct primary research, and then publish it in a peer-reviewed journal, is that of ethical approval. Most peer-reviewed journals will simply not accept any study that has not undergone this process and obtained such approval.
“For those working in academic institutions or the NHS there is provision through an ethics committee to obtain this. But for an individual working in industry it can be a real challenge to find an ethics committee that will even consider taking on your project.
“So, before criticising the OH nursing practitioners, perhaps it might have been better to have ensured that the arrangements are in place to make such research a practicable proposition.”
Caroline Minshell, health director, BP Exploration:
“I would like to thank Richard for the call to arms. Unfortunately, our hands are full, with businesses demanding ever more for much less. Conducting research is certainly a gap in our discipline, though evidence-based practice is not lacking in many aspects.
“Much of our practice demands a pragmatic and sensible approach, however, so underpinning practice more with empirical evidence can only benefit it. How this can be addressed is uncertain. More and more health services are supplied by OH providers who won’t subsidise research that doesn’t produce an income.
“Many nurses lack the confidence or experience in research and therefore the motivation to engage in it. Studies do not have to be large or onerous. However, they are often viewed in scale, particularly if they are to be taken seriously (publication and reproduceability). Many OH degree courses don’t even have a research module or a study element any more, hence again a gap in competence and research opportunities.
“The NHS and the National Institute for Health and Clinical Excellence may be able to fund research internally. However, most OHNs work outside the NHS. Satisfying ethics committees is also a minefield.
“In general, funding opportunities have been greatly retracted. Added to this, success with research bids is difficult to gain, even for academics who are experienced in applying for research funds.
“I do not wish to present this in a negative light. However, without the competence and motivation in our profession to question and research those questions, there will be little change in the current situation. There is a solution to this: our discipline needs to produce and control the curriculum and standards for practice. There are OH nursing bodies planning to do just that.”
Graham Johnson, operations manager, Bupa Wellness:
“Richard Preece talks a lot of sense, although his language is quite inflammatory. If what he is saying is true, then it is disappointing that [some] nurses do not feel capable of producing or publishing evidence-based documents. But many do.
“We do need to stand up and be counted. At the moment, many nurses will probably be in survival mode, so it is even more important that they are showing best value for money. If they are not producing or following best practice then that is a worry, because the Nursing and Midwifery Council requires it. Often it does tend to be the same names who seem to publish documents.
“If you look at an issue such as latex gloves, there is no evidence to support a total ban, but a number of trusts are moving towards that. So, what is the evidence base to support that? Nurses should be saying: ‘Hang on, where is your evidence?’ But there is a danger they will leave it to doctors to produce their guidance, despite the fact that there are many consumers out there who are not doctors and would welcome nurse-led evidence.
“If you think back 10 to 15 years ago, it was unheard of for a nurse to do a management referral for sickness absence. Now there are technicians doing stuff that nurses used to do. So nurses do need to be doing more to stand up and be counted. They need to be prepared to be brave enough and just do it.”
Dr David Coggan, president, Faculty of Occupational Medicine:
“My perspective is that some aspects of OH practice have, for many years, been quite well evidence-based, particularly activities related to the protection of health in the workplace. On the other hand, for many areas of OH practice, the evidence base is really rather limited.
“People should be thinking more about aspects of their practice that are perhaps not evidence-based and could benefit from being so. OHAs, for example, spend a lot of time doing pre-employment assessments, so it makes sense to consider whether what they are doing is not only efficient and well organised, but also compatible with good science. This requires a review of published scientific evidence and, if necessary, primary research to fill gaps in knowledge.
“I would not expect the majority of OH nurses to get involved in scientific reviews or research, but there will be some who are well placed and equipped to do it, and it would be nice to see them getting involved.”
Gail Cotton, head of occupational health, Leicestershire Fire and Rescue Service:
“It is money and time that stops us, but if we do not do it, someone else will. It is just about raising our profile. It does not necessarily need to be scientific research – it could just be about more sharing of best practice. It is using the documentation out there and adding to it.
“We often do not think what we are doing is maybe new or different, but it may well be different and new to someone else. I’m not saying we need to shout about everything that we do, but because we are all busy, it is very easy just to get carried away with what we are doing.
“This is a wake-up call for us to look at our practice and tell people what we are doing [in order to] re-evaluate it. A lot of us do a lot of very good work, but we are just not very good at sharing it within the right arenas. Just because something is written by a nurse, you do not have to assume it is not going to be as good as something written by a doctor.”
Kit Harling, chief executive, NHS Plus:
“Evidence-based practice is developing within occupational health, but it is slow and probably slower than anyone would like. Nevertheless, the work of bodies such as the Occupational Health Clinical Effectiveness Unit (OHCEU) is gradually building up a recognised base of evidence. When the OHCEU reports at international conferences, you get people across the globe saying it is a world leader.
“I also do not think it is exclusively a problem for OH nurses, and this is where I would take issue with Richard Preece. In framing it in that way, he has diverted attention from the fact that a lot of people find it difficult to alter their practice.
“Part of the issue may well come back to training, and the lack of training nurses get in areas such as research and getting work published. The status of single practitioners is also an issue. I was one myself many years ago and it can be very isolated. You don’t have the ability to bounce ideas around.
“Many employers, particularly in pressured financial times, will not put the same emphasis or value on research, which can make it difficult. So there may be scope for the NHS to take more of a lead on this.”
Dr Tony Stevens, president, The Society of Occupational Medicine:
“Doctors and nurses come from a different tradition but, as their respective roles develop, both professions need a firm evidence base. As nurses take on more challenging roles within OH practice, it is essential that they recognise the important contribution they can make to developing the evidence base.
“We must recognise that our speciality cannot be as reliant on medical science as some other specialities. Often a pragmatic response is required to dealing with the socio-economic or bio-psychosocial problems we face. The evidence we rely on therefore has to reflect this broader base.
“We need to identify best practice where it exists, and develop process and outcome measures to ensure reliability in the application of this practice. The key for me is ensuring that doctors and nurses provide clinical leadership in the development and delivery of high quality services that are critically appraised against agreed best practice, which should increasingly be supported by an evidence base.”
Cynthia Atwell, chair, The Royal College of Nursing Society of Occupational Health Nursing:
“Many nurses have a wealth of information and knowledge about what works and what doesn’t for their organisation, but the stumbling block can be getting it published. OHNs often do not even see it as research that needs to be published.
“Nurses do use evidence-based practice, but they don’t tend to sing about it from the rooftops, partly because they think they will be pooh-poohed by people like Richard Preece. There is sometimes a sense that if it is not number-crunched and epidemiologically based you should not put it forward. But I think nurses can be their own worst enemies sometimes. They don’t see the importance of what they are doing.”
Sharon Horan, occupational health consultant:
“I agree that not enough gets published, but these criticisms are generalisations. What dismays me is the generalisations that OH nurses do not do x, y or z. There are many medical professionals out there that do not use evidence-based practice.
“I often find myself speaking to OH nurses who are doing excellent work and always tell them they should get it published, but rarely they do. Once OH nurses can be freed from all the work that could be done by someone else, then they can do more of the leadership things that we all want them to do. It is also, I think, perhaps up to our educators to take more of a lead on this.”
Janet Patterson, OH adviser, Greggs:
“My knee-jerk reaction [to Preece’s comments] was ‘How dare he’, followed by a realisation that indeed, while I study for my Masters in OH, I find the research-based evidence for practice is slim pickings. Most significant is that we base our health surveillance on Health and Safety Executive legislative guidelines, many of which have little evidence base.
“For example, with asthma, the MS25 medical aspects of occupational asthma reference little evidence and still we have no validated tool for surveillance. Also, I only recently become aware of the Nice and OHCEU projects because of my studies. However, where is the invitation for consultation for those in practice?
“More generally, in my opinion, OH nurses are such a small group and have not got the clout behind them that doctors and other specialities do. It is only in the past five to 10 years that OH has really started to become recognised within the profession.
“Also a lot of OH jobs are predominantly isolated, non-NHS positions, perhaps with a single employer, so there is not the same level of clinical supervision that you would expect within the NHS. There may, too, be fewer role models and leaders than within the NHS.
“A lot of it is that nursing within the OH field is becoming extremely proactive, but a lot of the time is spent working on the frontline, out there day after day trying to get through the work, often with limited resources. So there is no real incentive or time to become more educated and do research or even to climb the career ladder. But people do need to see there is an opportunity there to submit articles and raise their profile. There are many OH nurses who have a lot to offer, but do not know how to do it.”
Dr David Snashall, clinical director and senior lecturer in OH, St Thomas’ Hospital, London:
“It is not only OH nurses who have not until recently used much evidence-based practice. There hasn’t been much of an evidence base within the profession as a whole, which is why the Occupational Health Clinical Effectiveness Unit (OHCEU) was set up specifically to address that gap.
“Traditionally, OH has been delivered without much evidence of its effectiveness. A lot of OH departments have simply followed custom and practice rather than looking for positive outcome measures. The attempt to make evidence-based practice the norm started about 20 years ago within the medical profession, but has really only become a part of OH within the past five years.
“But through the work of organisations such as the OHCEU, there is now a small body of evidence that is developing, and so it is quite easy to use that as a gold standard against which you can audit your practice. There are quite simple standards around things such as back pain, dermatitis, asthma, depression and chronic fatigue syndrome where there is now a reasonable evidence base.
“So if you are getting your record-keeping right, it is now quite easy to audit those sorts of areas. It does not need to be an audit to the standard of what the OHCEU does. A few years back, for example, we did a doctor and nurse joint audit of how we managed needlestick accidents during the day against what accident and emergency (A&E) did at night, and found there were significant differences and valuable lessons to be learned, particularly for A&E, on how to improve practice.
“Those sorts of audits are interesting to other people because they are practical attempts to improve practice, and so are the sort of things nurses could quite easily get on with and do more of within their practice.”
Code of Standards for OH practitioners
The Nursing and Midwifery Council’s Code of Standards of Conduct, Performance and Ethics for nurses and midwives makes it clear that nurses “must deliver care based on the best available evidence or best practice”, and ensure any advice they give “is evidence-based if [they] are suggesting healthcare products or services”.
It also says nurses must “ensure that the use of complementary or alternative therapies is safe and in the best interests of those in [your] care”.
Contact Occupational Health
If you have a comment on evidence-based practice or you have a research paper that could be published in Occupational Health, then contact: [email protected]