The third part of a series of articles on the evolution of OH focuses on OH nurse competencies and education. Noel O’Reilly asks if future training of OH practitioners will take place alongside that of allied practitioners.
The launch of a National School of Occupational Health in 2014 signalled a recognition among occupational health practitioners that future workplace health and wellbeing services will be provided by a range of professions.
Furthermore, the initiative acknowledged that the roles and educational requirements of practitioners will overlap. The school, launched by Health Education England (HEE) and the Faculty of Occupational Medicine, is intended to “promote and develop multi-professional training of work and health” (Council for Work and Health (CWH, 2014).
However, collaboration between practitioners does not always prove straightforward in practice. OH doctors’ body the Society of Occupational Medicine (SOM) opened up its membership to associated healthcare professionals in OH in 2012. Many practitioners hoped that a ballot of members for a merger of SOM and the Faculty of Occupational Medicine (FOM) in 2014 would lead to further integration of OH doctors and other practitioners. These expectations were thwarted when too few faculty members supported the merger. OH nurses responded by seizing the initiative with the launch in 2015 of a project to develop a Faculty of Occupational Health Nursing (FOHN).
While some physicians voted against joining forces with other practitioners due to concerns about protecting specialist education for doctors, the reality is that both OH doctors and nurses will have to share responsibility for delivering services with allied practitioners in future. This is because numbers of OH nurses and doctors in the UK are small and are now in decline.
Practitioner case study
Maria Goldby, senior occupational health & wellbeing adviser, Reed Business Information
Over the past few years my role as an OH adviser has changed to a role that encompasses all aspects of preventative healthcare as a specialist community public health nurse.
The role has become much more proactive and preventative, in line with recommendations made by Dame Carol Black’s report, “Working for a healthier tomorrow”.
A major part of management referrals to me are due to employees suffering with stress or other mental health issues. The cases seem to be more complex as managers are not routinely taught how to notice early signs of stress or mental illness, so the employee can be quite unwell by the time I see them.
Due to a lack of NHS resources and possible long waiting times, the OH adviser has had to become more knowledgeable and resourceful about support charities and other external organisations to try to direct and enable employees to get the right help as quickly as possible. I will often call GPs now to discuss fit note recommendations, or write to consultants, to ensure we all work together to support the employee safely back to work.
I feel that doctors respect our role and expertise much more now, as they know that work has a positive impact on wellbeing. The focus is shifting for us to be much more involved commercially within corporations (within the remit of our code of conduct). I think my title and/or role should evolve to become “occupational health business partner”.
For the past 18 months, I have been working closely with RBI’s global marketing director, Lawrence Mitchell, and Kamwell (an external wellbeing company) to look at innovative ways to focus on more wellbeing initiatives within RBI. We initially carried out a wellbeing survey to ask what our employees wanted and now have a team of volunteer global health champions to help us promote wellbeing in its broadest sense across all our communities.
I am very excited to work across so many areas of the business and believe that in working together, we can offer something for everyone.
Over the next decade, I anticipate that we need to grow more as specialists, take on more training and develop other skills with peer support, to promote best practices.
Meanwhile, other practitioner groups are poised to take on wider responsibilities. An illustration is the Chartered Society of Physiotherapy’s OH competency framework for physiotherapy, covering knowledge and skills up to PhD level. And within the 2015 Safe, Effective, Quality Occupational Health Services (SEQOHS) standards, a voluntary OH accreditation scheme, OH physiotherapy services are able to gain SEQOHS accreditation.
Leaders of the OH nursing profession are debating whether or not postgraduate OH education should be integrated into multidisciplinary training with students from a range of allied professions. This would mean a shift away from training dictated by the Nursing and Midwifery Council’s (NMC) requirements for registration. The challenge will be for OH nurses to identify their unique and most valuable competencies, and decide which among their current responsibilities could be delegated to other practitioners.
Drivers of future OH services
A report by the CWH (2014) identified three fundamental drivers that will shape OH requirements over the next 20 years:
- financial pressures on the NHS requiring radical changes in the delivery of healthcare;
- demographic changes; and
- chronic and long-term conditions and the health issues arising from obesity.
The report identified a range of specific factors affecting the occupational health market which will determine future OH competencies and knowledge. These include physical impairments such as musculoskeletal conditions or mental health, and a wide range of broader societal factors such as: meeting the needs of people capable of work but not in work; ethnicity and illness; and the need to provide health and work services to smaller companies.
This raises questions about what areas OH nurse practitioners should focus on. It is not clear, for example, the extent to which OH practitioners will provide advice about return to work for people who are unemployed. And, while in the past OH services have often worked in self-contained units, in the future they may have to work within an integrated care pathway involving primary or secondary care and a range of allied practitioners. There may be more OH services based outside the workplace as a result.
The CWH report argues: “Occupational health will need to be effective in engaging with local health and wellbeing boards and clinical commissioning groups.
As the health system moves resources towards prevention and care rather than medicine, OH will need to review the knowledge and skills required of the multidisciplinary workforce, including behavioural psychologists, therapists, physiotherapists, etc. The term “occupational health” does not, in this context, refer to the professions of OH nurses or doctors but to those delivering work and health services in general.
Practitioner case study
Dwayne Gillane, occupational health nurse manager, Royal Berkshire NHS Foundation Trust
Over the past few years, there has been a gradual change in focus for OH departments to be more proactive in their approach to staff health and wellbeing. Employers are requesting more health and wellbeing initiatives for their staff, which indicates that both the Boorman review of NHS health and wellbeing and Dame Carol Black’s report on “Working for a healthier tomorrow” are helping to influence employers to look after their staff.
Providing training and support to managers in the workplace has been commonplace in OH, however, offering staff this opportunity has not. Employers now understand the need for staff to be equipped with the appropriate knowledge and skills to manage in today’s busy and demanding working environments. Providing training for staff on issues such as how to manage workplace pressure and helping to break down taboos around mental health are part of the recent examples of how the view of OH in the workplace is expanding.
The challenge to OH department managers is, and will continue to be, getting the right balance and skill mix within their teams to meet the needs of their organisation. The focus on the health and wellbeing agenda gives OH teams the opportunity to change the way in which organisations and staff view our services.
There will be a continued demand for the traditional elements of our services such as sickness absence referrals, vaccinations, etc.
However, there is also likely to be an everincreasing demand for the pro-active services available from our departments. OH departments in the NHS are in an excellent position to liaise with specialists, both within their organisations and externally, and must develop these relations for the benefit of the department, the organisation and staff.
Occupational health advisers will need to have a broad spectrum of specialist skills in future to not only include the traditional services such as case management or health surveillance, but also have the ability to deliver health education and training to various management and staff groups throughout their organisations.
This presents an exciting opportunity for our speciality to liaise with and develop excellent working relationships with our multidisciplinary colleagues for the benefit of staff health.
Other drivers for future OH practice come from within the NHS and the nursing profession itself. Royal College of Nursing (RCN) guidelines for OH competencies (RCN, 2011) present a framework for different levels of competence which relate to nursing grades: competent nurse; experienced nurse; and expert nurse. The guidance was developed in response to NHS initiatives: Agenda for Change (Department of Health (DH), 2003); the Knowledge and Skills Framework (NHS KSF, 2004); and the Development and Review Process (DH, 2004). The guidance is based on:
- the need for leadership in specialist nursing;
- the need for the development of standards, new public health strategies and government reviews on occupational rehabilitation and fitness to work;
- increased focus on work-based and lifelong learning and clinical supervision; and
- a changing focus towards professional
rather than academic accreditation.
This guidance suggests that OH nurses with advanced practice competencies could play a key part in managing future workplace health services (Kirk, 2012).
Beyond the crisis in OH nurse education
One of the challenges for OH nursing practice is that the profession must meet the standards of the nursing regulatory body, the NMC, while at the same time fulfilling the expectations of employers. In recent years, these two requirements have come into conflict.
OH nurse leaders have campaigned for the NMC to make allowances for skills specific to OH nurse practice in the NMC’s Standards of Proficiency for Specialist Community
Public Health Nurses (SCPHN). OH nurse educators accept the broad principles in the NMC curriculum, but argue that there is a need for a specific OH skills cluster and for OH courses to have a maximum proportion of core specialist content. The joint education of OH nurses with other public health nurses has not taken account of crucial differences in training needs between OH and health visitors and school nurses.
In January 2015, the Government’s response to a Law Commission report stated that there is uncertainty about the continuation of the NMC SCPHN register. Anne Harriss, associate professor, occupational health, at London South Bank University, believes ending the SCPHN register would have an impact on OH educational provision.
“If the SCPHN register is disestablished then the NMC is likely to become less relevant to the approval of OH Nursing programmes,” says Harriss. “Public protection will be ensured by registration as a nurse on what is currently referred to by many as the first part of the Nursing Register. The National School of Occupational Health and the establishment of a Faculty of Occupational Health Nursing will assume more importance in what is included in OH nursing programmes.”
However, the future of the NMC Nursing Register is not the only influence on the future of OH education. Another factor is the way in which OH nurses are represented by the RCN. The RCN’s Society of Occupational Health Nursing has been replaced by a Public Health Nursing Forum supporting public health nurses in a variety of practice settings, not just OH nursing. This signals a shift of focus for OH from the workplace to a broader public health role.
Another influence on OH education will be the National School of Occupational Health, established in 2014. Harriss believes the school will expand its remit from approving courses for medical practitioners, to approving courses for other professions involved in the delivery of workplace health. These will not be limited to nursing, but could include, for example, physiotherapy or health and safety. The school is in the process of identifying evidence-based competencies across professions in order to promote opportunities for multi-professional learning.
Harriss says: “This initiative will influence core and specialist components of educational programmes offered exclusively for professionals delivering work place health management initiatives.”
Harriss believes that OH doctors and nurses will increasingly be educated alongside allied practitioners: “Multi-professional education of OH nurses with a range of OH practitioners (medical, nursing, physiotherapy) based on core and profession-specific elements will influence how OH practice is delivered.”
What are the core competencies?
While there is no formal consensus on what constitutes core specialist OH nursing competencies, the chapter headings in “Contemporary Occupational Health Nursing” (2013), written by members of the Association of Occupational Health Practitioners (UK) (AOHNP), suggest the broad remit of OH nurse advisers. The themes are: leadership; health promotion and health needs assessment; health surveillance; health assessment, case management and rehabilitation; mental health at work; management of OH services; epidemiology and research; and quality and audit.
These dimensions are similar to those in the RCN guidance on OH competencies (2011): self assessment; core transferable skills; core leadership and management skills; core quality assurance and research skills; legal and ethical issues; risk assessment; public health, health promotion, protection and surveillance; attendance management, case management and rehabilitation; psychological and psychosocial interventions; ergonomics; occupational hygiene; and maintaining safety and accident control.
Most of these responsibilities overlap with the remit of practitioners allied to occupational health, such as OH physiotherapists, occupational hygienists or occupational therapists. While some of these areas of competence could be termed “clinical”, others such as “leadership” and “management of OH services” are managerial, administrative or business related.
Diane Romano-Woodward, president of the AOHNP, believes that both business or commercial skills and nursing skills will be important in future. “In terms of general competences I think the ability to problem solve by asking good questions to better define problems and to be creative with solutions [will be important],” she says.
“Additionally, I think an understanding of business and selling techniques is required to help organisations and individuals to change behaviours. As there will be multidisciplinary working, I think nurses will need to ensure that they have the basic nursing skills that no other disciplines will be offering. This will include giving immunisation and venepuncture, along with those that sit well within our discipline and which we can give supervision for those who are less well qualified: audiometry, spirometry, vision screening, skin assessment and basic HAVS [hand arm vibration syndrome] assessments.”
What current responsibilities could be delegated?
With limited resources, OH nurse practitioners will have to agree what is the best role for them in the multidisciplinary team, and what responsibilities can be undertaken by OH support workers under OH nurse supervision. RCN guidance (2011) has suggested that support workers, such as OH technicians, could take over a range of clinical and administrative tasks from OH nurses. The RCN divided these into three levels, rising in complexity:
Level 1:
- Measure blood pressure, pulse, height and weight including body mass index.
- Urinalysis.
- Audiometry.
- Measure visual acuity to occupational standard.
- Lung function testing to include peak flow and spirometry.
- Assess mobility.
- Drug and alcohol testing.
Level 2 (roles and responsibilities of Level 1, plus):
- Venepuncture.
- Chester step test.
- Skin assessment.
- HAVS assessment to level 1 and 2.
Level 3 (roles and responsibilities of Levels 1 and 2, plus):
- Display screen equipment assessment.
- Interpretation of lung function and audiometric results.
Romano-Woodward says: “Those activities that can be undertaken by appropriately trained lay people will need to be devolved to them. Activities such as first aid and display screen equipment assessments are already undertaken by others. The role of OH technician is likely to be expanded and might be undertaken by those with experience in the fitness industry.”
Is the future multi-disciplinary?
An article by Helen Kirk, head of occupational health transition at Public Health England (Kirk, 2012), addressed widespread feeling among OH nurses that OH education is not keeping pace with emergent practice. Kirk looked at whether or not advanced nurse practitioner (ANP) roles described by the NMC in 2005 could provide a solution.
The NMC did not describe ANP roles in terms specifically relevant to OH nurses, but Kirk’s survey of OH nurses found that most agreed that the generic ANP competencies defined by the NMC were relevant to OH nursing practice, and could become more important in future. In the survey, 63% of OH nurses agreed that not all OH teams need a specialist, but, on the other hand, 57% agreed that, in future, where OH nurses were working as specialists, they should be trained as advanced nurse practitioners.
Kirk points out there is no existing consensus on what these competencies should be. Over seven in 10 (71%) of those surveyed also welcomed a potential new multidisciplinary training programme and qualification that met the challenges of future OH practice.
Kirk surveyed OH nurses on the importance of specific ANP competencies to OH practice now and in the future. It is interesting to note that these competencies would also be requirements of other allied practitioners. Examples included:
- doing consultations on your own;
- examining the back (range of movement, power, sensation, etc);
- assessing upper limb function;
- carrying out a mental state examination;
- identifying the potential explanations for spirometry findings;
- distinguishing between patients that might benefit from physical therapies;
- writing a detailed rehabilitation plan with milestones; and
- implementing evidence-based care.
This implies that many of the NMC’s generic ANP competencies are relevant to allied practitioners as well as nurses. The other implication is that today’s OH nurse education programmes are failing to train students in the competencies required for the future.
“We accept OH is changing a great deal – the key issues in workplace health today are very different to those that dominated the agenda 30 years ago,” says Kirk. “Nurses entering OH need preparing for the challenges of the coming decades. I am not convinced that education has kept up.
“There is an increasing demand for more advanced skills and increasing opportunity to delegate tasks, from immunisation to clinical measurement. Today’s courses are dealing with yesterday’s issues better and better but I’m not convinced they are preparing new OH nurses for tomorrow.” Romano-Woodward does not believe that the NMC will have a monopoly on OH nurse education in future. “I see a future where there will be a range of courses and modules provided by many training organisations which can be put together to provide the required underpinning knowledge deemed appropriate by occupational health specialists, rather than the NMC,” she says.
There have been precedents for multidisciplinary training, Romano-Woodward says. “When I did the MMedSci at the University of Birmingham in the 1990s, we were a mixed group of nurses, doctors and others. We learned alongside each other, debated and shared the benefit of our experience. It mattered not what our background was, we were all students. I would like to see much more multidisciplinary training so we are comfortable understanding each other’s areas of expertise (mutual and individual) and can refer clients to each other appropriately.”
Should OH nurses be involved in wellbeing and health promotion?
Most of the OH competencies referred to so far in this article relate to individual workers, whether by preventing ill health through, for example, health surveillance, or by assessing employees who are unwell and suggesting a rehabilitation plan. In future, however, many employers will want to adopt wellbeing programmes targeting the workforce as a whole with the goal of cutting the costs of ill health. To what extent should OH nurses participate in wellbeing and health promotion?
Romano-Woodward believes that nurses have a role in education. “I think the reality is that employers will still want their employees to have the benefit of OH advice. Public health authorities, particularly in local authorities, are waking up to the fact that there are experienced practitioners in workplaces and that workers spend a good amount of their week at work , so there may be an opportunity to positively influence general health.”
However, she sounds a note of caution about the capacity of OH nurses to lead corporate wellbeing programmes. “OH practitioners may have a battle to focus on their specific area of expertise, the prevention of work-related ill health, rather than being swept up in general health promotion strategies,” she says. “These activities can probably be provided by lesser-qualified individuals, and we need to continue to make a case for our specific expertise.”
While wellbeing approaches focus on the working population as a whole and all the factors that influence individuals’ health, OH nurses seem to have a built-in orientation towards a focus on identifying health risks at the workplace.
Romano-Woodward has worked recently with HR managers to reduce stress and her method exemplifies this approach: “My focus was on identifying why this was the case [ie employees were stressed] and suggesting targeted training to this group and their managers on management style. I would be very happy to spend more of my time doing this, but there has to be a change in organisational perception that “illness” is due to susceptibility in individuals and is strongly influenced by attitudes and conditions at work.”
Only time will tell what the role of OH nurses and doctors will be in the future. Kirk, for one, is happy to embrace uncertainty. “I honestly don’t know. Thank goodness things change. Change is what keeps this profession so interesting.”
References
Council for Work and Health (2014). “Planning the future: Delivering a vision of good work and health in the UK for the next 5-20 years and the professional resources to deliver it”.
Department of Health (2004). The Knowledge and Skills Framework
Kirk H (2012). “The role of advanced nursing practice in occupational health”. Occupational Medicine; 62(7), pp.574-577.
RCN Guidance (2011). Roles and responsibilities of occupational health support workers. Cynthia Atwell.
RCN Guidance (2011). Occupational health nursing – career and competence development
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Regulation of Social Care Professionals in England, the Government’s response to Law Commission report 345, Scottish Law Commission report 237 and Northern Ireland Law Commission report 18 (2014) Cm 8839 SG/2014/26.
Thornbory G (Ed) (2013). Contemporary Occupational Health Nursing. Routledge. ISBN 978-0-415-82295-4.
