Evolution of occupational health part 1: pioneers and 21st century challenges

occupational health

Part one of a four-part special report by Noel O’Reilly looks at how the specialty has evolved, what the drivers are for change and how practitioners will face the demands of the 21st century.

The key factor that separates occupational health nurses and doctors from others in their respective professions is that they are based in the workplace. This has meant that, throughout the history of the specialism, OH practitioners have been caught between two masters: the nursing and the medical profession on the one hand and employers on the other.

As this publication enters a new phase in its evolution with a change in title from Occupational Health to Occupational Health & Wellbeing, the OH profession stands at a crossroads. OH nurse leaders have seized the initiative by working towards a Faculty of Occupational Health Nursing. It is therefore a good moment to reflect on where OH has come from and where it is heading to in the future.

History of Occupational Health & Wellbeing publication

In March 1949, the first issue of a new quarterly, The Manchester University Journal
for Industrial Nurses, was published. The foreword highlighted the importance of the education of industrial nurses and doctors for special work in preventive medicine and nursing. The publication became bi-monthly in 1950, and it was taken over by the Royal College of Nursing in 1955. In January 1963 the title was changed to Occupational Health. From October 2015, the publication became Occupational Health & Wellbeing, again signalling a new era in the evolution of OH.

This article will focus on the journey that OH has made from its origins in industrial nursing to the complex challenges of work and health in the 21st century. We will ask what model of OH will be needed to meet the diverse needs of public health, employers and the Government, and what part OH nurses and doctors will play in that model.

No statutory requirement to provide OH services

With no statutory requirement for employers to provide access to OH services, practitioners have always had to justify their existence to the organisations that employed them. As Anne Harriss, associate professor for occupational health at London South Bank University says: “Without a statutory requirement to provide an OH service, employers will only do so if they consider that it adds value to their organisation.”

Successive generations of OH practitioners have had their hopes raised, only to have them subsequently dashed. The Dale report in 1951 recommended expansion of industrial health services into a national OH service.

There were great expectations for the 1972 Robens report that led to the enactment of the Health and Safety at Work Act, but these were disappointed when the report was published and included only one section on OH out of 19 in total. Three decades later Dame Carol Black’s 2008 review of health and work, “Working for a healthier tomorrow”, revived hopes but, once again, the Government of the day stopped short of resourcing a national OH service. For the foreseeable future, OH practitioners will have to demonstrate their value to employers just as their predecessors always have done before them.

Will doctors and nurses lead workplace health services in future?

Historically, nurse- and doctor-based OH services have been the stalwarts of workplace health, but there will not be sufficient capacity among these professions alone to manage the health needs of the future workforce. The Council for Work and Health (CWH) 2014 report, “Planning the future: Delivering a vision of good work and health in the UK for the next 5-20 years”, sets out the challenge facing OH in stark terms: “The funding for [OH] training is unsustainable, the research base is diminishing and affordable access to comprehensive occupational health services for the majority of the UK’s working age population is limited or nonexistent.” (CWH, 2014).

Nor are OH nurses and doctors necessarily the best-equipped practitioners to lead the health and work services of the future. There is broad agreement that OH practitioners will be just one part of an integrated model of OH yet to be agreed. Any model that emerges will include a wide range of allied practitioners and business-driven “wellbeing” professionals.

There is a risk that commercial pressures and government policy could pigeonhole OH practitioners into a narrower role than they have had historically, focusing on sickness absence management. But there is also a hope OH that will become an increasingly specialised function and assume a leadership position in workplace health services.

Meanwhile corporate “wellbeing” programmes and government-sponsored public health initiatives are shifting resources from traditional OH approaches focused on supporting employees who are ill and preventing work-related illness (for example, using health surveillance), towards broader-based health education and health-screening interventions that not only cover employees, but also people who are out of work.

Whereas OH has generally focused on protecting employees from work-related ill health, wellbeing interventions focus on preventing ill health in the workforce as a whole. They address all potential causes of ill health, and not just those illnesses caused by the workplace.

While employers must meet regulatory requirements to protect workers from ill health, their priority with sickness absence is to cut costs. And absence costs employers the same, regardless of whether the cause is something within work or something outside it.

While sickness absence is the most tangible measure of the benefit of an OH service, an over-emphasis on sickness absence management is unlikely to position OH practitioners as potential leaders of health at work strategy. Leadership of workplace health services will require management skills to coordinate collaborative and integrated services. Leaders might also need a broad insight into HR and business goals, such as raising employee engagement and productivity.

And even if there was a dramatic surge in the numbers of OH doctors and nurses, they would not, on their own, have the capacity to single-handedly manage all sickness absence management services, or fulfill related roles in assessing employees’ work functional capability or managing return-to-work programmes. So it is not a given that OH practitioners will lead sickness absence and return-to-work services.

A future model for workplace health services

OH practitioners would not want to be pushed into a sickness absence management role in any case, given the wide range of skills in their arsenal. But where will they fit into the vision of future workplace health services? Black envisages a future work and health model where OH makes up part of a collaborative public health partnership between employers and healthcare providers.

“With almost 30 million adults in the UK, spending about a quarter of their wakeful time each week in employment, most of them subject to a workplace environment, this shift in focus is already taking place,” says Black. “But it is uneven. We have yet to see the well-organised collaborative effort between healthcare, chiefly primary care, employers and their HR and occupational health services, which signals a strong arm of public health. This requires a larger change than that in occupational health alone.”

Black hopes that the example set by employers that have embraced health and wellbeing will spread among organisations as a whole.

“Fortunately, enlightened employers recognise the importance of shaping a workplace culture in which supporting and safeguarding the health and wellbeing of all members of the workforce is important for the success of business and the ground has been prepared,” she says. “It is important that this culture permeates other organisations and becomes the norm. It means establishing a strong lead and example, an investment in management training in recognising and responding to the health needs of the workforce; and working more closely with other health supporting agencies, particularly primary care.”

If you set out today to build a model for work and health from scratch, what role would you give to OH practitioners? The CWH report says: “It has been evident during this project, and in the workshops held in 2012, that there is not a large majority view about what occupational health is and which populations should be served.”

A brief history of occupational health

So what is occupational health? It might be helpful to define the word “health” first. The World Health Organisation’s (WHO) definition in 1948 is widely cited: “Health is a maintained state of physical and social wellbeing, and not merely the absence of disease or infirmity.” This holistic definition anticipates the biopsychosocial model used in many of today’s OH services and also suggests the need to adapt work to the worker, and vice versa, which foreshadows the idea of “good work” developed over the last decade (Waddell and Burton, 2006).

Although the origins of what we call “occupational health” can be traced back to the Ancient Greeks, the true forerunners of the 21st century OH profession were “industrial nurses”, those heroic pioneers who moved from hospitals into factories, mines, transport and manufacturing. Indeed, on its launch in 1949, Occupational Health & Wellbeing was called The Manchester University Journal for Industrial Nurses.

How much did the work of industrial nurses resemble those of today’s OH practitioners? The answer is: more than we might imagine. An early definition of “occupational health” (Slaney, 2000) is a 1950 report by the International Labour Organisation and the WHO:

“Occupational health should aim at:

  1. The promotion and maintenance of the highest degree of physical, mental and social wellbeing of workers in all occupations.
  2. The prevention amongst workers of departures from health caused by their working conditions.
  3. The protection of workers in their employment from risks resulting from factors adverse to health.
  4. The placing and maintenance of the worker in an environment adapted to his physiological and psychological equipment.”

Apart from the way that the worker appears to be viewed as an industrial machine rather than a human being, this definition of OH holds up well even to the present day, with its acknowledgment of the role of health promotion and what pioneering OH nurse educator Brenda Slaney referred to as “the adaptation of work to man and of each man to his job”. (Slaney, 2000)

In the foreword to the CWH’s 2014 report on future OH needs, Professor John Harrison offers an equivalent explanation of the unique contribution of OH practitioners: “We are distinctive because we offer a holistic approach that focuses on the person, their work and the business rather than just the disease.”

The first issue of The Manchester University Journal for Industrial Nurses in 1949 covered topics such as the treatment of industrial burns, tuberculosis in industry and the role of the industrial nurse in mass radiography. This industrial environment remained largely unchanged in the two decades that followed.

Former OH nurse leader Cynthia Atwell recalls: “I first went into OH in 1968. I was employed as a ‘works nurse’ in a metal bashing firm, GKN, and my role was purely treatment, with emphasis on patching people up who had accidents and who were feeling unwell.

“To give a good example of this: in this factory there were large vats of trichloroethylene, which was used as a degreasing agent in which employees used to place cages of components for a few minutes. Trichloroethylene was a common anaesthetic, and employees used to come to me feeling drowsy. I was told to let them sit in the fresh air for a while and then get them back to work!

“So I was doing my treatment and first aid duty. When I started to find out more about the causes of all of this, I was very unpopular with managers as they did not think it was my job to be involved in prevention.”

Health and safety at work

This situation changed after the introduction of the Health and Safety at Work Act (HSWA) in 1974, as Atwell explains: “[Before the HSWA], accidents were reduced but not ill health caused by workplace exposures. I was then working for Rank Hovis McDougal and my role there was very much aimed at prevention, including fit-for-work assessments, health education and training programmes on food hygiene and manual handling. Also, I carried out risk assessments and put in place health surveillance for those potentially exposed to hazardous environments. This was long before the Control of Substances Hazardous to Health Regulation (COSHH), came into place [in 1988].”

If OH practitioners were sometimes hindered by employers reluctant to invest in the health of workers, another stumbling block was the culture clash when hospital-trained nurses had to adapt to the world of work. Slaney describes her experience as an OH nurse in the late 1950s: “It came as a rude shock to many [nurses] to realise that the primary objective of all industry is to produce goods and services for profit. Nurses would argue that their primary objective was for the good of the patient. Even in the most advanced occupational health services, there could be clashes between the two points of view.”

Then, as now, the most tangible proof of the value of OH was in reducing sickness absence rates, but even in the 1960s enlightened managers realised there were other less tangible benefits in having an OH service. In 1965, Parry Rogers, a former director of personnel at IBM told a Royal College of Nursing conference in London that tangible benefits of using an OH service included savings in time lost due to sickness absence, and the prevention of ailments before they progressed to the disabling, time-losing stage. He calculated that the value of these savings exceeded the total running costs of the OH service by 20% (Slaney, 2000).

Rogers also cited intangible benefits including the effect on employee morale, preventive work in environmental control, rehabilitation and general raising of employee health level.

However, while sickness absence management helped to demonstrate the cost benefit of OH, it has always been a two-edged sword for practitioners. One problem is that this responsibility can lead to workers viewing OH practitioners as a stooge of management, there to flush out malingerers and get the genuinely unwell back to work before they are fully fit.

A perhaps greater risk is that the OH role is seen by managers in industry almost entirely in terms of sickness absence management. Today’s outsourced OH providers are at risk of being reduced by service level agreements to an endless, pressurised round of referrals and report writing. Given the high level of training that OH nurses undergo, this does not seem the most productive use of their time.

Worker treatment

Another aspect of OH responsibility that has fluctuated over time is the responsibility for carrying out treatment of workers. For Atwell, the advent of health and safety regulations was embraced as an opportunity to move from a role providing treatment to an ill-health prevention role, but treatment has, to a greater or lesser extent, always remained a part of OH nurses’ remit. Research by Helen Kirk, head of OH transition at Public Health England, suggests this is likely to remain the case. Her study of advanced nursing practice in OH found that 26% of nurses considered treatment an important competence for their practice and 39% believed it will be important in future (Kirk, 2012).

An enduring characteristic of OH work is the isolation felt by individual practitioners, many of whom work alone in organisations, and the isolation of OH nurses among the nursing profession as a whole. Slaney’s lament that “professional isolation can inhibit the development of occupational health services because nurses often work alone and lack specialist training” is still relevant today (Slaney, 1980).

This Cinderella complex relates not just to the position of OH services in the workplace, often down a corridor away from the heart of operations, but also to the small size of the OH profession. Data drawn from a number of sources suggests that the total number of nurses in the UK with OH qualifications may be about 4,500 (Kirk, 2009). Capacity is likely to remain a challenge with declining entrants and an ageing demographic among both doctors and nurses in OH. This raises the question of whether OH practitioners have a role in future as leaders of OH services, or whether they will be better placed as specialist advisers on clinical matters.

Continual professional development is another issue where having one foot in the nursing camp and the other in the workplace has not always served OH practitioners well. In the 1970s, efforts to modernise the regulation and training of nurses resulted in the Briggs report in 1972, which led to the creation of the Central Nursing and Midwifery Council. This brought about an expansion of specialist education and led to the 1979 Nurse, Midwives and Health Visitors Act and UK Central Council.

However, the centralisation of nursing regulation has risked the marginalisation of OH nurses. Even at the time the UK Central Council was formed, OH professionals feared that the interests of specialist groups such as OH would not be safeguarded. Those fears resonate in the present day with 21st century OH nurses feeling that the Nursing and Midwifery Council fails to understand the nature of OH or recognise the specialist educational needs of practitioners.

Part two looks at recent developments in the evolution of OH. Part three will look at the evolution of OH nurse competences and education, professions allied to OH and multidisciplinary working, and ensuring the quality of OH delivery. Part four will look at the evolution of corporate wellbeing and the role of health insurance and employee benefits in work and health.

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”.

Kirk H (2009). “Occupational health education: Healthy progress?” Occupational Health, vol 61, no.9; pp.20-22.

Kirk H (2012). “The role of advanced nursing practice in occupational health”. Occupational Medicine, 62(7); pp.574-577.

World Health Organisation, Preamble to the Constitution of the WHO (Official Records of the WHO, no.2, p.100) entered into force on 7 April 1948.

World Health Organisation. Report of the Expert Committee on Nursing, 5th report, Geneva, 1966.

World Health Organisation (1975). “Environmental and health monitoring in occupational health”, Technical report no.535 (WHO, Geneva).

Slaney B (2000). Nursing at Work. ISBN 0-9539284-0-3.

Slaney B (1980). Occupational Health Nursing. ISBN 0-7099-2322-8.

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