Fit for the job?

Pre-employment health assessments can be described as the collection of detailed information on the health status of an individual. This includes details of their occupational history and clinical measurement tests to identify abnormalities, which would provide a baseline at pre-employment and assessment of an individual’s fitness for a particular job.1

Pre-employment screening may help to determine whether someone is fit to do the job, what health and/or safety risks they pose to themselves or others, the financial risks they pose to the employer, and to reduce accident compensation risks and absenteeism.2

Often the main reason companies have OH support is that they are concerned for the health, safety and well-being of employees.3 Assessing fitness for work is, in some cases, a legal requirement – for example, with Ionising Radiation Regulations or Railway Safety Critical Work Regulations. And pre-employment screening is the first stage of surveillance in those job areas where health monitoring is necessary.2

Companies usually pay for a pre-employment service dependant on the type of work that is to be done. Very few companies require a full medical to assess fitness for work, as it may not be required.

The primary care trust (PCT) in which I worked requires a paper screen, and provided this is satisfactory, the OH nurse (OHN) will issue a fit form and may then call the employee in, at a later date, for an immunisation check or to comply with certain regulations such as COSHH or VDU regulations.4

A paper screen may identify the need for a face-to-face health assessment to comply with COSHH regulations – for example, if the employee has a latex allergy.

Current practice
Currently, my OH department routinely offers pre-employment health assessments to student nurse applicants to assess their fitness for student nurse training, in line with trust policy.

The OHN paper screens all potential new employees, and only sees the employee for a health assessment if the paper screen meets a certain criteria – for example, a large amount of sickness absence or any condition that may affect proposed employment.

A pre-employment self-administered questionnaire, which is scrutinised by a qualified OH doctor or nurse, is usually sufficient.5 Any answers that ‘indicate there is health problem’ are then investigated further. The potential employee may not be passed fit for their post if they are required to meet health and safety regulations, such as under COSHH (for example, latex and Hepatitis C).

The newly-qualified staff nurses at the PCT, however, are not paper screened but are all seen for a health assessment by the OHN. They cannot be passed fit until they have been seen by the OHN for a health assessment.

Often these assessments are short, if there is nothing to discuss, and very often the OHN is questioned by the candidate as to the relevance of the appointment. After discussions with colleagues, I have learned that these assessments are required because of the Beverly Allit Inquiry, also known as the Clothier Report.6

The PCT’s OH pre-employment screening policy states that: “prospective staff need to be physically and psychologically capable of carrying out the work proposed, taking into account any current of previous illness”.

Most in OH would agree that OH professionals should be using evidence, not event-based practice. However, can this be done when there appears to be very little research on the pre-employment process?

Pre-employment screening in the NHS
A health service circular issued in May 2002 by Nigel Crisp, accounting officer to the NHS at the Public Accounts Committee, brought together various elements of good practice in relation to the checks required before an NHS body appoints a person.

The circular stated: “many problems can be avoided if thorough pre-appointment checks are undertaken before a position is filled”. It stipulates 19 points of guidance including:



  • NHS bodies are required to obtain an OH questionnaire completed by the applicant prior to making an unconditional offer of employment
  • A suitable and sufficient OH and risk assessment must be undertaken before a person employed by an NHS body transfers to a new position involving a significant change of duties to ensure that the person is capable of carrying out the work proposed. Account is to be taken of any current or previous illnesses and the duties imposed by the Disability Discrimination Act 1995.7

This requirement could, therefore, lead the recruiting NHS body to interpret this as applying to newly-qualified staff nurses who, undoubtedly, will be taking up new positions and undergoing the transition of change from student nurse to staff nurse.

However, would each trust interpret this requirement in the same way? This implies there will be a ‘significant change of duties’ regardless of whether they are employed for their new post within the same NHS body. If the work requires a specified and justifiable standard of physical and mental health, or the applicant may affect the health and safety of others, a medical examination is likely to be necessary.8

Justification of need?
Previous research on the value of the pre-employment assessment process suggests that routine pre-employment medical assessment is of limited value.9

Formulas have been written to calculate the effectiveness of the pre-employment examination. These measure the cost of completing the pre-employment assessment with the numbers of prospective employees designated as unfit for the task, against the costs of employing that employee and taking a chance on the employee remaining fit for work. It suggests the pre-employment medical is likely to make only a small contribution to safe working practices, hazard control and sickness absence.10

As discussed previously, OH texts refer to the pre-employment assessments as being essential for those occupations where health monitoring is necessary. The forgotten aspect of pre-employment assessments is that of health promotion and primary healthcare. In The Netherlands, it was noted that one-fifth of all prospective employees who had a pre-employment health assessment had some underlying pathology. Although in the past this may have been used to deny the applicant a job, the other effect is that earlier intervention can be provided.

If each prospective student nurse is routinely seen for a pre-employment medical prior to starting their training, any relevant medical conditions could be made aware to the OH department.

The applicant’s sickness absence record before they were selected for student nurse training is another indicator of physical and psychological suitability for entry to nursing, an aspect which was stressed in the Clothier Report.

And the stresses of training sometimes trigger depression – with affected students then perceived as unsuitable.11

Research suggests that the prevalence of minor psychiatric disorders among NHS staff is high compared with employed people generally. The hazards they are exposed to, such as manual handling and stress for example, after their training period are higher than other professions. However, a routine paper screen or evidence of health problems from the OH record would suffice to detect problems.

It could be argued that the transition from student to staff nurse is daunting, but what about moving to a higher grade or a different speciality? Why are we not routinely seeing these employees?

Evidence-based practice
Pre-placement medical evaluation is non-predicative of risks relating to work attendance or job performance in non-hazardous assignments. More recently, when fitness for work and mental illness were considered, it was concluded that there is a lack of good data to aid accurate prediction.12

Why pre-employment health screening is a requirement by the Department of Health (DoH) is unclear, except for the opening statement in the circular for pre and post appointment checks for all persons working in the NHS in England: “Recent cases have highlighted the need to strengthen current recruitment and selection procedures”.

Recent cases refer to the Clothier Report and the Bullock Report. Both reports offered recommendations on staff recruitment following the cases of two nurses who were found guilty of murdering patients.

These cases led the author to look into what the OH department does in pre-employment and throughout an employee’s career. Surely it is not just the pre-employment process that needs to be scrutinised by the OH professional to avoid a repeat of these particular cases?

One considerable spin-off from the Clothier Report into the Beverly Allit case has been large numbers of potential nursing students screened out because of a history of mental illness, including depression with others discouraged or prevented from returning after such illnesses.

This ambiguity has led to the exclusion from training, or the prevention of a return to nursing, of people with a range of mental health problems that may pose absolutely no cause for concern.

It could be argued that screening for common mental disorders is pointless as half of those examined will change their status during the following year.13

Conclusion
This research suggests that promoting the OH service to the staff in the NHS and offering support at the end of nurse training, rather than determining fitness, may be a more positive practice.

If there is a health problem during training it will, in all likelihood, be addressed before the employee becomes a newly-qualified staff nurse. The OH service should seek to establish a therapeutic relationship with staff and staff with relapsing mental health issues should be already receiving extra attention.

Where an employee deals with vulnerable client or patient groups – doctors, nurses, teachers, social workers – where impaired concentration or short-term memory could have a significant, and perhaps catastrophic, effect on care, a follow-up should be routine.15

The need for support for all staff is widely recognised in the provision of OH and counselling services. Without this support, there would be an extra burden on line managers.

While it is true that frequent lengthy sickness absences impose a strain on other staff and management, and can make running a service difficult, early evidence from the UK suggests that if staff receive proper support with mental health problems, they will on average take less time off sick than other staff.7

Recommendations
There is little value in routinely seeing all newly-qualified staff nurses for a pre-employment health assessment. It appears that this is a waste of time and resources, which could be used to promote the service.

Each employee should be regarded individually and previous OH notes screened, together with the possibility of new references while they have been training.

There is also the danger that the employee may be discriminated against if they are seen by OH unnecessarily. The DoH states: “Pre-employment health assessment of all new staff should be carried out fairly, objectively and in accordance with equal opportunities, legislation and OH practice”.14

If all NHS OH departments were operating in the same way, it would save confusion, particularly for rotating staff. A national framework would be ideal.

The way forward would be the ‘national framework’, together with the OH department promoting itself and ‘supporting staff’ throughout their career using evidence-based practice and not events.

At the time of writing, Laura Dunn was working for a PCT in the West Midlands. She is now an OHA for UNIQ Prepared Foods based in Minsterley, Shropshire and can be contacted on Laura.Dunn@uniq.com

References
1. Atwell, C (2002) Managing Occupational Health Services. In Oakley, K, eds. Occupational Health Nursing. London: Whurr: 1-31
2. Haywood, P (2003) Pre-employment Health Screening – Is it useful? Nursing Standard, 11 (17) Nov: 7-12
3. Paton, N (2002) An age old problem. Occupational Health 54 (12):18-20
4. Whittaker, S (1993) National Audit of Pre-employment assessment in the NHS. Occupational Health, May: 173-175
5. Artus, K (2002) Pre-employment Screening. Occupational Health 54(12) Dec: 24-27
6. Hobson, J (2004) Editors Choice – Evidence not events-based practice. Occupational Medicine, 54:141-142
7. Department of Health (2001) The Effective Management of Occupational Health and Safety Services in the NHS. Ref 25770. London. HMSO
8. Cox, R, Edwards T & Palmer K (200) Fitness for Work – The Medical Aspects, 3rd Edition. London. Oxford Press
9. Waclawski, et al (2004) Is there value in routinely obtaining a report from the GP as part of pre-entry health screening of students for nursing studies? Occupational Medicine 54(3):176 -181
10. De Kort, W & Van Dijl, F (1997) Preventative effectiveness of pre-employment medical assessment. Occupational and Environmental Medicine. 54(1); 1-6
11. Brandon, D (1999) Wounded Healers. Nursing Standard Vol 13 (28) April – March: 17-19
12. Glozier, N (2002) Mental ill health and fitness for work. Occupational and Environmental Medicine. 59 (10): 714
13. Timmins, F & Kaliszer, M (2002) Absenteeism among nursing students – fact or fiction? Journal of Nursing Management. 10: 251 -264.1
14. www.DoH.gov.uk
15. Wynne PA & Archer AD (2004) Psychiatric disorder and the role of Occupational Health, Occupational Medicine, 54. March, 143-144


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