The number of OH nurses taking part in published research is sadly small, finds Nic Paton. So what can be done to get more people interested in this vital part of the OH profession?
In August 2012, occupational health nurse Helen Kirk published an article in Occupational Medicine on the role of advanced nursing practice in OH. So what, I hear you say? Not only was the research the first on UK nursing issues to be published in Occupational Medicine in 60 years, it was also one of the very few OH nurse-led research papers to be published in a UK peer-reviewed journal this millennium (see box 2).
So why is this? And what can be done to raise the profile and presence of OH nurse-led research in the UK?
Kirk, who is a managing consultant at consultancy HK Consulting as well as a visiting lecturer at the University of Chester, agrees that the lack of OH nurse-led research in the UK is an issue for the profession – something that was recently highlighted by the Royal College of Nursing’s Willis Commission on Nursing Education (see box 1).
“There isn’t much OH nurse research out there. If OH nurses want the title ‘specialist’ to mean something, then our contribution to the evidence base must improve substantially,” Kirk contends.
“We should be up there with all the other nursing specialities. It’s hugely important for nurses to get involved, and there are lots of opportunities for nurses to start to participate and to learn more.
“It is possible to get involved through the MoHaWK clinical registry and national audit. Nurses can also register as a National Institute for Health and Clinical Excellence stakeholder to help develop forthcoming workplace guidance, they can present projects as posters and presentations at conferences and so on.”
Lack of UK nurse-led research
Former University of Cumbria senior lecturer in OH Dr Stuart Whitaker agrees that, compared with some countries, OH nurse-led research is sadly lacking.
Whitaker, who two years ago left a career in formal academia to set up independent academic centre the Centre for Occupational Health and Wellbeing and now does a lot of international work as a result, points to the US as an example, where there are a number of government-funded academic centres that specialise in occupational medicine and nursing, which also run training programmes.
OH nurses in the US regularly publish high-quality papers in peer-reviewed journals, but by comparison, there are far fewer research and funding opportunities available in the UK.”
OH nurses in the US regularly publish high-quality papers in peer-reviewed journals. By comparison, there are far fewer research and funding opportunities available in the UK, little in the way of career pathways for research-focused OH nurses and a lack of any real demand for research from practitioners or employers.
“Many of the UK’s OH nurse training courses are based in universities that are not regarded as research intensive, and many of the OH tutors that lead these courses are not research active – in terms of publication of studies in high-quality peer-reviewed journals – and these facts point to a picture of research being something we talk about, but don’t do very much of,” Whitaker says.
So, how do you get started? Kirk concedes that finding the time and funding to do research is not easy: “It’s important to try and get support, and most people are normally very willing to give advice if you ask. Another important element is to collaborate – don’t try and do it all on your own. Almost all OH nurse researchers have done research through collaborating with medical colleagues or experienced academics.
“Recognise, too, that it’s a marathon, not a sprint – so you need to have stamina. It can be a good idea to start with something simple, as a small, well-designed study can have lots of value.”
Focus on the detail
Most research will have an element of hard graft and grind about it, Kirk says, so celebrate milestones along the way to maintain your motivation. These will normally be progressing from finalising the proposal through to ethics approval, data collection, drafting the initial report, your first conference presentation, being accepted by a journal and, finally, being published.
“One good tip is to turn an idea into a research question, but keep it as simple as possible – usually just one key question. It’s important, too, to review the literature with an inquisitive mind. You need to be clear why your study is new,” she adds.
“Spend some time on the design of your study and your methodology – and it may be an idea to get some professional academic advice on this, perhaps from a statistician. Preparation is everything. Another important point is to obtain ethical approval. This can take time but it demands focus, and if the study design is good enough to get ethics approval then it is off to a very strong start.”
Then it is a question of collecting and collating the data, analysing it and interpreting findings, followed by the actual preparing of the report, Kirk says, adding that for this last point it makes a lot of sense to get some “critical friends” to comment on it.
“It is important to recognise that getting published in a journal is not the same as writing a dissertation. You need to be really focused, especially if it’s a case of needing to edit down what is a longer paper. Don’t, for example, just cut out sections; a long dissertation will need careful editing in every part,” she says.
“It’s perhaps an obvious point but worth emphasising: pick the most suitable journal. Get some advice on style from people who have published in it and don’t be afraid to talk to the editorial team about what it is they are after. It is vital to follow the ‘instructions for authors’ precisely; if you don’t, then rejection is almost inevitable.
“Accept, however, that you may well have to revise the paper once or twice, so do this with good grace. Finally, deal with any feedback – hopefully this will be constructive, but occasionally it may be a little unpalatable.”
Kirk also recommends developing a thick skin, as any papers are likely to be received with a tough critique: “This, of course, can be very disheartening at times, but it goes with the territory – and, after all, nothing ventured, nothing gained.”
Learning how to research
OH nurse Karen Coomer, who runs consultancy KC Business Health, is two years into a PhD in applied psychology at Nottingham University’s Institute of Work, Health and Organisations.
“For me, learning how to do research has been quite a journey, because it was something that was not taught, or at least not to me, when I trained 20 years ago,” she says.
It is important to recognise that getting published in a journal is not the same as writing a dissertation.”
Being able to interpret research papers and studies more effectively and simply developing a more research-focused mindset has certainly helped her in her practice, she believes.
“When I go into an organisation now, instead of thinking: ‘I have a hunch about something’, I will go and examine the research and, if there isn’t any, consider how some research can be designed around it,” she says.
“For example, is there a connection between health and shift work? That’s an area that I would now feel confident about trying to build up a research base around. More widely, of course, it helps to build up the evidence base for OH practice, but also helps in terms of bringing back solutions to the customer.”
Coomer firmly agrees more nurse-led research could help to raise the profile of OH nurses within the profession. She cites the fact that, for example, she recently gave a talk to the London Deanery’s OH physicians “and got the distinct sense that it was considered unusual for a nurse to be standing there talking about research”.
All about self-improvement
Coomer is also realistic enough to recognise that, for most employers, an OH nurse’s research profile is unlikely to be a key topic for debate or a deciding factor when it comes to employment.
“They might be interested in it but they are not going to employ me rather than someone else because of it. So, it is a self-development and improvement process, informing your practice and taking it further. It is about being able to bring it together, interpret it and then put it into practice,” she says.
“We see the problems on the front line that a lot of academic researchers do not understand, so we can make connections much more readily and see what the problem areas are, and that is exciting. Being able to research something, being able to find out about it, is exciting – you just have to have the confidence to do it.OH nurses have a natural sample in front of them of people from the working population. So it is just a mindset change, going from looking at people as individuals that need to be treated to thinking, as well, how you can use this as a research ‘population’.”
Anne Harriss, the course director for OH nursing and workplace health management at London South Bank University, also agrees that carrying out research can help contribute to more evidence-based practice: “On our OH nurse training programme at the South Bank University, we include how to evaluate research and what you should look for from a good research paper. That is a transferable skill for when it comes to doing your own research.”
We see the problems on the front line that a lot of academic researchers do not understand, so we can make connections much more readily and see what the problem areas are, and that is exciting.”
For Harriss, the key barriers are predominantly funding and time: “It could be lack of confidence, but more likely it is that OH nurses do not have the time to do research. They have so many tasks they have to get on with at a day-to-day level and, while it is a really nice idea, the reality is that employers are employing you to do other things. That’s particularly the case in the current climate. I also suspect that, partly, it is down to opportunity. Thankfully, now, we are getting more nurse-led services but still a lot of services are doctor-led and they tend to want to be the ones doing it because it looks good on their CV. “
Nevertheless, having been involved in, or even having led, a research project can be equally valuable on a nurse’s CV, especially if you can show that because of that research you were able to change or improve your practice as a result, she contends.
A feather in the cap
Rather than trying to replicate what is being done in universities, one solution for OH nurses could be to concentrate their efforts on practice- and action-based research, says Whitaker.
“Those who practise action-based research are those who do well, who should produce better results for the organisation with which they work. For nurses to become a bit more research focused, there needs to be more of a mindset of how are we doing it, how are we evaluating it and can we do it better?” he says.
“This process needs to be led by the academic community, by the tutors who lead OH courses who can coordinate and pull it together, but also nurses in blue-chip companies could be taking more of a leading role.”
He concludes: “Nurse leaders in industry can also do a lot to promote practice-based research with the right support.”
The Royal College of Nursing’s (RCN) Willis Commission on Nursing Education was set up to gather evidence on the best methods of delivering pre-registration nursing education in the UK and to gauge how efficient the current education system is.
To that extent, its remit, clearly, was much wider than OH nursing and research; nevertheless, the role of research in nurse training and practice was one area that was considered in its report, published in November 2012.
For a start, it argued that there needed to be better evaluation of and research into nursing education programmes themselves.
More importantly for the purposes of a wider discussion, it suggested that universities “need to recognise nursing as a practice and research discipline”.
Vice-chancellors, the commission argued, “should work with nursing deans to develop a collective narrative about and commitment to the rightful place of nursing in universities”.
The RCN, in turn, while welcoming the recommendations, stressed it remains committed to “strengthening the workforce and career structure for academic nursing”, as well as “recognising the need for continual improvement in the evidence that drives improvements in care”.
OH consultant and columnist for Occupational Health Dr Richard Preece looked into the prevalence of OH-nurse-led research published in peer-reviewed journals since the year 2000 in 2009. He discovered that not only was such research rather few and far between, but not many of the OH nurses involved had been the principal author listed on the studies that had been published.
His analysis of research studies by UK OH nurses in peer-reviewed journals as listed on PubMed only found six studies with OH nurses listed as authors:
Since then – and Preece concedes both this and his original analysis may well not be definitive – he has identified three more studies with OH nurse authors:
Preece has urged readers of Occupational Health to send in references to other nurse-led, peer-reviewed research that they know of to allow the profession to create a more complete list. Readers can send emails to: [email protected]
Preece also says his list does not take account of OH nurses who have taken part in wider research projects – for example, developing evidence-based guidance.
Nor does it recognise the contribution OH nurses frequently make to “innovation”, with Preece highlighting the contribution of Hilary Winch, an OH nurse manager at Norfolk and Norwich University Hospitals NHS Foundation Trust’s Centre for Occupational Health. In 2008, the trust won the NHS Plus Occupational Health Service for Staff award for its work in developing the “Norwich Back Pal” kneeling stool.
This two-year project focused on improving the working posture of community district nurses, who were spending long periods of time kneeling when applying leg dressings in patients’ homes. The stool was developed following a significant rise in referrals to the OH centre for back and knee pain experienced by these staff members.
Winch led the project, working with the then-primary care trust’s manual handling adviser to help develop and subsequently commission the manufacture of the stool.
As part of the Modernising Nursing Careers initiative launched by the UK’s four chief nursing officers back in 2005, research was published in 2007 by the UK Clinical Research Collaboration’s Subcommittee for Nurses in Clinical Research (Workforce) that reviewed the scale and extent of research being done among or by UK nurses.