This year’s Ruth Alston Memorial Lecture was given by Judy Cook, head of
employee health services at British Airways. She inspired the audience at the
Association of Occupational Health Nurse Practitioners’ (AOHNP) Forum with a
stirring call to face the future by breaking down boundaries and embracing
change
For 50 years the NHS has lived by the inverse care law that says those with
the greatest need get the least health care. Hopefully the introduction of
primary care trusts and the inherent swing towards a holistic approach will
change the imbalance. Some primary care groups have been granted trust status
and these primary care trusts already control 50 per cent of NHS resources.
PCTs will bring together managers, clinical leaders, social services, local
agencies and the community they serve. This is no evolution, it’s a revolution,
and a funded one, at that. We need to move upstream and use disease management
and prevention rather than remain downstream with acute admission to hospital.
We have known this for years but now we see the political party that first
gave us the Black Report putting its money where it counts. One of the aims of
the change is to foster a new culture of public service enterprise to rival
that seen in the private sector.
PCTs create an opening for occupational health professionals who want to
influence and help paint this revolutionary health picture. There will be
opportunities for participation as consultants, advisers and, of course, on the
strategic board, and some will rise to the challenge.
Healthcare advances
The genetics revolution will also transform healthcare. We will be able to
map the genetic code of individuals and understand their risk of developing
specific diseases. Individuals can be advised how best to protect themselves
against the complex interactions of their genes, environment and lifestyle.
This is another revolution – scientific and technological.
Similarly the world of surgeons has been transformed by progress in the use
of endoscopy and key-hole surgery. There have been recent reports of surgical
operators performing to instructions broadcast remotely. One might question
whether this is some future super technician’s function or the domain of
surgeons. Unless we begin to share the future appropriately, then someone
labelled as doctor or a nurse – whether wielding a stethoscope, a scalpel or
some other tools of the trade – may be pushed aside as irrelevant.
Losing labels
I have no wish to see anyone elbowed aside, but I do believe we need to stop
being limited by stereotype labels. The generic healthcare worker is a vision
of change, it is the way forward and I do not believe we should just dabble
with the notion. To date, most NHS-led studies have only involved multi-skilled
generic support workers – a kind of nursing assistant meets physiotherapist and
occupational therapist. It seems to be a role substitution, or a downgrading
almost, rather than a blurring of the boundaries between professions.
Whether we want to or not, we have to change the current concept of
healthcare workers. Nursing may no longer be thought of as an attractive and
sought-after career. And the same is becoming increasingly true of medical
training. Lines of responsibility are blurring – shaking up the once-secure
territories of doctors, nurses and others. It is no longer just a question of
these medical professionals needing to increase their understanding of each
other and work together, they will need to train together as well.
We should not be afraid of deregulation of the professions as we know them,
but contribute to their re-shaping.
Clinical guidelines
In the US it is recognised that it is impossible for individual medical
practitioners to keep up to date with the global body of medical knowledge. For
10 years Americans have worked with the concept of clinical practice guidelines
used for disease management of well-known conditions.
Disease management recognises that it is not only great doctors who make
healthcare, but great teams1. The difference between these practice guidelines
and a text book or a professor’s opinion is that the guidelines are developed
using evidence from outcome-based research. They acknowledge that, despite
decades of biomedical research, scientific evidence is lacking to support most
of today’s healthcare. There is recognition that it is difficult to measure
outcomes for non-scientific interventions such as grief counselling and social
worker support.
Clinical practice guidelines could clear the way for a more multi-skilled
approach, as in the US where guidelines are used by physicians, physicians’
assistants and nurse practitioners.
Technological support
Do we even need the generic healthcare worker to diagnose, treat and care or
could more be done by robots? In 1990, I attended an international health
promotion conference at which an American talked about the use of robots for
treating patients with leukaemia who had been discharged home. The care ranged
from drug administration to limited help with summoning assistance.
Technologies will be developed to respond to the demands to switch to more
care in the community. In the US, there is already a 12-week course on robotic
applications to nursing, in which students have to design, use and evaluate a
prototype robot2.
One company has invented a toilet that will take temperature, pulse and
blood pressure, monitor weight, and check sugar and protein levels in urine.
Nasa has a two-armed, voice-controlled robot destined for the market in 20053.
Occupational health practitioners should not be left behind. They should be
aware of and actually be part of these developments, seriously considering if
and how these or similar robotic applications could facilitate their work.
Nurses may say that it will never happen here or that patients or clients
want people not machines. This is how today’s nurses feel, but they have little
idea how future generations will think. Perhaps one day it will be as normal to
be washed and dressed by a machine as it is now to receive intravenous fluid or
drug therapy via a sophisticated computer.
Net gains
To move to things available to us now – I propose that e-working, rather
than NHS Plus could be occupational health’s revolution. Using the vast
resources currently available on the Internet, occupational health can be
brought to many more people.
The scope for practitioners developing electronic occupational health
management systems is endless. This could provide tools such as information on
how to access specific services, advice and education, and a guide to risk
management for both client and corporation. The only limiting factor may be
that nurses spend so much time debating the pros and cons, they will be left
behind.
If we embrace technology and, of course, are prepared to pay for it, the day
of the disempowered, isolated occupational health nurse will disappear. Nurses
will be able to use telemedicine to transmit images and data to a colleague or
consultant for a swift second opinion or advice. Nurses will be able to access
a national electronic library which will contain the latest guidelines and
evidence on which to base their clinical decisions.
The life blood of occupational health is risk assessment, risk management
and strategies aimed at promoting the health of the working population. It will
be interesting to see how much nurses in business contribute to a national
library to empower the profession to use real evidence to inform risk
management decisions.
Some say the Internet boom is over, the market is saturated, mobile phone
and PC sales are down, and dotcom share prices have collapsed. Don’t believe
it. There are new technologies around – admittedly only in laboratories at
present – that will only fail if people do not buy them when they come to the
market. Business strategists believe this is unlikely as, despite falls in
current sales, people remain in love with their mobile phones, and their
successors will be at the heart of any new systems.
Resistance is useless, the world is changing, high streets will reinvent
themselves without banks, travel agents, bookshops, and electronics shops, with
perhaps the only survivors being specialist and clothing shops where people
need to see and feel the goods before choosing what to buy. This is not as
far-fetched as it may seem as analysts have looked in detail at the future of
the high street. Cash will become scarce and credit cards non-existent as
people switch to e-cash. Voice-recognition and thumbprints will facilitate
access for wireless, fibre optic, multi-function global communication devices.
If ever there was a time for entrepreneurial nurses to influence these life
changes in the home, at work and at leisure, this is it.
The future
American management guru Peter Drucker compares the Internet with printing
and the railways4. Both changed the world completely but not immediately. The
numbers of users rose slowly at first and then took off in an almost vertical
climb. We are still in the slow stage, but Drucker suggests the information
revolution is now almost at the same explosive stage as the industrial
revolution was in 1820. It is hoped that occupational health practitioners will
be able to respond.
Think of the health promotion opportunities of a notice-board that detects
your presence as you walk past, addresses you by name and relays a message
specifically for you. Today’s infants will one day look back and laugh at our
quaint booklets, posters, PowerPoint presentations and CD-Roms.
Third-generation mobile phones with colour screens and built in cameras will
offer video-conferencing – we have seen a comparatively crude prototype with
the BBC’s John Simpson reporting from Afghanistan via video phone.
Bluetooth is a completely wireless concept into which companies have poured
hundreds of millions of pounds. Quite simply you will never have to plug into
anything again and cables will become a thing of the past as you surf the
Internet from your sofa. Interestingly, medical monitoring equipment may be one
of its first applications. Clicks, not bricks, will continue to transform
businesses. Corporate headquarters will shrink as people either work at home or
live nearer their place of work.
Now is the time for occupational health practitioners in business to
collaborate fully with as many skills mixes as possible to ensure this
revolution does not merely wash over them. Nurses – and unfortunately this
includes occupational health nurses – can be poor at sharing processes, let
alone visions. As a profession we jealously guard our ideas in a curious
attempt to make ourselves important and indispensable.
I fail to understand why occupational health professionals would be
reluctant to share knowledge with practice nurses. Unless we actively look for
opportunities to work with those in primary care trusts, we may find ourselves
out in the cold.
I struggle to understand why sharing knowledge and equipping colleagues to
understand the workplace is detrimental to OH professionals as a group. Are we
that insecure? Surely in the 21st century the informed public will be able to
decide who is best placed to help them. I suggest we are arrogant in assuming
that our clients, whoever they are, cannot make a rational and sensible
judgement about who they choose to provide a service.
Occupational health nurses are usually there from an organisation’s choice,
not obligation, and such an opportunity to influence is almost unparalleled.
Sometimes individuals fail to grasp opportunities and wait to be directed as if
there are clear pathways through the intricacies of occupational health. We
used to say scathingly, "all they do there is treatment", now some
frustrated practitioners say, "all we ever do is the management of
attendance". How long before we hear the cry, "all we do is
rehabilitation"? I sometimes worry that lateral thinking is missing and we
too easily revert to a task-orientated model rather than a holistic problem
solving one.
Meeting client needs
In occupational health we continue to struggle to develop meaningful audits
to provide the evidence to develop best practice. I fear we have moved forward
very little since the 1990s and standards-based systems. When we do attempt to
audit, we tend to focus on cost and cost-benefit analysis rather than using the
language of managers.
Client satisfaction can be as powerful as number crunching. Sometimes we
fail to listen to our employers to find out what they want and simply revert to
telling them what we are prepared to give. I prefer to work as part of the
business, looking for opportunities and seizing them to do things differently.
Whether working alone or in a team, there is huge power in harnessing and
co-ordinating knowledge and then innovating.
About 6,500 nurses work in private sector occupational health and they will
not all be movers and shakers.
Nurses in the workplace, however, must be encouraged to think more of their
clients as a population and to link with primary care trusts. They need to
identify those with problems and work towards planned care for individuals and
the organisation.
To make the move away from reactive care, it is not enough to endorse a
preventive stance, we must develop concepts and models of planned,
population-based corporate care.
Take the lead
I believe the best leaders are those who are self-aware, those who innovate,
and develop processes and people. They challenge the status quo and ask what
and why. They do the right thing even though it may be personally
disadvantaging or difficult. They are honest and can admit they have got it
wrong.
In occupational health, anyone can be a leader – quality is not always tied
to a management post, it is more linked to characteristics. So don’t leave it
to your managers, true leadership can be exercised at every level throughout
the organisation.
References
1. AAPA (2001) Clinical Practice Guidelines. www.aapa.org/gandp/cpg
2. Matthews J, Thrun S (2001) Robotic Applications to Nursing.
3. Wilke K (2001) Long-term Care: A Status Report.
4. Drucker P (1999) Beyond the Information Revolution. www.theatlantic.com/issues/99oct/9910drucker2
News from the AOHNP seminar day
Voice of reason
An interesting session of seminars preceded the Ruth Alston Memorial
Lecture at the AOHNP study day.
Of particular note was a presentation by Yve Corkett,
occupational health nurse at the Royal National Theatre, on the care of the
actor’s voice.
As the voice is the primary tool for about 33 per cent of the
labour force, many of her findings are applicable to workers in a wide variety
of occupations. Corkett outlined some of the most common presenting symptoms in
the actors she works with, including hoarseness, pain, loss of pitch, a dry
cough and general vocal fatigue.
Some of the most common causes for these symptoms are acid
reflux caused by lifestyle factors such as eating late at night and voice
fatigue/overuse, which has a number of causes and needs to be treated by rest,
increased hydration and the avoidance of causative factors such as dust,
smoking, alcohol, shouting or prolonged talking.
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Corkett emphasised the importance of good vocal hygiene and
gave advice on vocal conservation, much of which is directly relevant to other
professions.
She identified use of the telephone as a key area to watch as
many patients have identified that their voice deteriorates more rapidly while
on the telephone. This appears to be due to the fact that an excessively loud
voice is frequently used, combined with different vocal behaviour which
constitutes the telephone voice. The lack of visual feedback and elements of
non-verbal communication also appear to put more onus on the voice.
