Practice nurse Julie Lennon gained competence and confidence from an e-learning Open University course on musculoskeletal disorders (MSDs) and believes that OH nurses would also benefit from the format. Here, she reports on her training experience.
While balancing the demands of family and work commitments, I chose to make my life even more complicated and embarked on a level 6 distance e-learning module focusing on MSDs. Education for Health (an organisation for which I am a trainer) in collaboration with Arthritis Research UK, has developed a standalone e-learning musculoskeletal module accredited by the Open University, Assessing and managing patients with joint pain.
The level 6 academic study offers an opportunity for clinicians to develop their knowledge and understanding of musculoskeletal conditions; critically analysing the impact of inflammatory, noninflammatory and work-related problems for a patient, their family and carers, work and society.
Offering a flexible method to study, the blended-learning approach comprises e-learning, taught study days and activities to support adult learning, enabling the student to participate at a time convenient to them. The standalone e-learning module offers units of learning that underpin key elements of musculoskeletal conditions, enabling OH nurses to apply the findings to their place of work, and manage and support workers with musculoskeletal conditions in the workplace.
Why musculoskeletal disorders are a priority
Disorders of the musculoskeletal system represent a considerable burden for workers in the UK. Figures from the Labour Force Survey (Office for National Statistics (ONS), 2014) identified that 31 million days are lost to musculoskeletal conditions. Nursing, personal care, building trade workers and skilled agricultural workers featured higher than many other occupations.
Employers have a legal duty to consult with employees, or their elected representative, involving them in the risk-assessment process. This is because identifying susceptible employees with back pain can moderate future work-related problems. The ONS (2014) identified that most work days lost as a result of musculoskeletal conditions were due to back, neck and muscle pain.
Working through the principles of the profile of musculoskeletal conditions, examining the normal and abnormal joint and associated pain and exploring the approaches to pharmacological and non-pharmacological pain management will complement the OH nurse’s responsibility of ergonomic assessment and “reasonable adjustment” when focusing on workplace adaptation (Government Equalities Office, 2010).
The “wear and repair” of osteoarthritis (OA) presents particular challenges. OA can be found in any synovial joint, but major weight-bearing joints such as hips and knees affected by OA can have an impact on the workforce, particularly in a manual occupation. The hands, spine and feet, also targets for the disease, need equal attention.
Recognition of the potential impact that OA can have for an employee, together with supportive non-pharmacological management from the OH team, will support a collaborative self-management approach. The e-learning “Assessing and managing patients with joint pain” module provides education and evaluation for modifying approaches to the prevention and management of OA, exploring risk factors and risk-reduction strategies for primary prevention, as well as possible secondary prevention measures.
OH nurses and MSDs
The OH nurse is ideally placed to collaborate with the employee and their employer, agreeing non-pharmacological approaches to risk-reduction strategies for the management of OA in the workplace. The learning from the module regarding the impact of OA on health-related issues will empower the OH nurse to develop their critical discussion with employers.
The new skills will enable them to influence policy change and work practices in the workplace. Engaging in critical discussion with employers as an advocate for the employee is a common theme for OH nursing. The learning from the module regarding the impact of musculoskeletal conditions such as OA will enable the OH nurse to engage in influencing policy change, criteria or practice at a strategic level, facilitating the process of change.
Rheumatoid arthritis (RA) is an inflammatory, progressive and destructive autoimmune disease affecting multiple joints. Hands, wrists, elbows, shoulders, knees and ankles are commonly affected symmetrically and sufferers present with pain in the metacarpophalangeal joints of the hands or metatarsophalangeal joints of the feet. Onset can be insidious or rapid, and pain is often a constant companion for many patients.
Early diagnosis is essential; the symptomatology of heat, redness, swelling, pain and loss of function, (all features of inflammation) are characteristics that require urgent intervention. Identification in the workplace of an employee presenting with these symptoms places a responsibility on the OH team to refer promptly to the GP, thus expediting the referral pathway, supporting the recommendations for early referral and management to reduce disease impact.
A more systemic manifestation of disease trajectory, fatigue, lethargy and depression can sometimes be identified. With their expertise in disease recognition, OH nurses are well placed to undertake occupational management, including “reasonable adjustment” in the workplace, non pharmacological management, identification of stress, anxiety or depression and the potential impact that RA can have on work-related issues (such as stiffness and how this can affect mobility).
The importance of the multidisciplinary team cannot be over emphasised. RA can appear in any age group, women being disproportionally affected; about three times as many women are diagnosed than men. With a prevalence of approximately 400,000 people in the UK, it can affect adults at any age, although often begins between the ages of 40 and 50. It is therefore probable that OH nurses will meet some employees with this debilitating disease, as it represents a significant number of the potential workforce.
The OH nurse is a pivotal member of the multidisciplinary team. Arthritis Research UK acknowledges the importance of keeping people with RA in work. In an attempt to reduce work days lost, Arthritis Research UK is exploring the effectiveness of “vocational rehabilitation”, a portfolio of measures often negotiated with the employer, making it easier for the employee to stay in work.
A course of action might include retraining, flexible working and workplace adaptations, all measures where the OH nurse is ideally placed to support the employee in their objective to remain an active contributor to the workforce.
A valuable intervention for the employee is an ergonomic assessment of their workstation. Employers have a general duty of care to ensure that seating is suitable (HSE, 2014, b). Inflammation of the joints may be improved with suitable seating, and assessing whether or not the seat design is safe and can accommodate the person with RA.
Pain associated with joint destruction, self-image and selfawareness can put an enormous amount of pressure on the employee. The OH team can be an effective contributor to holistic management.
Value of e-learning
The qualification delivered by Education for Health in collaboration with Arthritis Research UK is acknowledged by employers and has national and international recognition. Education for Health is pioneering e-learning and, in partnership with the Open University, accreditation for the learning provides academic rigor and supports students with competency development and increasing confidence in the recognition and management of long-term conditions including MSDs.
The flexibility of the blended e-learning approach enables the student to study at a time convenient for effective learning. The interactive online course provides opportunities for the nurse and healthcare professional to develop both academic and practical knowledge. Activities are designed to be engaging, pragmatic and add a new dynamic to the learning experience. Two taught days add breadth and expertise to learning; while the trainers, all clinicians in practice, have first-hand experience in the field of study.
Clinical background to MSDs
Pain is a significant problem for patients with musculoskeletal conditions. The interrelationship between pain and anxiety and depression is well documented (Lépine and Briley, 2004; Vachon Presseau et al, 2013). The co-morbidity of chronic pain and stress needs exploration if an agreed strategy on how to de-escalate its impact on the employee is to be reached.
Through a common chemical language of neurotransmitters, to de-escalate its impact on the employee is to be reached. Through a common chemical system of neurotransmitters, Chapman et al (2008) argue that social stressors can compound the stress experience. Kiecolt-Glaser et al (2002) discuss how psychological factors influence the immune system and impact the length of time that a particular stressor has on immune function. Exploration of pain and stress commands further investigation when stress in the workplace is a consideration.
The Health and Safety Executive (HSE, 2014) defines work-related stress, depression and anxiety as “a harmful reaction people have to undue pressures and demands placed on them at work”. Figures for 2014 offer compelling reading. From 2013-14, work-related stress, depression and anxiety affected 487,000 employees representing 39% of the total for all work-related illnesses; the number of new cases for 2013-14 was 244,000. Against this backdrop of work-related stress, the argument for increasing competencies in pain recognition and management juxtapositioned with stress management and its myriad presentations is compelling.
The current economic climate also brings considerable constraints. With increased awareness of the complexity of managing patients with musculoskeletal conditions, the focus for keeping people in work is undeniable. Stress at work is business critical; the CIPD (2008) estimates that 60% of stress-related absence from work is non-work related. Understanding the impact of stressors for the employee is essential if we are to engage them in the holistic management of their long-term condition and its potential impact on their employment.
Musculoskeletal pain is a complex phenomenon. Adopting a patient-centric approach, careful assessment of pain, including psychological, social, behavioural and cultural factors, should precede any decisions regarding non-pharmacological and pharmacological pain management.
Disability due to chronic pain (pain of more than 12 weeks’ duration) is increasing faster than any other form of disability. The e-learning module apportions an entire unit to evidence-based approaches to pain management.
These include the exploration of: the peripheral and central mechanisms of pain; neurological pathways to pain; non-pharmacological approaches to its management, such as thermotherapy; transcutaneous electrical stimulation; aids and devices and pharmacological approaches to pain management including disease-modifying anti-rheumatic drugs; and biologic therapies.
Exploring and critically analysing pain management, identifying and evaluating pharmacological, non-pharmacological, complementary or alternative approaches to pain management, is fundamental to supporting the employee if we are to achieve alignment in the management of musculoskeletal conditions.
Balancing the commitment required for studying while putting the theory from the learning materials and study days into practice was my priority. But being on the course and being a student again started to generate a fear of failure, which was an emotion I did not want to nurture.
However, Education for Health provided a climate of interaction and engagement, so there was no need to worry. There was a positive dynamic within the group and the trainers were mindful of our needs as adult learners, respecting and valuing our experience and opinions.
They encouraged interaction, discussion and debate. The opportunity for networking with fellow students offered connectivity, sharing of information and the exchange of ideas. It was an exciting time.
Supporting and maximising our potential as adult learners is fundamental to Education for Health’s philosophy. Knowles (1984) suggested four principles that can be applied to adult learning: involvement in the planning and evaluation of their knowledge; personal experience as the platform for their understanding; relevance and impact to their occupation; and a problem-centred approach.
Formative self-assessments throughout the e-learning programme supported the andragogical learning methodology (Knowles, 1984; Kearsley, 2010). Summative assessment consolidated the learning and demonstrated the academic attainment. The relevance of the assignments to the workplace illustrates how personal experience and academic development inform future clinical decision making. The additional support provided by the student helpdesk contributed positively to the whole experience.
The success of the OH nurse as an exemplar for leadership in public health in the workplace will ultimately demonstrate the value and significance of this module. The requirements of the employee and employer are safeguarded by OH nurses. Their skills include: developing an understanding of the effects of work on health, and health at work; and the provision of workforce and workplace monitoring in response to a musculoskeletal health needs assessment.
Understanding and recognising the clinical expression of a musculoskeletal condition is professionally rewarding and critical to permit timely interventions. The reward for successfully completing the “Assessing and managing patients with joint pain” e-learning module will be increased confidence and competence.
Chapman CR, Tuckett RP, Song CW (2008). “Pain and stress in a systems perspective: Reciprocal Neural, Endocrine and Immune Interactions”. Journal of Pain; 9(2); pp.122-145.
Government Equalities Office (2010). Equality Act: information and guidance on the Equality Act 2010.
Health and Safety Executive (2014). Health and safety statistics: key figures for Great Britain 2013-2014
HSE (2002). Seating at work
Kiecolt-Glaser JK, McGuire L, Robles TF, Glaser R (2002). “Psychoneuroimmunology: psychological influences on immune function and health”. Journal of Consulting Clinical Psychology; 70(3); pp.537-547.
Knowles M (1984). Andragogy in Action. San Francisco, Jossey Bass.
Lépine JP, Briley M (2004). “The epidemiology of pain and depression”. Human Psychopharmacology
Miller M (2010). Why stress may cause abdominal pain. Harvard Health Publications. Harvard Medical School.
NHS (2014). NHS Choices: back pain at work
Office for National Statistics (2014). Full report: sickness absence in the labour market
Vachon-Presseau E, Roy M, Martel MO, Caron E , Marin MF, Chen J, Albouy G, Plante I, Sullivan MJ, Lupein SJ, Raineville P (2013). The stress model of chronic pain: evidence from basal cortisol and hippocampal structure and function in humans. A Journal of Neurology
Vargas-Schaffer G, Cogan J (2014). “Placing the patient at the centre of the WHO analgesic ladder”. Canadian Family Physician; 60(3); pp.3,235-3,241.