This month will see the launch by the Nursing and Midwifery Council (NMC) of a wide-ranging consultation on pre-registration nursing education. And for many disgruntled and worried occupational health nurses and educationalists, it’s not before time.
Speak to ministers, civil servants and medico-politicians and it is clear that OH has never had a higher profile within Whitehall and elsewhere. Similarly, as numerous surveys have shown, not least those by the Confederation of British Industry and the Chartered Institute of Personnel and Development, employers of all sizes are finally getting the message that paying for OH expertise can bring real bottom-line and business benefits.
Yet within the nursing profession, OH nurses more often than not continue to feel overlooked and misunderstood. OHNs generally have long accepted that they represent a relatively small lobby within the wider, more vociferous nursing community. But the changes to how nurses are registered and trained brought in by the NMC over the past few years have left many in the profession feeling more isolated and ignored than ever before.
Out of touch
As one leading educationalist – who wishes to remain anonymous, such is the continuing sensitivity surrounding these issues – complains to Occupational Health: “The NMC is completely out of touch with the OH profession it does not really understand what we do. There is a push to introduce a model that does not really work, and which OH nurses do not want.”
The fears and concerns of OH nurses when it comes to the NMC focus on two different, albeit inter-connected, problems. Both go back to 2004 and the creation of a new register, the third part of which – for specialist community public health nurses – lumped OH nurses in with school nurses, health visitors and, in Scotland, family health nurses.
The first problem remains the issue of the continuing problems some very experienced OH nurses have had in migrating to the new register. The second, perhaps more serious, concern, is the impact the register is having on training and education – in particular fears that it is leading to a dilution in the quality of OH education provision.
For a change as wide-reaching as the launch of the new register, it is hardly surprising that there were some initial teething problems, but three years on, you might have thought most issues concerning migration to the register would have been resolved. In fact, as far back as September 2005, the NMC was urging nurses to check that they had been successfully transferred, as the system had at that time failed an estimated 190 nurses.
But the issue is still causing problems, according to veteran OH nurses Mary Rafferty and Pat Brennan. They have spent years trying to sort things out, so far to no avail. For both nurses, no-one disputes the fact that they are qualified to practise – it is just that they have fallen into a bureaucratic black hole where the record of their qualification cannot be verified.
“I have been working in OH constantly since 1978 but have been told that my qualification is not recordable, which is frankly quite hard to take on the chin,” Rafferty, an OH business manager, tells Occupational Health. “The NMC should be more sympathetic about keeping people like me within OH.”
Brennan was registered through the UKCC (the forerunner of the NMC) back in the 1980s and has been practising OH for 20 years. But, she says, the NMC lost her record, and now neither side can prove that anything was sent.
“At the moment I am OK my employer is happy and I can still practise. But were I to change employment or the rules to be changed, perhaps I would not be able to,” she explains.
“The NMC has not been unhelpful, but it has not really been helpful either,” she adds. “I have a certificate confirming my qualification which was issued by the Royal College of Nursing at the time. “But that simply is not enough for them and I cannot understand why. I have been asked to prove what the content of the course was, but the course I did no longer exists.
“If you can practise and not be on the third part of the register, why should you bother? It is a shambles. You can work in occupational health and not have any qualifications at all,” Brennan stresses.
It is this last point – what sort of qualification and level of expertise an OH professional should have attained before being allowed to practise – that is also at the heart of the wider concerns about training and education that the profession has over the NMC.
After the register was introduced, a transitionary period was set up to allow educational institutions time to incorporate the new standards of proficiency in public health that came into their curricula with the register.
This transitionary period comes to an end on 1 September next year, after which graduates of institutions that have not had approval from the NMC will not be able to gain part three registration.
There is one small loophole, in that students can enter a non-validated course up to 31 August next year, and so technically still graduate and go on to the register up until 31 August 2011, but for the majority, next September will be the crunch point.
Lack of focus
Leading OH educationalists are increasingly concerned that the focus on shared learning that has come with being part of the specialist community public health umbrella has diluted the quality of OH education that nurses are receiving, and often left them unprepared to meet the challenges and demands that employers expect them to handle.
“The standards have been set by the NMC and they are very broad,” complains another educationalist anonymously to Occupational Health. But the flip-side is that you can more or less put anything in. You could have the bare minimum OH input, just one unit perhaps, because the idea is to have specialist community public health nurses.
“It is all very well to have this all-singing all-dancing public health nurse, but the courses are not meeting the need for practitioners. Employers are ending up with people who do not have the right depth of knowledge,” she warns, adding that some academics are coming under pressure from deans to switch to NMC-validated courses that they feel are not really up to scratch.
“I know of at least one manager who has employed nurses who cannot do the bare necessities of occupational health nursing, despite having completed an NMC-validated course,” she adds. “It feels to me as if OH has been downgraded to fit in with the NMC.”
Caroline Whittaker, senior OH lecturer at the University of Glamorgan, agrees that the current system is raising concerns within academic circles and, even more importantly, among employers.
“A nurse could, a year after qualifying, do an NMC-validated specialist community public health nurse course, complete it, and be able to call themselves a specialist occupational health nurse,” Whittaker says.
“But they may be barely competent in general nursing let alone be a specialist.
A GP who fancies doing a bit of OH will often go on a short diploma course to provide a basic snapshot. But we would not class them as a specialist,” she adds.
The third part of the register, Whittaker argues, was primarily set up for health visitors and school nurses, and many OH nurses now feel they have been left playing second fiddle.
“OH nurses have just had to drop into it [the third part of the register]. And there has been a real push to go down the shared learning route, but then people come off these courses with a good general knowledge but without the right specialist knowledge,” she says.
Employers, too, have been left floundering at the changes, just at the time when increased interest in workplace health is fuelling growing demand for well-qualified, competent OH professionals to come into the workplace.
“There is anecdotal evidence that a lot of employers and industries do not understand the registration system,” Whittaker says. “We have a lot of employers saying that people coming off these specialist courses cannot do the job. They also find the current system confusing and don’t understand it.
“I would like to see the NMC recognising that there is graduated development. I’d want employers to be able to see what level people are at,” she adds.
Under Whittaker’s leadership, for instance, the University of Glamorgan has recently launched a course for OH technicians, which makes it very clear what sort of skills level and qualification the graduates will have.
Similarly, the university runs a highly-regarded diploma course which, while set at a relatively basic level, gives a good grounding in OH, but is not validated or recognised by the NMC because it is only a diploma.
“Because of the third part of the register, we need to be able to make sure we know what experience people have in OH,” stresses Whittaker.
“There are also a lot of OHNs out there who are not on the register but are still working within occupational health. By going down this specialist community public health nurse shared route, they are driving people to seek courses elsewhere,” she adds.
“The health visitors are a very powerful lobby. And OH has had to bend its standards to fit in. I do not see the point of the third part of the register, and I think the NMC needs to rethink what the third part is for,” Whittaker argues.
The danger for the profession, argue some educationalists, is that if employers begin to feel that the specialist courses are not giving people the competencies they need, they may simply decide to go the cheaper route and hire technicians whose competencies are much more clearly defined.
There is also evidence that the NMC’s reforms, however well-intentioned, have not had the desired effect of creating a shared “specialist community public health” identity. In fact, the change appears to have had little effect at all on how nurses on the third part of the register see themselves and their role.
Reading University lecturer Val Thurtle has been carrying out a research project looking at how those on the third part of the register articulate their identity. She has interviewed health visitors, school nurses and OH nurses based in London.
“The general sense is that none of them really see themselves as specialist community public health nurses. They mainly identify themselves as occupational health or whatever other area they are working in,” explains Thurtle, programme leader in public health nursing at the university. “Some OH nurses I interviewed have concerns about the educational provision as prescribed by the NMC, and health visitors are saying the same thing,” she adds.
“Health visitors and school nurses see themselves as having a lot in common, but OH nurses, while they know what they do, do not work with them, and do not necessarily see themselves as doing the same sort of job, just in a different setting. More are saying they are not sure what specialist community public health nursing is about,” she explains.
The fact the NMC is consulting on at least some of these issues from the autumn onwards is, perhaps, a light at the end of the tunnel for the profession. But there is still a question mark over how far the consultation will go and what impact, if any, it will have when it comes to resolving the profession’s concerns.
The November consultation will be the third part of a much wider NMC review of fitness for practise at the point of registration, explains NMC spokeswoman Polly Kettenacker.
While the second phase looked at the general entry requirements for joining a programme, the November consultation is set to home in on the standards of proficiency in pre-registration nursing education, she points out, and within this will “presumably” look at the issues surrounding the new register.
“The project as a whole aims to secure a nursing workforce equipped with the competencies required for contemporary healthcare and professional practice with a career structure that promotes flexibility mobility and competency transfer throughout the healthcare system,” says Kettenacker.
“Big issues expected to be covered in the debate include, for instance, whether nursing should follow the lead of midwifery and move to degree level, and the question of how generalist or specialist pre-registration preparation of new nurses really needs to be,” she says. “We’re not so much looking at identifying any problems or concerns about the current system, it’s more a question of encouraging participants in the consultation to look at the kinds of healthcare environments the profession might be facing in around 2015,” she adds.
Whatever the outcome of that review, it is clear the NMC has a lot of work to do if it is to rebuild confidence among OH professionals that it has the profession’s interests at heart, and not just those of the big nursing lobbies.
As Whittaker puts it: “The NMC does not seem to believe that anyone works outside the NHS. But probably in five to six years’ time, half of nurses will be employed by private organisations, and I do not think the NMC has grasped that.”
What’s needed, she argues, is for the profession, and OH education, to have a much more clearly demarcated position within the nursing community.
“I think we need some sort of faculty of occupational health nursing, or perhaps a combined faculty of occupational medicine and nursing could be answer,” she says.
“I think we need to get the third part of the register right and we need an advanced nurse clinical practitioner qualification we need postgraduate qualifications that show very clearly the progression within your chosen specialty, running the scale from diploma through to degree,” Whittaker stresses.
OHNs, with their emphasis on risk assessment, employment law and health and safety, have for a long time felt outside – or, at the very least to one side of – mainstream nursing, agrees Rafferty.
“I think that occupational health nursing and training has for a long, long time been the poor relation. It is often an after-thought, just tacked on,” she points out. We should, of course, be part of the NMC, but perhaps we should have our own separate specialty, because we are not like anyone else. A lot of general nurses find it difficult to grasp the concept of occupational health. We should be being nurtured and cared for by the NMC, but we feel like we are not.”
Nursing and Midwifery Council remit
The core function and powers of the Nursing and Midwifery Council (NMC), which replaced the UKCC, are set out in the Nursing and Midwifery Order 2001. The NMC’s remit is “to establish and improve standards of nursing and midwifery care in order to serve and protect the public”.
To this end, it has six key tasks:
to maintain a register listing all nurses and midwives
to set standards and guidelines for nursing and midwifery conduct, performance and ethics
to provide advice for registrants on professional standards
to quality-assure nursing and midwifery education
to set standards and provide guidance for local supervising authorities for midwives
to consider allegations of misconduct, lack of competence or unfitness to practise because of ill health.
The new register consists of three parts. Part one is for general nurses and nurses in fields such as adult nursing, mental health, learning disabilities and children. Part two is for midwives and part three, specialist community public health nurses, covers health visitors, school nurses, OHNs and, in Scotland, family health nurses.
The third part of the register came into effect on 1 August 2004. All existing health visitors were immediately transferred over, as were OHNs whose OH qualification was on record at the NMC, and school nurses with a recordable qualification, regardless of whether the specialist qualification was at certificate, diploma, degree or higher level.
What was important was not the academic level of the qualification, but that it was on record.
A transitionary period, to September 2008, was introduced by the NMC alongside the new register to allow institutions to incorporate the new standards of proficiency in public health into their curricula.
Graduates of institutions that have not obtained approval from the NMC by the end of the transition period will not be able to gain part three registration.
Educational providers must have their programmes approved by September next year, and the final date from which students can complete a non-validated course but still go on to the third part of the register (assuming they started by or before 31 August 2008) is 31 August 2011.