The Nursing and Midwifery Council’s review of public health nursing education must address concerns about the quality of the occupational health component of courses, says Anne Harriss, director of occupational health nursing courses at London South Bank University.
Occupational health nurses (OHNs) have an important public health role and the “Improving health and work: changing lives” (Department for Work and Pensions and the Department of Health, 2008) document will extend the role of OH services to encompass assistance for those economically inactive as a result of poor health or disability. This article has been developed from a paper that was prepared for the Council for Work and Health in 2010. It highlights the challenges in developing educational programmes that effectively meet the needs of OHNs.
Historical perspective
OHNs have long been recognised as having an important public health function. As long ago as 1947, there was an industrial nurses’ discussion group in the public health section of the London branch of the Royal College of Nursing (Charley, 1954, p.133).
OHN education has a long history: the original Certificate in Industrial Nursing offered in 1932 by the Royal College of Nursing evolved into the Occupational Health Nursing Certificate, with holders considered to be “qualified” occupational health nurses. This qualification was recordable on the nursing register.
Pre-registration nurse education has evolved significantly since the late 1980s, affecting post-registration qualifications. Although some pre-registration courses have been delivered at degree level, the majority of nurses completed SRN/RGN courses that emphasised practical skills (“knowing how”), rather than a more academic approach (“knowing why”). Raising pre-registration nurse education to a minimum of diploma level necessitated the raise in the academic level of post-registration education.
By the mid-1990s the English National Board for Nursing Midwifery and Health Visiting (ENB) required OH programmes to be delivered at degree level and incorporate a proportion of shared learning with other primary care nurses.
The principles underpinning the ENB curriculum were broad, requiring:
- “exercising of higher levels of judgment, discretion; and
- decision-making, focusing on four broad areas: clinical practice; care and programme management; clinical practice development; and clinical practice leadership” (UKCC, 2001, p.5).
Multidisciplinary learning outcomes resulted in a focus change, a significant requirement being the inclusion of a “common core of preparation and specific modules. The core modules shall consist of no less than one-third and no more than two-thirds of the total programme” (UKCC, 2001, p.7).
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The requirement for common material taught across pathways coupled with resource constraints resulted in the proportion of OH specialist material varying across institutions. This emphasis on core content has influenced the development and delivery of OH courses. The relevance of shared learning across primary care pathways is questionable. Anecdotal evidence from OH students and graduates suggests that shared learning does not necessarily enhance the learning experience. Shared learning outcomes with students enrolled on programmes preparing practitioners of occupational medicine, mental health, physical therapies, management and HR management would be more helpful.
The current standards with which higher-education institutions (HEIs) must comply in order that their graduates may register with the Nursing and Midwifery Council (NMC) as specialist community public health nurses (SCPHNs) is encompassed within the document Standards of proficiency for specialist community public health nurses (NMC, 2004).
It includes standards for the qualifications of practitioners supporting students in the practice setting and curriculum content.
NMC standards for practice teachers and the curriculum
NMC standards require OHNs supporting students in practice to hold an approved teaching qualification. The paucity of qualified practitioners causes difficulties in accessing placements, which affects the number of nurses enrolling on SCPHN courses.
In essence, the NMC standards for curriculum content emanate from the following 10 broad principles:
- surveillance and assessment of the population’s health and wellbeing;
- collaborative working;
- working with communities to improve health and wellbeing;
- developing health programmes and services reducing health inequalities;
- policy and strategy development;
- research and development to improve health and wellbeing;
- promoting and protecting the population’s health and wellbeing;
- developing quality and risk management;
- strategic leadership; and
- ethically managing self and resources.
The broad principles encompassed within the NMC curriculum are sound. However, there is no requirement for a specific skills cluster underpinning practice within these standards, nor is there a maximum proportion of core specialist content. Standards for curriculum content are broad, allowing HEIs the flexibility to develop excellent courses to prepare competent graduates. However, the absence of specific OH skills clusters results in the practice competence of graduates being variable.
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Integrating curriculum into course delivery
Course content is influenced by external and internal factors. External influences include market forces and validating body requirements. Institutions delivering NMC-validated programmes incorporate the same broad curriculum. However, the focus of courses between institutions is variable. Internal influences include:
- requirements of the university regarding a common academic framework delivered across other role preparation courses;
- a range of professional experience of those involved in curriculum development; and
- resources for course delivery that can be supported by the HEI.
NMC-validated SCPHN programmes prepare OHNs and nurses working with children and young people within the age range 0 to 19, ie health visitors (HVs) and school nurses (SNs). Most universities package these programmes together and teach a proportion of material across all pathways. The proportion of pathway-specific material is variable and is dependent on the number of specialist OH lecturers within the team and their influence on curriculum development.
Most HEIs educate a larger proportion of SCPHNs working with children and young people compared with those working with the working-age population. This affects the degree of influence of OH specialists on curriculum content. In the case of the author’s institution, London South Bank University, places for students on the OH pathway are oversubscribed, allowing a high proportion of pathway-specific units taught exclusively to OH students.
Where institutions have few OHN applicants, financial pressures limit OH specialist content. Graduates of some programmes will have a broad appreciation of general public health principles but be unable to apply these effectively to the workplace setting (Garnham, 2008).
The Department of Health has recently published its “Health visitor implementation plan 2011-2015 – A call to action”, confirming the department’s commitment to providing an extra 4,200 full-time-equivalent health visitors (Department of Health 2011, p.8). Sadly, there is little evidence of a similar commitment to workplace health. The lower number of applicants to OH programmes compared with those applying to train to become HVs reflects both funding issues and government commitment. While HV students gain funding via the NHS, fewer OHN applicants secure similar funding. Many OHN applicants therefore “self-fund” their studies, which involves a significant financial outlay including living costs, course fees, books, stationery, travel costs and placement attendance.
In order for HEIs to produce competent and employable graduates, experienced OHNs must be included in curriculum development. The NMC must only approve courses meeting public health competencies focused on OH practice delivered in institutions having an appropriate number of OH-qualified lecturers. A dearth of OHNs wishing to move into HE reflects university salary structures, which do little to attract experienced OHN practitioners. Furthermore, increased student fees from 2012 may adversely affect student numbers, making teaching posts insecure.
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Range of educational provision
A variety of OHN programmes have been offered by HEIs, some making a conscious decision not to offer courses in OH conferring SCPHN registration. Provision of high-quality, non-SCPHN courses range from diploma courses offered by HEIs in both England and Wales, and degree programmes in England, Wales and Scotland. These programmes prepare nurses to practice OH competently, although graduates of these programmes are ineligible to register as SCPHNs. This does not seem to adversely affect recruitment; stakeholders value the course content and competencies of diplomates/graduates of these programmes.
The Black review
Dame Carol Black’s review, Working for a healthier tomorrow, and the subsequent government response, Improving health and work: changing lives, will significantly affect public health delivered through workplace health initiatives. Improved access to high-quality OH advice, provided by an increased number of well-qualified and highly specialised practitioners is integral to this strategy.
Career pathways
As OH nursing is integral to fulfilling the recommendations of the Black review, it is essential to raise the profile of this specialty in order to attract the best people.
Opportunities for OHNs are inaccurately reflected within the framework prototype in the December 2009 bulletin of the chief nursing officer of the Department of Health, which fails to do justice to the speciality by not recognising the level of responsibility of OHNs nor the career paths available to them.
The model implies that OH nursing is at a level below district nurses, HVs and SNs and clinical nurse specialists. In reality, qualified OH nurses are specialist practitioners with many delivering nurse-led, rather than doctor-led, services. OH nursing should therefore be recognised as involving advanced clinical practice.
Documents that could influence course content
The “Working for a healthier tomorrow” document and the Government’s response are viewed positively by OHNs and will influence the curriculum of courses preparing these nurses. Both documents highlight the benefits of work to the individual, their families and the community. They incorporate recurring themes highlighting the importance of:
- robust data collection informing academic knowledge;
- partnership work that aims to reduce health inequalities;
- reducing the financial burden of sickness absence;
- improving the quality of work and workplaces;
- strategies promoting mental health;
- early interventions utilising effective vocational rehabilitation programmes supporting those with disabilities to return to being, or remain, economically active;
- multidisciplinary working;
- improving the health of those out of work and enabling those with the potential to return to work to do so;
- emphasising fitness for work to those who have been absent due to ill health;
- better integration of skills, health and employment provision;
- linking health with safety; and
- business awareness – working in partnership with Business in the Community.
These themes are significant drivers for workplace health. If OHNs are to become competent to participate in these initiatives, role-preparation programmes must incorporate appropriate specific skills.
It is timely for the NMC as a validating body to make skills clusters an integral part of the curriculum for OH nurses. Many practitioners currently choose to follow SCPHN programmes, however, the current paucity of practice teachers holding the requisite qualifications in some areas may result in institutions discontinuing NMC-validated programmes.
Occupational health competencies
Interesting times are ahead for OHNs with the challenges for OH educators. It may now be time to build on current curricula and the Council for Work and Health has met with the NMC in relation to reviewing its standards in relation to the integration of specific OH-focused skill clusters.
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In order for OHNs to be competent to participate effectively in strategies encompassed within the government document “Improving health and work: changing lives”, they must be competent in devising robust return-to-work strategies and have an in-depth appreciation of a range of issues to assist people with disabilities to remain in, or gain, employment.
There are distinct differences in the role and responsibilities of HV, SN and OHN practitioners. Shared learning is beneficial to HV and SN students. However, a heavy emphasis on shared learning across three pathways has the potential to detract from the learning experience of OHNs.
All SCPHNs support a range of government public health initiatives. Elements of particular importance to OHNs, but less so to these other SCPHNs, are initiatives supporting a return to, or maintaining, gainful employment for people with disabilities and/or long-term physical or mental health conditions.
Shared learning with physicians, human resource specialists and physical therapists may be a more appropriate strategy in order to prepare practitioners involved in workplace health.
In January 2011, Professor Diana Kloss, chair of the Council for Work and Health, accompanied by Anne Harriss, course director of an occupational health nursing degree and author of this article, and Helen Kirk, OHN consultant, were involved in high-level discussions at the NMC. Their discussions with Professor Dickon Weir-Hughes, chief executive and registrar, and Roger Thompson, director of standards and registration, focused on the organisation’s standards for SCPHN programmes.
Although OHNs are public health practitioners, OHN practice incorporates advanced clinical practice as defined by the NMC (NMC, 2005). These discussions indicated that a current review of the SCPHN register is likely to take a considerable length of time and there were indications that should the NMC develop a separate part of the register for advanced practitioners, then graduates of OH nursing programmes able to demonstrate their advanced practice should have the opportunity to be registered as such.
There is currently no legislative requirement for all organisations to provide access to an OH service. Large employers see the benefit to their organisation; smaller ones may decide that the current financial climate results in OH provision being unaffordable. The health of the economy is likely to have as great an impact on OHN education and the characteristics and distribution of workplace health services as government policy will have on public health. It will be interesting to watch how the future unfolds.
This article is a shorter version of “The challenge of preparing nurses competent to promote, improve and maintain the health of the working-age population practising in the workplace setting”, written by Anne Harriss for the Council for Work and Health. Anne Harriss is a reader in educational development and a director of occupational health nursing courses at London South Bank University.
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References
Black C. (2008). “Working for a healthier tomorrow”. A review of the health of Britain’s working-age population. London: TSO.
Charley IH. (1954). The Birth of Industrial Nursing. London: Balliere Tindall.
Department of Health. (2009). The CNO bulletin (accessed 3 March 2010). The chief nursing officer’s bulletin for all NHS nurses and midwives in England.
Department of Health. (2011). Health visitor implementation plan 2011-2015 – A call to action. London: Department of Health.
Garnham P. (2008). “NMC needs a radical rethink on course content for SCPHNs”. Occupational Health, vol.7, 15.
Department for Work and Pensions and Department of Health. (2008). “Improving health and work: changing lives”. London: TSO.
Nursing and Midwifery Council. (2004). “Standards of proficiency for specialist community public health nurses”.
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Nursing and Midwifery Council. (2005). “Proposed framework for the standard for post-registration nursing”.
United Kingdom Central Council. (2001). “Standards for specialist education and practice”. London.
