There is a general consensus that current specialist occupational health (OH) training programmes are not delivering OH nurses (OHNs) fully equipped to meet the demands of contemporary practice. There are many reasons for this, but it is not always clear which are the real obstacles.
Demand for OHNs
The demand for OHNs has not been quantified. There are 3,300 specialist OHNs on the public health part of the Nursing and Midwifery Council (NMC) register, which is sometimes referred to as ‘Part 3’ of the register. However, Part 3 does not include nurses with a qualification in OH who have not followed the approved specialist path. Many nurses who trained several years ago had no reason to register their OHN qualification, and so did not migrate to the specialist register when it was established.
The NHS OH workforce was surveyed in 2007. Only about a third of organisations responded, and these employed more than 500 nurses in OH. The total number is likely to be at least twice this, so there are likely to be about 1,200 nurses working in OH in the NHS.
The NHS Plus survey also revealed only half of NHS nurses in OH were on Part 3 of the NMC register, while a further 20% were in posts for qualified OH nurses, and about 30% of NHS nurses in OH on general grade. (The NHS has a high demand for general nurses in OH that is not mirrored elsewhere, due to the high volume of immunisations needed for clinical staff.) About 80% of nurses on Part 3 of the NMC register do not work in OH in the NHS.
This is consistent with vacancy data. For example, a snapshot survey of recruitment in June 2009 revealed only about 10% of advertised vacancies were for posts in the NHS.
Taken together, the data from the NMC register and the NHS OH survey suggest the total number of nurses in the UK with OH qualifications may be about 4,600. A reasonable estimate of the total number of nurses working in OH is 5,000-7,000 nurses. Assuming a 5% turnover from qualified OH nurses retiring and leaving the speciality, about 250 new OH nursing students must be recruited each year to sustain the current workforce, but data on student numbers are not routinely published.
OH nursing is unique in that most posts are outside the NHS and most training is likely to be outside the NHS (although there is no data to confirm this).
Nurses wishing to pursue a career in OH face numerous challenges, including:
Finding a suitable post where they are supernumerary or away on a course for significant periods of time.
Getting on a relevant course at university and funding this.
Identifying a funded and qualified practice teacher.
The cost for employers – in training fees and especially unproductive time – is substantial. Many will be reluctant to make this investment.
The lack of willingness of employers to invest in training is compounded by a weak business case. The need for a specialist OHN and the benefits of having one, over and above any nurse, are not defined. In some areas, Strategic Health Authorities will financially support students, including those employed outside the NHS, but this does not seem consistent.
The availability of courses is good. At least 15 universities offer OH programmes suited to nursing in England, Scotland, Wales and Northern Ireland.
The requirements for specialist training in OH nursing are established by the NMC. The NMC only sets high-level standards for training programmes and approves the detailed curricula set by universities that comply with the standards. The NMC:
Maintains a register of specialist community and public health nurses, including OHNs
Sets the outline curriculum
Sets standards for educational supervision (which are very flexible)
Insists all specialist programmes are at degree level with teaching by degree-level nurses and supervision from specialists
Approves university courses for training specialist nurses and training their practice teachers.
There is no obligation for OHN courses to lead to specialist registration, and an increasing number do not. This in itself reflects the dissatisfaction with the current system.
There is substantial financial pressure on universities to deliver as much of their specialist training programmes as generically as they can. OH-specific modules add cost to the core programme. As courses tend to be generic, they inevitably become oriented to the biggest student population – health visitors, not OHNs. School nurses face the same problem.
There is no detailed curriculum for specialist OHN programmes. The Royal College of Nursing (RCN) produced a curriculum in 2005, but this has no formal status (for example, with the NMC). Only one university has openly adopted this in its own programme. Detailed analysis of this curriculum shows that it is very similar in content to the curriculum prepared by the Faculty of Occupational Medicine for specialist training in occupational medicine, although laid out slightly differently.
Even where universities are training specialist OHNs they are not obliged to have OH specialist nurses on the teaching faculty, although most do. Some universities make excellent use of invited guest lecturers, but others are reluctant to do this because of the associated additional cost.
All students on specialist nursing programmes need a designated practice teacher. Ideally, the NMC indicates this should be one student to one practice teacher. The rules are very flexible and the NMC guidance explicitly addresses the challenges for OH nursing. Many OHNs would not be eligible to become practice teachers – a 2004 survey showed about half are not qualified to degree level. Only 11 nurses declared a practice teacher qualification in the 2007 NHS OH workforce survey.
Registered specialist nurses can quickly qualify as NMC approved practice teachers. Courses are widely available, are completed part-time within a maximum of six months, and constitute only a few days in an academic setting. Previous training and experience can be taken into account.
Universities are supposed to keep a register of qualified practice teachers (from all specialist disciplines) so that they can be linked up with students pursuing any specialist path. It seems unlikely that non-OH specialist nurses in the NHS (for example, health visitors) would be willing to take on an OH nursing student from a private company.
The current specialist training structures have a number of weaknesses:
There is no need for any OH-qualified teaching staff on the university course even where OH students are taught.
There is financial pressure to fill student spaces, so the course is kept general.
There are relatively small numbers of OHN students and a tendency to cater for the majority (health visitors).
There is no detailed curriculum defined by the NMC.
There is a perceived bureaucracy among experienced nurses: OHNs do not appreciate why they cannot teach on a specialist programme if they only have a certificate (OHNC) or diploma (OHND) because degree courses were not available when they trained.
Requirements of future OHNs
The NMC curriculum is strongly oriented towards the health of populations and individuals within populations:
Surveillance and assessment of the population
Working with, and for, communities
Developing health programmes and services and reducing inequalities
Policy and strategy development and implementation
Research and development
Promoting and protecting the population
Developing quality and risk management within an evaluative culture
Ethically managing self, people and resources.
This model was reasonably well-suited to the historical ‘factory nurse’ model of care with the surveillance and immunisation of groups. However, it is not consistent with contemporary needs that focus on case management and rehabilitation. OH nursing has become more interventionist, and this is what employers seek in new OHNs.
Beyond public health, the NMC model of specialist practice is based on advanced nurse practitioners (ANP). In recent consultation, the NMC wrote: “Advanced nurse practitioners are highly skilled nurses who can:
take a comprehensive patient history
carry out physical examinations
use their expert knowledge and clinical judgement to identify the potential diagnosis
refer patients for investigations where appropriate
make a final diagnosis
decide on and carry out treatment, including the prescribing of medicines, or refer patients to an appropriate specialist
use their extensive practice experience to plan and provide skilled and competent care to meet patients’ health and social care needs, involving other members of the healthcare team as appropriate
ensure the provision of continuity of care including follow-up visits
assess and evaluate, with patients, the effectiveness of the treatment and care provided and make changes as needed
work independently, although often as part of a healthcare team
provide leadership; and
make sure that each patient’s treatment and care is based on best practice.
“Only nurses who have achieved the competencies set by the NMC for a registered advanced nurse practitioner are permitted to use the title advanced nurse practitioner. The title will be protected through a registrable qualification in the council’s register.”
At present, the NMC work on the ANP model has been delayed pending the outcome of the chief nursing officer’s review of post-registration nursing and the Modernising Nursing Careers programme.
This is a model of specialist nursing that is more consistent with current and future OH nursing practice. The current trend to deliver OH nursing courses that do not lead to specialist registration on Part 3 may well be followed by a trend to deliver advanced OHN practitioner programmes.
Most of the barriers to entering training are perceived ones. Determined nurses identify posts, courses, supervisors, and practice teachers, and if they can’t find funding, they fund their own studies.
Employers are not under pressure to employ nurses trained in OH (eg, from the Health and Safety Executive to comply with health and safety law, or the Care Quality Commission to comply with care standards).
Specialist registration with the NMC has limited value to nurses, employers, and patients. Pressure to deliver cost-effective specialist programmes has diluted the focus of OHN courses. A trend towards non-specialist OH nursing programmes has now emerged.
There are a number of actions that could be taken that would improve the flow of suitably trained students:
Critical mass – the NHS could take the lead in restricting financial support to universities on a limited list of preferred suppliers of OH nursing qualifications that have adequate OH nursing student numbers and an adequate OH nursing faculty.
Teaching support – the NHS could take the lead in providing an accessible pool of practice teachers that support trainees in the NHS and elsewhere.
Course approvals – the NMC could make sure that approved courses have sufficient speciality-focus in terms of detailed curriculum, modules, and faculty for each of the specialist routes offered.
Funding -strategic health authorities could offer funding to all OHN students.
Course development – a model OH advanced nurse practitioner course could be developed with input from non-NHS and NHS employers.
Career paths – the chief nursing officer could be lobbied to make sure the future of OH nursing is recognised as advanced clinical practice, and not absorbed into family nursing.
Helen Kirk MA BSc (Hons) BA RN RM SCPHN is an independent OH consultant. Email: firstname.lastname@example.org
UKCC (1994) Standards for specialist education and practice
NMC (2004) Standards of proficiency for specialist community public health nurses
NMC (2005) [Advanced Nurse Practitioner definition.] http://www.nmc-uk.org/aArticle.aspx?ArticleID=82
NMC (2008) Standards to support learning and assessment in practice
RCN (2005) Competencies: an integrated career and competency framework for occupational health nursing
FOM (2007) Specialist training curriculum for occupational medicine
NHS WRT (2007) NHS Occupational Health Workforce Mapping Report
COHPA (2007) Press release http://cohpa.co.uk/index.php?id=29&tx_mininews_pi1[showUid]=14&cHash=dccc08c0fd