Maintaining professional standards is key to the state of occupational health nursing and its impact across industry, argues Greta Thornbory, occupational health and education consultant.
The renowned occupational health nurse Ruth Alston once refused to validate the Royal College of Nursing occupational health course I taught in the early 1990s until the college agreed to send me on a teacher training course. Needless to say I was signed up on the next course at Surrey University. It was probably the most worthwhile and interesting course of my whole career.
Maybe this was because it was the first time that I was on a multidisciplinary course. The person sitting next to me in the lecture theatre could be a dancer, saxophone player, mathematics graduate or an engineer. I started to see the outside world beyond nursing. It was on this course that my interest in professionalism was aroused, mainly by the work of Professor Peter Jarvis.
But what does professionalism actually mean? When checking various text books, dictionaries and, of course, Google and Wikipedia, the following definitions were presented to me:
- An expertness characteristic of a professional person.
- The status, competence and correct demeanour of a professional person.
- A commitment to professional ideals and career expressed in attitudes, ideas and beliefs.
Obviously then, the professional person has a lot to live up to. But who exactly is a professional person? What makes us professional? What is a profession and is nursing a profession?
Qualities of professionalism
We talk about professional sportsmen, but are they actually professionals? We all know the typical characteristics of a professional footballer as they are generally plastered all over the red-top newspapers.
But they are deemed to be professionals because they are paid, as opposed to the amateur sportsperson who does it as a hobby, “amateur” coming from the Latin – to love. This distinction between paid and unpaid work applies to many sports and across the arts.
There are professions that are regarded as the “traditional professions”. These are divinity, medicine and law, but do they fulfil the criteria for a profession?
Let us look at what are regarded as the criteria for a profession and how the traditional professions and nursing fulfil these. I have gleaned that the following five criteria are required for a profession:
- it is based on a body of knowledge;
- it offers a service;
- its practitioners are autonomous and self-regulating;
- it has a code of ethics and conduct; and
- it is licensed and requires study.
Taking each of these criteria in turn, is nursing – occupational health nursing in particular – really a profession?
Is it based on a body of knowledge?
Divinity: I hope I am not going to insult or upset anybody by questioning the body of knowledge of this “profession”.
Is there any empirical evidence? The debate is ongoing and maybe I should leave it for those that know better than me, a complete atheist.
However, it was indeed the monastic orders that originated the universities as places of learning back in the 11th century in Italy, so they have a long history of developing a “body of knowledge” throughout the world.
Medicine: Today, medical practice is based on research and the gold standard of research is regarded as the random control trial. Quantitative research is good for determining the efficacy of a drug or treatment, but more qualitative research is needed to improve healthcare.
Medicine has only really been based on research evidence rather than experiential learning for the last couple of hundred years, particularly since Dr Snow established that outbreaks of cholera in London’s Soho were caused by contaminated water in the 1850s – and so invented epidemiology.
For OH practitioners, the most significant historical figure was Ramazzini, whose treatise on the diseases of occupations was written from personal observations and experience.
When working in occupational health in the civil service in the 1980s, I remember removing something called a “strychnine and mercury” dressing dated (if I remember correctly) about 1911 from a well-known Whitehall department. I was told it was used for syphilis and I wondered how many survived such treatment and what evidence base it had.
Today, nurses are encouraged to carry out their practice based on empirical evidence and this is now an essential part of clinical governance.”
Law: Lawyers do have a body of knowledge based on the four types of law: criminal, civil, case and statute.
But as for nursing… When I started nursing nearly 50 years ago things were done because they had always been done, not because they were based on empirically proven findings. A classic example of nursing activity with no sound basis was putting salt in a patient’s bath water. Salt was believed to have healing properties – but on what basis? We never queried it because we did what we were told and, contrary to public belief and the “Carry On” films, matron was not the one who told us (in a London teaching hospital you only ever saw matron if you were in trouble).
The ward sister was God; she was an experienced nurse and a spinster and she ruled with a rod of iron. The salt went in the bath, no measure, no actual procedure, just a splash from whatever container came to hand. Eventually, research showed that many patients had sore bottoms caused by undissolved salt grains. Further information on such nursing rituals can be found in Walsh & Ford’s 1989 book Nursing Rituals, Research and Rational Actions.
Prior to the 1970s very little actual nursing knowledge was scientifically based or followed any research criteria that would have stood up to scrutiny. Nursing research really started in the late 1960s when Virginia Henderson published “The Nature of Nursing” in 1966. The body of nursing knowledge is young but it has challenged many traditional practices and encourages rather than dissuades an enquiring mind.
Today, nurses are encouraged to carry out their practice based on empirical evidence and this is now an essential part of clinical governance. Therefore, nursing in the 21st century has an ever-developing body of knowledge and fulfils this criterion.
However, there are still those who say and believe that there is no body of knowledge for occupational health nursing. I would have to disagree.
According to Baranski and Whitaker (Baranski, 2001), the OH nursing role is: clinical, managerial, communication, health promotion, counselling and research.
All of these disciplines have empirical evidence on which their practice is based; it can also be applied to OH and OH nursing in a workplace setting. OH nurses have to learn how to apply knowledge from all these different areas. This is what it meant to be a specialist practitioner, certainly an advanced practitioner.
One of the most important aspects of OH nursing is the ability to adapt to different and changing situations.”
At this level of practice one must be able to take evidence, then analyse and synthesise it for one’s own practice. That is at the essence of higher-level education. Those who decry the need for nursing as a degree-based profession are showing a lack of understanding of what higher education actually means.
One of the most important aspects of OH nursing is the ability to adapt to different and changing situations. The pre-registration training that qualifies you to nurse someone following a hernia operation or an unconscious patient in ITU does not directly relate to OH. The knowledge and skills required to care for the workforce population has been developed in a variety of different spheres and disciplines from management, health promotion, public health, communication, counselling and nursing itself.
Does it offer a service?
No contest here, divinity, medicine, law and nursing all offer a service. In OH that service is offered to both the employer and employee of a workplace. OH practitioners may not be the patient’s advocate in the manner of a GP, but we are advisory to both employer and employee. Whatever else we think or believe, health and safety of the client, the workforce and the public at large override all other considerations.
Is it autonomous and self-regulating?
Some years ago I applied for an OH job at a well-known high-street bank. At the interview, when they asked if I wanted to ask any questions, I asked who I would be accountable to. I was told HR for the managerial side of my role and God for the professional and clinical aspects. I realised then that some places do understand that nurses are not handmaidens to doctors and that we are autonomous practitioners.
Unfortunately, there are still people who believe that we can only do what doctors tell us and many employers who believe that they can tell us what to do. Yet, we are autonomous practitioners and responsible for our actions, and when called to account by our regulating body, the Nursing and Midwifery Council (NMC), we will have to answer for those actions.
The NMC is a regulatory body that exists through law to protect the public; it is not for our benefit. The NMC is a quango (quasi-autonomous non-governmental organisation) and as far as I can see the council does not have one single public health nurse member. It appears to be mostly school nurses, mental health and midwifery experts who regulate us. Therefore we tenuously fulfil this criterion.
Is there a code of ethics and conduct?
However, the NMC does provide us with a code of ethics and conduct. I am sure you have all seen it, read it and abide by it. It is the section on confidentiality that causes most grief in OH. It takes time and experience to see that getting consent from clients to disclose sensitive medical information is probably the easiest way to deal with things and, to quote the Data Protection Act Employment Code of Practice s.43, it gives OH good, sound support. If you haven’t read it then please do download it from the Information Commissioner’s Office website, read it and keep it close to hand in case you have any difficulties with your company management.
Case study 1
At a conference for a large pharmaceutical firm all the medical speakers turned up smartly dressed; the last speaker was a nurse who turned up in leggings, Ugg boots and a large angora jumper. I, for one, had no confidence in what she was saying.
To sell ourselves as professionals we need to be “different because of what we know, not what we look like”. That means we should blend in with the surroundings and dress appropriately to the environment of the business.
Is it licensed and does it require study?
After we become registered nurses we pay the NMC to grant us a licence to practise each year. OH specialist practice courses for nurses are also validated by the organisation, although there is no legal requirement for OH nurses to be registered as specialist practitioners.
In order to continue to be licensed to practise each year we have to sign on our own cognisance that we have practised for a minimum number of hours each year and have kept up to date through continuing professional development for a minimum number of 35 hours of learning activity in the previous three years. Just as a reminder: learning activity does not have to be study days or conferences, it can be:
- reading a journal article and reflecting on how you can apply it to your practice;
- undertaking a project that requires research and reading published material; and
- carrying out activities and evaluating the results against published criteria, such as watching a film, TV or radio programme and reflecting on what you have learnt and how you can apply it to your practice.
Provide a lasting impression
I have explained how nursing and in particular OH nursing is: based on a body of knowledge; a service; autonomous and self-regulating; based on a code of ethics and conduct; and is licensed and requires study.
Let’s just finish on “demeanour” or the outward, physical behaviour and appearance of a person. How we present ourselves is so important. How we look and dress is up to us, but we have to remember that research has shown that first impressions are important. When we meet someone, it is within the first three seconds that the person makes up their mind about us.
To sum up, in the 21st century nursing is a profession. The key to our success as OH nurses is to extol the expert characteristics of a professional person through our status, competence and correct demeanour in order to demonstrate our professionalism.
This article is an edited version of a paper delivered for the Ruth Alston Memorial Lecture, organised by the Association of Occupational Health Nurse Practitioners, which took place in Birmingham in March 2011. Greta Thornbory is CPD editor of Occupational Health magazine.
Jarvis, P. (1983). Professional Education. Kent, Crook Helm.
Baranski, B, Whitaker, S. (2001). “The role of the occupational health nurse in workplace health management”. Bilthoven: WHO.
Data Protection Act Employment Code of Practice.
Case study 2
In the early 1990s, I sent a student on a work placement to the Lever Brothers head office at Blackfriars, London, where the OH staff were suited and booted by Austin Reed. Our student, despite being told to be “smart”, turned up wearing jeans and a denim jacket.
Learning to be appropriately dressed, clean, tidy and with shoes polished, not necessarily in a suit but according to the situation, is absolutely necessary for OH nurses in the business world and can determine how seriously you are taken.
Think about aircrew; when you see them in the airport and when you get on the plane they are wearing a smart corporate uniform. You know who they are and you have confidence that they know their job and will see you safely to your destination, especially if you are apprehensive about flying.
Once on board the plane they remove the stiff starchy jackets and hats and work in shirt sleeves or tabards to serve you. On reaching your destination they change back to the full, smart uniform. You know where you are with these people and it should be so with all nurses in or out of a uniform, but while working. Would you feel the same way about them if they were in jeans and a t-shirt?