Reflecting on the OH role

Course director Anne Harriss discusses the disparity between
those with traditional OH qualifications and the new generation of OH
graduates, and the careers advice she would offer to newly-qualified
occupational health nurses.  By Nic

What should an occupational health nurse (OHN) be? It is a big question, and
one that doesn’t have a right, or wrong, answer. But, for OHN Anne Harriss,
course director at London South Bank University, and who maintains professional
competence via consultancy, it is a question that gets to the very heart of the
debate about where the OH profession has come from and where its future lies.

Leadership, competence, fitness to practice – these are themes carried
throughout her work and her teaching. At a time when the profession is changing
rapidly, and is faced with the prospect of daunting challenges ahead,
particularly the possibility of changes in the way sickness certification is
carried out, they are themes that are hugely relevant.

"I don’t think OH nurses can rely on a job for life in a company
anymore," says Harriss. "You have got to be adaptable and you have to
stay one step ahead of the game the whole time. You have to identify what
knowledge and skills you need to carry out your job competently."

Harriss has led London South Bank University’s OH course since 2000 and
before that was initially a lecturer/practitioner and then course director for
the BSc OH nursing degree at the Royal College of Nursing. With stints in the
field, notably at InterContinental Hotels and, as it was, Glaxo Holdings, under
her belt, she is more than qualified to have a view on the state of the

"When I was a student undertaking my occupational health training there
was not such a focus on doing things such as risk assessment. Now, the bread
and butter of a lot of occupational health work is not necessarily doing that
assessment for people, but teaching them how to do it," she says.

"There has been a move towards health and safety management,
occupational health management, and away from treatment services. The more we
get involved in doing risk assessment, the more we can use all our skills. We
are a very holistic bunch of people, we have lots of skills. One thing that OH
nurses are very good at is identifying what a problem is and the, if they can’t
resolve it themselves, finding somebody who can," she says.

It was while working in the Sultanate of Oman for the Royal Oman Police
Force Medical Unit in the early 1980s that Harriss caught the OH bug. The force
had its own hospital, including a treatment room, where police personnel and
their families were treated.

"At first, I was working in the treatment room and, for me, it was
heaven. I was being a nurse practitioner, occupational health, A&E clinic
and well-baby clinic – everything rolled into one. It was fantastic.

"Then I was told they wanted to allocate me to the paediatric ward.
When you take a job you go where you’re told but, compared with the treatment
room, there was no comparison. I told them I really wanted to stay there
because one day I might like to be an OH nurse – and that was it," she

So, where does she stand on the specialist practitioner/OH nurse
practitioner debate? Can the profession have it both ways, and how can
employers be better educated about what occupational health can and cannot do?

"We can have both," says Harriss. "To call yourself a
specialist practitioner, you have to be qualified as a specialist nurse.
However, there is also room to have a practice nurse. But you do not need a
qualified OH nurse to do a vaccination service. What you do need is somebody
who understands about vaccines," she explains.

"At Glaxo, we ran a comprehensive travel health clinic for people going
overseas on business. I really enjoyed doing it but, with hindsight, did I
really a need a qualification in OH to do it? No, I didn’t. We could have had a
practice nurse doing that just as effectively, who could have called in an OH
nurse if there had been an occupational health issue that needed

OH nurses are unusual among health professionals in that they need to
understand business, to ‘add value’. As Harriss puts it: "If you
understand what the business needs are, you can help your employer address
those needs. But we should not be a tool of the employer."

While fewer and fewer services do now adopt the ‘sticking plaster’ approach
to OH, it has not disappeared altogether. Yet most OH services are now moving
on to a more proactive, strategic level, and that can only be welcomed.

"One of the other movements is that a lot of companies are not having
OH services anymore and are bringing in consultancies. This can be good, but
the quality of the occupational health service you get depends on the
continuity of the people who are providing that service," Harriss warns.

Within this, there is strong evidence too that more and more services are
becoming nurse-led. While undoubtedly a recognition of how far the profession
has come, being required to lead a service, and having the skills and training
to do so effectively, can be daunting. It is at this level that the profession
needs to recognise the need for greater management and leadership training,
Harriss suggests.

"More and more places have nurse-led services, which is brilliant. The
best person to manage an OH service is the person who’s best placed to manage,
and that does not have to be a doctor," she says.

"One of the things we want to develop in our students is leadership
potential. We have a whole unit on leadership. We cover things like developing
leadership potential, but also the nitty gritty of managing an OH service, such
as negotiating service-level agreements.

"Many OH services, particularly in the NHS, have to sell their services
out, as they have to generate income. So if they can negotiate well-planned and
managed service level agreements, then it puts them ahead of the game.

"One of the things we talk about with the students is where they think
their interests lie. Some people are going to make fantastic managers and
fantastic leaders. Other students do not have the attributes to be able to lead
a service forward, and it is not where they want to be anyway. What they want
to be is competent, solid practitioners who can deal with clients and managers
on a one-to-one basis, they don’t want to be leaders. They don’t want to be
budget holders, they are quite happy doing hands-on occupational health, and
that’s fine – a service needs a mix of leaders and practitioners," she

Other skills becoming more important as the OH role expands, include not
only being able to do risk assessments, but being able to integrate them with
health assessments. Similarly, it is important to be able to plan recovery
programmes, while at the same time thinking about attendance management.

Better attendance management – the bane of so many employers’ lives – is one
of Harriss’ passions.

With both GPs and employers becoming increasingly frustrated with the
current system of sickness certification, and GPs wanting to make ‘significant
progress’ to abandoning certification altogether by April 2006, there are both
opportunities and dangers ahead for the profession, Harriss believes.

"I think GPs still write medical certificates on sufferance, for the
most part. They don’t necessarily understand the work environment. Some GPs do
have some occupational health training, but at the end of the day, their
allegiance is to their patient. If their patient says they have back pain and
they can’t do their work and their work involves x, y and z, then the GP is
likely to write a sicknote, which I can understand. But the quality of what is
written on the certificates varies so much. Some are very helpful, others will
say things like ‘unwell’, and what does that tell you?" she asks.

"But to some extent, changing sickness certification could be a
double-edge sword.

"On the one hand, it could be really good and could mean early
referrals – I think the key to good attendance management is early
intervention. If you see people early it does not necessarily mean you’re going
to get them back early, but you can start planning their return-to-work
programme and think about a recovery programme, putting the emphasis on
recovery, and bringing in appropriate people to give further advice.

"But it could also put OH in a difficult position in that we become a
policing service for management. The OH service has to define how it gets
involved. But on the plus side, it could be very good. You get to know the
client and their needs early, but I would not want to be part of a team that is
a policing service," she says.

At London South Bank University, Harriss carried out a study among her
students looking at what sort of OH competencies are likely to be commonplace
in five years’ time compared with now. Intriguingly, the study threw up the
following suggestions: working more within a multi-disciplinary teams,
communicating more, having a greater understanding of issues such as health and
risk assessment skills, more legislation, and being able to lead a team.

Harriss adds contracting out recovery programmes to this list, something
that could rapidly move up the agenda if sickness certification is radically
changed. Similarly, disabilities are becoming a much more important issue.

"OH nurses need to think about developing skills in core areas. One
thing in the future that would be really helpful to specialise in is an
in-depth understanding of disability issues," she says.

"Under the Disability Discrimination Act (DDA) if someone has a
disability – however you define that – the employer has to make suitable and
sufficient modifications to the workplace to allow that person to carry on
working," she adds.

So does this mean OH nurses now do not have enough of an understanding of
this issue, despite all the legislation currently in place? "It depends on
the service," says Harriss.

Stress, of course, has been high on the OH agenda for sometime. But stress
among OH practitioners has, up to now, been something of a taboo issue. In the
February issue of Occupational Health, for instance, there was a report of a
survey which concluded that OH practitioners were increasingly stressed out,
with some turning to drugs and alcohol to cope.

The study of 129 OH practitioners, by recruitment firm OH Recruitment, found
more than half admitting to feeling stressed, and two-thirds saying their work
had become more stressful over the past 12 months.

On this, again, it comes to down to the leadership of the OH nurse in the
unit or department, Harriss contends. Generally, there is still too little
recognition that OH practitioners, despite all their own expertise on stress,
are simply human and prone to the same stresses and strains as everyone else.

"A good OH manager will identify that their OH staff also need the same
benefits of the OH service that other staff in the organisation do," she

The ideal would be to have a system whereby OH practitioners can be referred
to a separate OH service and, so, not be seen by someone with whom they have
direct contact at work. "You know if you have a problem and you want to
discuss it with an OH professional, there is someone there," she says.

There are huge amounts of organisational change going on within the
workplace, and OH is no exception. "So you need to think about how you
deal with that change among your own staff," says Harriss.

The only certainty, it appears, is that the workplace and with it, the
demands on both will alter. The profession, in conjunction with people such as
Harriss, needs to work at how it responds.

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