Occupational health models: Ruth Alston’s legacy and influence

Can occupational health models can help the profession grow like a dandelion with the most minimal resources?

The Ruth Alston memorial lecture is an annual reminder of how occupational health models have evolved over the last 25 years. Susan Carty, OH specialist at Medgate UK, looks at Alston’s pioneering work and its continuing relevance today.  

Vivek Bapat, senior vice-president and global head of marketing strategy at technology company SAP, wrote an article in the Harvard Business Review this year in which he argued that dandelions are a good metaphor for modern day leadership.

Bapat explains that dandelions fall under a class known as beneficial weeds, which help the plants around them. Dandelions do this by sending taproots deep into the ground. These taproots pull nutrients up to the surface, improving the quality of the soil and feeding shallow-rooted plants nearby.

Dandelions also attract insects that enable pollination, like bees, which helps other flowering plants. Plants that might not otherwise have a chance to germinate or survive get a shot at life because of the nutrients and insects that dandelions send their way. Yes, dandelions are prolific and fight for territory and they may not be the showiest plants, but they leave the environment a better place. I believe that the late Ruth Alston demonstrated similar characteristics as a leader for occupational health nursing.

Ruth Alston’s legacy

It is 22 years since OH nurse leader Cynthia Atwell presented the first Ruth Alston Memorial Lecture, entitled “The business of occupational health”. I attended this inaugural lecture and wondered how many other OH professionals knew why the Association of Occupational Health Nurse Practitioners (UK) (AOHNP), which is celebrating its Silver Jubilee this year, designated this annual professional lecture.

Ruth Alston was an occupational health nurse who wholeheartedly believed in our speciality and always considered that we did not promote our role as well as we could. This was partly because we had not defined what our unique role was on the bigger stage of occupational health practice.

Alston began to address this by embarking on a research project in conjunction with Canterbury Christchurch College, funded by Esso Petroleum, to look at the uniqueness of the OH nurse’s role. She was diagnosed with cancer while she was employed at the English National Board, at that time the English nurses’ regulatory body, as educational officer.

During this time Alston worked to promote OH nursing with the then UKCC (United Kingdom Central Council for Nursing, Midwifery and Health Visiting). It was OH nurse Carol Cholerton (the first president of the AOHNP) who, when Ruth knew she was dying, suggested a Ruth Alston Memorial Lecture (RAML). Alston was “tickled pink” by this and allowed the AOHNP (UK) to designate an annual professional lecture in her honour.

Her remit to Cholerton was that the content of RAML should reflect the contribution that OH nursing makes to corporate and community health, her legacy taproot.

Occupational health models after Hanasaari

When I think of Ruth I think of the Hanasaari model. This model was largely attributed to Alston, who was a major contributor to the published model in 2001.

It was devised during a workshop at Hanasaari, Finland (1989). Diana Kloss, chair of the Council for Work and Health, describes in her book Occupational Health and Law how early occupational health nurse degree courses were planned using the framework of the Hanasaari model.

Kloss states in the fifth edition of her book: “The revolutionary changes in nurse education brought about by Project 2000 have had significant effects on the training of occupational health nurses. Courses are validated jointly by the National Boards and the universities and have been updated to degree level. The syllabus has been planned using the framework of the Hanasaari

model, developed at a conference in Finland. This stresses the need to regard the total environment in which the workplace is set, but has been criticised for not giving sufficient training in topics specific to OH.”

The model combines three fundamental concepts: total environment; human, work and health; and occupational health nursing interaction.

The Hanasaari Conceptual Model provided me with a framework to define my vision both personally and for my then organisation, Midland Bank. Together with the late Denis D’Auria, (chief medical officer at Midland Bank from 1992 until 1997), we introduced a biopsychosocial approach for our OH service.

The Hanasaari model may have been a breakthrough in 1988, and only remembered by a few, but the biopsychosocial model forms the basis of the rehabilitation framework. It was refined by academics Gordon Waddell and A. Kim Burton in the late 1990s and into today (2006).

AOHNP (UK) takes lead on developing the model

You could also apply the dandelion metaphor to the leadership role provided by the AOHNP. In her 25th anniversary address Cholerton, the founding AOHNP past

president, shared how the AOHNP Board (of which Alston was a member) had developed a problem-solving workshop (with Cranfield University Business School) to consult with OH nurses around the country.

At these workshops the vision for the AOHNP was formulated, obstacles were identified and solutions found. These solutions, when prioritised in terms of urgency and importance, were then incorporated into a five-year AOHNP Business Plan (Cynthia Atwell, 1995)

Cholerton also described some of the obstacles to OH in 1992:

  • OH educational syllabi did not reflect the needs of OH nurses or employers.
  • There was no mandatory requirement to hold a specialist qualification in order to practise in OH.
  • People did not understand what OH nurses did.
  • The role of the OH nurse was not clearly defined.
  • OH advisers sometimes had to articulate the threat of litigation to stimulate employers into action.
  • OH nursing had a low profile within the nursing profession and in the business community.
  • OH could not measure its successes; the profession has no measurement tools.
  • OH was not on the agenda of decision-makers.
  • OH nurses were not taught to market their services.

While progress has been made, it is striking how many of these priorities are as relevant today as they were in 1994 when Cholerton gave her address.

As Alston once said, “OH nursing has a distinct lack of vision which leaves it far behind other professional groups.”  Is there a clear vision for occupational health today?  Who are our/your visionary leaders?

Mandy Murphy, deputy head of The National School of Occupational Health (NSOH), a collaboration between Health Education England and the Faculty of Occupational Medicine, remembers Alston for her quick mind and forthright manner.  She was a driving force for improving quality in OH nursing, particularly in education, says Murphy.

It’s timely to remember Alston now as we see a shared vision evolving of what we mean by quality in learning and education.  Evidence of this vision is the establishment of a Faculty of Occupational Health Nursing (FOHN), and a core curriculum with a multi-professional focus on education developed by a number of projects led by Public Health England, the Faculty of OH Nursing and the NSOH.

Collective approaches to building occupational health models

What we need now is not an expectation that an individual such as Ruth Alston will take the podium stand and speak on behalf of the OH nursing profession, but collaboration and a collective voice to demand better quality in our speciality and to drive forward the ambition for improving professional standards and the reputation of OH.

Murphy suggests we need an education system that provides an OH workforce for today and tomorrow that has the right skills, values and behaviours and a capability to respond to the evolving needs of the workplace.
The FOHN is being developed to provide direction, leadership quality and a voice for OH nursing, according to Christina Butterworth, chair of the FOHN. To maintain the specialist nature of OH nursing we not only need to educate nurses to meet the changing needs of the workplace but to set standards of practice and provide support in order to demonstrate the significant impact OH nurses have in keeping people healthy and well.

It is widely recognised in the OH profession that the need for OH greatly outstrips the supply of appropriately qualified professionals. Changing workforce demographics are likely to complicate this, with more people having to stay in employment longer.

However, it is also clear that new approaches have a part to play. For instance, OH provision is not restricted to face-to-face interventions, but can be delivered remotely by telephone consultations. Self-help websites also have a part to play.

In order to map out future requirements the Council for Work and Health is supporting a project that aims to articulate a vision of how OH should be delivered over the next 20 years and to identify the workforce planning needed to support that vision.

“The work we are doing on behalf of the Council for Work and Health challenges the status quo in healthcare delivery and training,” says Professor John Harrison, head of the NSOH. “The occupational health needs of working age people will, increasingly, be addressed by a broad-based healthcare workforce, of which specialist OH practitioners will be a part. We need to be clear about future models of delivery, about the USP [unique selling point] of specialist practitioners and about how to train them.”

Is wellbeing key to new occupational health models?

Just as Alston and the Hanasaari model were my key influences in the early 1990s, a presentation by What Works Centre for Wellbeing chair Dr Paul Litchfield, entitled “Wellbeing, What It Is & Why It Matters”, at the NSOH 2017 Conference, galvanised my thinking today.

Litchfield said that wellbeing is a vital component of OH today. He warned that traditional OH is outdated. He further said that the activities/revenue streams that most OH services have focused on for the past 20 years are declining in frequency and importance – they may see out the current baby boomer workforce but they don’t offer job security for the future.

We have fled into our comfort zone of focusing on the impact of illness on work says Litchfield. If we are to have influence (relevance) in the 21st century world of work, he believes we will need to stake out our place in the other three quadrants, in the Wellness framework for good business (see below) – if we leave the space unoccupied others will fill it says Litchfield.

Litchfield added OH can do good by playing in all the quadrants with a health focus but many of the determinants for human happiness and business success lie outside our traditional healthcare scope.

He’s not saying we should lead on reward, security or employee relations in an organisation, but we do need to make our presence felt and help pull the overall employee proposition together.

Isolated activities can become coherent when viewed through a wellbeing lens and Litchfield believes that the whole is greater than the sum of its parts. We have a real opportunity to improve the world of work to the benefit of our people, shareholders and society as a whole.

Litchfield added that there are many who are sceptical, feel their vested interests are threatened or who are just intellectually lazy and therefore don’t want to hear the message. Effecting change always meets that type of resistance and the challenge (fun!) is to overcome it, he adds.

Heather White, CEO of Smarter Networking, who presented the 2017 RAML, also reminded us that everyone needs to be told and to understand the value of our input. “Nice to have” may not always be “essential to have”, especially when budgetary constraints gain priority.

White argued that the art of networking and professional branding is “about building up a strong network of contacts, internally as well as external to your organisation, who understand you, your expertise/experience and your products/services and are therefore able to support you when the moment arises”.

Finally, Cholerton stated in an editorial for OH Today (Cholerton, 1994) that “the most fitting memorial for Ruth would be for all OH nurses to take up the banner she so proudly and consistently carried and become actively involved in ensuring the on-going development and growth of the specialism for which she worked so hard during her lifetime”.

Cholerton reminded us at RAML in 2017 that while it is appropriate to reflect for a short time on the past, “a silver anniversary year is a very apt time to look forward and to create a vision or strategy, for you as individuals, for this excellent professional organisation and for the future of OH nursing”.

She also reminded us to make sure we respond to surveys, consultative documents and proposals and not to be afraid to say what we think. Most of all, she advised us to embrace the future.

A dandelion can find a way to grow with the most minimal resources – who hasn’t seen one popping up between the cracks in a concrete path? Similarly, today’s OH leaders need to be resilient, digital and dandelion-tough to embrace the growth and development of our specialism.


Atwell C, Ruth Alston Memorial Lecture “ The Business of Occupational Health”.  Occupational Health, June 1995, vol 47, no 6, pp 202-204.

Bapat V. Why the Lowly Dandelion is a Better Metaphor for Leaders than the Mighty Banyan. Harvard Business Review. 23 March 2017.

Cholerton C (1994). Occupational Health Today. November/December 1994. vol 2, no 2.

Action Plan is launched for occupational health. (1982) Nursing Standard vol 29, no 6 pp 16-16. http://dx.doi.org/10.7748/ns.6.29.16.s28

Waddell G & Burton A K (2006) Is Work Good For Your Health and Wellbeing? London: The Stationery Office


About Susan Carty

Susan Carty is OH specialist at Medgate UK.
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