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Occupational Health Nursing Third Edition
Edited by
Katie Oakley
John Wiley & Sons, Ltd
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Occupational Health Nursing
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Occupational Health Nursing Third Edition
Edited by
Katie Oakley
John Wiley & Sons, Ltd
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John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex PO19 8SQ, England Telephone (+44) 1243 779777
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Contents
Contributors Foreword to the Third Edition by Professor Dame Carol Black Foreword to the Second Edition by Nola Ishmael Foreword to the First Edition by Carol Bannister Preface to the Third Edition
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Introduction
The Role of the Occupational Health Nurse Daphne Bagley; Updated by Katie Oakley
1
PART I
MANAGEMENT
25
Chapter 1
Setting Up Services Anne Kennaugh
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Chapter 2
Writing Policies and Procedures Andrea Mummery and Katie Oakley
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Chapter 3
Managing Services Cynthia Atwell; Updated by Anna M. Cosgrove
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Chapter 4
Quality and Audit Linda Maynard
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Chapter 5
Independent Practice Kit Artus; Updated by Katie Oakley
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Chapter 6
Marketing Janette Murray
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PART II
INTERNATIONAL ISSUES
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Chapter 7
International Issues Panayota Sourtzi
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PART III
PRACTICE
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Chapter 8
Occupational Health and Safety Katie Oakley
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Chapter 9
Health Surveillance, Health Assessment and Health Screening Cynthia Atwell
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Chapter 10
Mental Health and Stress Angela Franklin
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Chapter 11
Musculoskeletal Disorders and Ergonomics Claire Raistrick
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Chapter 12
Health Promotion Tracy McFall; Updated by Katie Oakley
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Chapter 13
Rehabilitation Dorothy Ferguson
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Chapter 14
Case Management Philip Roy Richardson
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PART IV
EDUCATION AND RESEARCH
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Chapter 15
Education, Clinical Supervision and Professional Development Patience D. Kenny
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Chapter 16
Research Jan Maw and Stuart Whitaker
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Index
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Contributors
Contributors to the Third Edition Cynthia ATWELL (RN, OHNC, CertEd) Independent Occupational Health Consultant Anna M. COSGROVE (RN, BSc (Hons), MSc Occupational Health) Occupational Health Nurse Consultant, University Hospital of North Staffordshire NHS Trust Dorothy FERGUSON (RN, PhD, BA (Hons), MPH, SCM, RHV, OHNC, HVT, EdD) MSc Co-ordinator, Department of Nursing and Community Health, Glasgow Caledonian University Angela FRANKLIN (RN, MSc, DMS, OHNDip, Health Ed Cert) Occupational Health Service Manager, University College London Anne KENNAUGH (RN, MBA, RM, OHNC, MIOSH) Resource Development Director, Grosvenor Health Ltd Patience D. KENNY (OHNC, MSc, PGCEA) Formerly Teaching Fellow in Occupational Health, University of Surrey Jan MAW (RN, OHNC, DHP, M(Med)Sc, PGCE) Lecturer in Occupational Health, University of Sheffield Linda MAYNARD (RN, ONC, DOHN, BSc (Hons), MSc) COPE OH & Ergonomic Services OH Manager to EDF Energy
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Contributors
Andrea MUMMERY (RN, OHNC, Management Diploma) Occupational Health Manager, Nuffield Hospitals Janette MURRAY (RN, BA, OHND, NEBOSH Cert) Director of Scottish Region, WellWork Ltd Katie OAKLEY (RN, OHNC, BA (Hons), MA (Social Research)) Independent Occupational Health Adviser Claire RAISTRICK (MSc, BA, RN, SCPHN(OH), MErgS, Eur Erg, CMIOSH) Senior Teaching Fellow, University of Warwick Occupational Ergonomist, Matrick Ergonomics Ltd Philip Roy RICHARDSON (RN, BSc(Hons)) Occupational Health Adviser, IBM UK Ltd Panayota SOURTZI (RN, PhD) Assistant Professor (OHN), Department of Public Health, Faculty of Nursing, University of Athens Stuart WHITAKER (RN, RMN, OHNC, MIOSH, M(Med)Sc (Occupational Health), PhD) Senior Lecturer in Occupational Health, St Martin’s College Lancaster
Contributors to Previous Editions Kit ARTUS, Director, Cheviot Artus plc Daphne M. BAGLEY, Occupational Health Adviser, Healthcare and Education Consultancy Tracy McFALL, Specialist Practitioner OH, News International Charles McK GRAHAM, HM Inspector of Health and Safety (Occupational Health), HSE
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Foreword to the Third Edition
This publication provides a most useful tool for occupational health nurses, and highlights the real breadth and depth of issues which they deal with on a daily basis. It is refreshing to see these issues brought together into one publication; and the fact that the first edition was published over 10 years ago shows not only the ongoing popularity of the publication, but also its practicality and enduring relevance. Occupational Health Nursing – Third Edition has been published in the same year as my Review of the Health of the Working Age Population. This Review has reinforced my conviction of the pivotal role that occupational health must play in keeping people healthy and in work, or returning them to work as quickly as possible if they leave the workplace. Occupational health has the opportunity to redefine its relationship in the delivery of health care, and map out how it will meet the challenges of the future and be increasingly relevant to modern workplaces – occupational health nurses will obviously play a vital role in this. I am honoured to be involved with Occupational Health Nursing – Third Edition, and look forward to seeing many more editions over the coming years. Professor Dame Carol Black DBE FRCP FMedSci National Director for Health and Work
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Over the last five years I have been very privileged to work with occupational health nurses in a number of areas and initiatives through my role of policy development Nursing Officer for occupational health nursing. It has truly been an informative and enjoyable period in which much learning and sharing have taken place. At all times I have been inspired by the dedication, zest and energy, together with the depth of knowledge and range of experience, of the nurses who make up this branch of nursing. As individual, economic and professional horizons change within society, so do the expectations of people, including those in the workplace. It therefore follows that the knowledge and expertise of occupational health nurses must continue to increase to meet new challenges, deal with developments and act on requirements as they continue to deliver an evidence-based service. Occupational Health Nursing – Second Edition is a welcome and timely resource which will assist occupational health nurses to develop a strong knowledge base in their field of practice. The modernised world of work demands similar modernised thinking and approaches. Occupational Health Nursing – Second Edition allows readers to look back on the past and retain the lessons from it, to address the present and make it meaningful for themselves, the workforce and employers, and to look forward to the future with renewed assurance and confidence. I am delighted to be associated with this work and commend it to you. Nola Ishmael OBE Nursing Officer Department of Health, London
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Books on occupational health nursing are rare, and so it is all the more important that a new book on occupational health nursing should be by nurses and for nurses. Occupational health nursing is in the process of rapid development. New challenges face practitioners. Changes in patterns of work, legislation and education mean that the occupational health nurse needs to be responsive to and able to manage change. Changes in nursing and nurse education have produced a new kind of occupational health nurse. Occupational health nurses have to show constant reflection on and improvement in practice, and to demonstrate this through professional portfolios to the UKCC, for continuing their active nurse registration. In addition the new degree programmes produce nurses who challenge practices which are ritualistic and not grounded in research. These practice and educational policy changes were essential to ensure that occupational health nurses grow in confidence and ability and develop innovative approaches to practice, and offer employers and employees the best possible advice and support in reducing the risk of harm from work. UK legislation in health and safety at work now promotes a risk management and risk reduction framework to solving problems in occupational health. The world of business has also changed and the need for the occupational health nurse to show how the speciality of occupational health nursing ‘adds value’ to the purpose of the business is essential. While maintaining traditional values of nursing, the nurse must articulate and demonstrate the benefits of nursing practice to both employers and employees. This book is for all occupational health nurses who wish to develop quality initiatives and deliver a research-based service. Carol Bannister Adviser in Occupational Health Royal College of Nursing, London xi
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My original proposal to the publishers was to write a practical occupational health nursing policy manual – full of templates that people could adapt for local use. Having sent the proposal out for review, the publishers came back wanting something rather different. They asked me to put together and edit a multi-contributor reader on topics of interest to occupational health nurses, and Occupational Health Nursing was the result. It is more than 10 years now since the first edition of Occupational Health Nursing was published. The positive feedback and suggestions received, in particular from students of occupational health nursing and their tutors, have been most welcome and kept up the impetus to develop and refine the book. Occupational Health Nursing – Third Edition is three times the size of the first edition. Occupational Health Nursing is edited and written entirely by occupational health nurses and the focus remains on practical topics relevant to day-to-day practice in the workplace. Contributors have reviewed, revised and updated existing chapters, following appraisal of the latest literature and research and wide consultation with other expert colleagues. There are also two excellent new chapters on highly topical subjects: ‘Case Management’ by Philip Roy Richardson and ‘Musculoskeletal Disorders and Ergonomics’ by Claire Raistrick. The contributors share what has worked for them and their clients in practice – illustrating this with examples and sample documentation where possible. They are all familiar with the challenges of setting up and managing services, and with tailoring services to suit the needs of the employer and the employees of an organisation without compromising the quality of service. Why become an occupational health nurse? It’s a wonderfully varied job presenting opportunities to work with people from the ‘shop floor’ to board level and in a range of settings, from hospitals, prisons xii
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and laboratories, to oil rigs, to multi-national banks. There is a shortage of qualified occupational health nurses and there are therefore plenty of opportunities available. The contributors know how frustrating the job can be at times but recognise that being a good occupational health nurse means staying focused on and committed to the overall aim of helping make the workplace a healthier and safer place. This means, for example, persuading employers not just of the importance of implementing occupational health-related legislation but also of the benefits of generally paying attention to the health and well-being of their employees. As well as being morally right, looking after one’s employees is increasingly recognised as making good business sense – people are a vital asset to a successful business. Occupational health nurses have to earn the trust and respect of employers, employees and colleagues. This means being a good team member but also having the confidence, backed by knowledge, to negotiate with and influence others to have a positive impact on workplace health. The third edition starts with an introductory chapter on the wideranging and developing role of the occupational health nurse. This chapter, ‘Introduction: The Role of the Occupational Health Nurse’, also touches on some key general professional issues, such as competence and confidentiality, topics which are referred to repeatedly throughout the book. The main part of the book then follows, arranged by grouping the chapters together by related topic for easier reference. There are four sections: ‘Management’, ‘International Issues’, ‘Practice’ and ‘Education and Research’. In addition to the two completely new chapters already mentioned, Dr Panayota Sourtzi has updated and expanded Charles McK Graham’s ‘European Perspectives’ chapter to create a new chapter entitled ‘International Issues’. This new third edition presents up-to-date information and aims to assist occupational health nurses, at all stages of their career, to deliver effective services. I hope it might encourage nurses thinking of branching into occupational health to find out more. It might also be of interest to others, such as NEBOSH students, who undertake occupational health modules as part of their course. I would like to thank all the contributors to the book and those who have given their time to comment on chapter drafts. I would also like to thank the editors, in particular Tim West, and all involved at WileyBlackwell.
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Introduction: The Role of the Occupational Health Nurse Daphne Bagley; Updated by Katie Oakley
Introduction Occupational health nurses are the largest group of health care professionals involved in workplace health management in Europe (Whitaker & Baranski 2001). The Royal College of Nursing (verbal communication July 2007) estimates that 7000–7500 nurses work in occupational health settings in the UK. This number is unchanged from their 1996 estimate, quoted in the first edition of this book. Whitaker and Baranski describe occupational health nursing as a ‘frontline’ role involving a range of aspects, namely: clinician, specialist, manager, coordinator, adviser, health educator, counsellor and researcher. How can occupational health nurses contribute to improvements in public health by making a difference to the health, safety and well-being of the working community? What is their role as qualified nurses in the workplace setting? Initially, the role is discussed in general terms, taking the recognised functions of the occupational health nurse as a starting point. The historical context of occupational health nursing is then summarised, before moving on to some important professional issues such as competence, accountability, communication and role development in a changing workplace. The chapter concludes with five case studies illustrating the wide-ranging and varied nature of the role but showing that, whatever the setting, the overall aim of the job is the same – to help achieve improvements in the health of working people.
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Occupational health nursing is a specialist branch of public health nursing with its roots in traditional nursing care. Occupational health nurses are all registered nurses – in other words, they have been through years of rigorous training to qualify as nurses and obtain their official registration. They have subsequently maintained their registration by recording further education and experience and paying registration fees to the Nursing and Midwifery Council (NMC). Practice is regulated by the Nursing and Midwifery Council (the regulatory body whose primary function is to protect the public www.nmc-uk.org). Issues of accountability, confidentiality, professional standards and guidelines affect all nurses, and nurses are always conscious of the fact that they work within a legal framework. So an occupational health nurse is a qualified, registered, accountable professional with years of experience of confidentially supporting, treating and helping people (often at very difficult times in their lives) in both hospital and community settings. They should thus have excellent communication and problem-solving skills, and most have significant management experience, e.g. running a hospital ward. A nurse qualified in occupational health has an additional qualification which may be placed on the NMC specialist community public health nurse (SCPHN) register. The Nursing and Midwifery Council has 3698 nurses with a recordable occupational health qualification (as at 31 March 2006). Does being a registered professional command trust and respect? Not automatically, however we would argue that employers and employees are likely to value an occupational health nurse’s opinion on health matters and we must work hard to build on and retain this trust by acting with integrity to make a difference to health in the workplace. How can occupational health nurses improve the health of the working population? How do they work with employers and employees and with other professional groups to reduce sickness absence and assist with rehabilitation and making workplaces healthier and safer? What is it that the nurse has to bring to the workplace? This book attempts to answer these questions by exploring topical issues, illustrated with examples from a variety of settings and placed against a background of general developments in health care, and public health in particular. Every chapter is written by experienced occupational health nurse(s), many with additional qualifications and expertise, practicing in occupational health service provision, management, research, consultancy or education. This introductory chapter on the role of the occupational health nurse sets the scene by outlining the job functions, historical context and some of the governing principles and key issues of importance to occupational health nursing professionals today.
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What Do Occupational Health Nurses Do? The basic tenets of occupational health nursing practice are to promote health at work and to protect the health of the worker. Aw et al. (2007) define occupational health as: a multifaceted and multidisciplinary activity concerned with the prevention of ill health in employed populations. This involves a consideration of the two-way relationship between work and health. It is as much related to the effects of the working environment on the health of workers as to the influence of the workers’ state of health on their ability to perform the tasks for which they were employed. Its main aim is to prevent, rather than cure, ill health from wherever it arises in the workplace In general terms occupational health is about the relationship between work and health and health and work, and paying attention to this is part of good risk management for any successful business. The general functions of an occupational health service (OHS) identified by the World Health Organisation (WHO 2002 pp. 11–12) provide a classic framework (Figure 0.1). Dorward (1993) listed the functions of occupational health nursing as:
r r r r r r r r r r r r
health surveillance of the work environment accident prevention prevention of occupational ill health treatment of illness and injury at work first aid organisation promotion of health and prevention of ill health counselling rehabilitation keeping records and producing reports liaison and co operation (internally and externally) administration of the occupational health unit research.
All of the above functions are discussed in this book; some, such as rehabilitation, health surveillance, health promotion and research, have specifically dedicated chapters. Most occupational health nurses perform a wide-ranging and varied role, which may include activities such as health screening and health surveillance, establishing and managing occupational health services, case management, and running a travel clinic and health promotion programmes. Some are involved with teaching and clinical supervision and mentoring. Many participate in or conduct research, surveys and
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While the responsibility for workers’ safety and health rests with the employer, the OHS will be required to give expert advice to employers, individual workers and their representatives, and to carry out essentially preventive functions. These functions should aim at:
r r r r
Establishing and maintaining a healthy and safe work environment; Maintaining a well-performing and motivated workforce; The prevention of work-related disease and accidents; and The maintenance and promotion of the work ability of workers.
They hence may comprise the following:
r r r r r r r r r r r
Identification and assessment of the health risk in the workplace; Surveillance of the work environment factors and work practices that affect workers’ health, including sanitary installations, canteens and housing, when such facilities are provided by the employer; Participation in the development of programmes for the improvement of working practices, as well as testing and evaluation of health aspects of new equipment; Advice on planning and organization of work, design of workplaces, choice and maintenance of machinery, equipment and substances used at work; Advice on occupational health, safety and hygiene, and on ergonomics and individual and collective protective equipment; Surveillance of workers’ health in relation to work; Promoting the adaptation of work to the worker; Collaboration in providing information, training and education in the fields of occupational health, hygiene and ergonomics; Contribution to measures of vocational rehabilitation; Organization of first aid and emergency treatment; and Participation in the analyses of occupational accidents and occupational diseases.
Figure 0.1 Prevention, Health Protection and Safety: Occupational Health Service Functions Source: WHO 2002 pp. 11–12
investigations within the company, for example identifying trends in sickness and accident statistics, auditing health programmes and conducting environmental surveys and writing reports. They sit on health and safety committees and contribute to and write policies and procedures. Occupational health nurses are increasingly involved in assisting managers with sickness absence issues (see Figure 0.2). The job is varied – a nurse might hold a clinic in the morning and be out assessing and advising in the afternoon. They will be with people at their workstations listening, looking and talking to find out exactly how they are working, and whether this is affecting or has the potential to affect their health. Occupational health nurses are recognised at the highest levels and are involved in national target setting (e.g. the significant nursing representation on the Support Programme Action Group of Securing Health Together www.ohstrategy.net and www.hse.gov.uk/sh2/pags/ supportreport.pdf).
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r r r r r
Make welfare visits. Discuss medical problem in confidence with employee. Regular contact and support. Liaise with GP/hospital consultant/welfare officer/occupational health physician as necessary. In some cases, help to facilitate treatment if the company provides private medical insurance or is willing to ‘fast track’ staff by paying for investigations or treatment options. Advise management on:
r r r r
r
5
employee progress expected duration of absence rehabilitation retirement.
Offer advice and guidance on all health-related matters.
Figure 0.2 agement
The Role of the Occupational Health Nurse in Sickness Absence Man-
Where Do Occupational Health Nurses Work? Some occupational health nurses work as members of an occupational health team (more common in large companies, local authorities and the NHS). Many occupational health nurses work as sole practitioners. Other practitioners provide nurse-led occupational health services to different clients in both the private and public sectors. A small number work in education and research and alongside specialist doctors for the Health and Safety Executive’s (HSE) Employment Medical Advisory Service (EMAS). The occupational health nurse is expected to demonstrate a wide range of competencies, abilities and skills in a variety of work settings.
The History of Occupational Health Nursing Public health nursing now has a broad remit including health service provision, commissioning, health protection, management, education and research. Public health objectives and themes now go beyond the historical associations with clean water, food, hygiene and shelter, although these still remain key determinants of health. Occupational health nursing has always been associated with public health nursing, as the following historical overview illustrates. Following the industrial revolution of the 18th and 19th centuries, the migration of people from rural areas to cities and towns led to increased health problems associated with poor living and working conditions. Mortality rates were high among sufferers of tuberculosis, typhoid and cholera. High infant mortality and poor living conditions were noted by
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such men as Edwin Chadwick. Chadwick’s report on The Sanitary Condition of the Labouring Population of Great Britain influenced the introduction of the Public Health Act of 1848, which included the establishment of Local Health Boards and the appointment of health officials. The Royal Sanitary Commission (Chadwick 1842) emphasised the importance of preventive medicine, but this was never really followed through effectively, in spite of the creation of a National Health Service (NHS) after the Second World War. History records that the work of early industrial health nurses was based on public health principles. Charley (1978) provides an excellent account of these times, and describes the duties of Philippa Flowerday, believed to be the first industrial nurse in the UK, who was employed by the Norwich mustard factory of J. and J. Colman in 1878 at 26 shillings a week. In America, Wright (1919) and others (McGrath 1946), cited in Rogers (1994), described industrial nursing activities in the 19th century and beyond, emphasising the community focus, public health agencysponsored services and the school nurse role. The history and development of occupational health since then has been fully described in other texts, so a summary of the milestones is set down for reference in Figure 0.3. Acheson (1988) defined public health as: ‘the science and art of preventing disease, prolonging life and promoting health through organised efforts of society’ and placed public health high on the health service agenda. The Gregson Report (1984) acknowledged that occupational health practice should be a component of primary health care. Internationally and locally, new models of practice have been developed that place occupational health within public health frameworks and programmes of care. The Black Report highlighted inequalities in health (Townsend and Davidson 1982), and Calman (1995) stated that four key issues requiring special attention were: equity and equality, food poisoning, drug and solvent misuse, and health in the workplace. National health targets on equality aimed to bring up ‘the health experience of those in the least healthy groups closer to that of the currently most healthy groups’ (DoH 1995a). The health gap continues, and occupational health nurses have an important part to play in improving the health of the working population by promoting equal access to health information. Waddell and Burton (2006) found that work is ‘good for you’ but only if it is ‘good’ work. Ballard (2006c) says this evidence review ‘is important because assumptions about the health benefits of work have been extrapolated from evidence that joblessness is bad for health rather than direct evidence on the positive impact of work itself.’ Ballard warns that ‘people on benefits, coping with mental illness or facing discrimination on grounds of race and or disability are most likely to be at the wrong end of the “social gradient in health” and . . . where they can find work
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370 BC Hippocrates Agricola (1494–1555) & Paracelsus (1493–1541) Ramazzini (1633–1714) 1775 Percival Pott INDUSTRIAL REVOLUTION 1800s 1802 1831 Charles Turner Thackray 1833 1842 Edwin Chadwick 1844 1848 1855/72 1878 Philippa Flowerday 1895 1897/1906 Sir Thomas Legge (1863–1932) 1901 1916 1932 1934 1937–61 1946–48 1948 1949
1950 1972 1974 1988/92 2006
Figure 0.3
7
Observed appalling working conditions. Linked colic symptoms with lead poisoning. Miners and their diseases. ‘Father of Occupational Medicine’. Observed scrotal cancer in patients who had been chimney sweeps. Urbanisation; child labour and the employment of women. Health and Morals of Apprentices Act. The Effects of the Principal Arts, Trades and Professions on Health. First Factory Act (updated 1844). The Sanitary Condition of the Labouring Population of Great Britain. First certifying factory surgeon. First Public Health Act. Appointment of the first workplace medical officers. First industrial nurse (J. and J. Colman’s mustard factory). Legal requirement to notify certain substances harmful to health, e.g. lead, arsenic, anthrax. Workman’s Compensation Acts. First Medical Inspector of Factories Industrial Maladies (1934). Doctors inspect places of work. College of Nursing founded (Royal Charter 1928). Survey of Industrial Nursing, Royal College of Nursing (RCN). Training for nurses established by the RCN. Factories Acts. National Health and Insurance legislation. Appointed Factory Doctors. Report of a Committee of Enquiry (Gowers) into Health, Welfare and Safety in Non-Industrial Employment. Report of a Committee of Enquiry (Dale) on Industrial Health Services. Report on Health and Safety at Work (Robens’ Committee). Health and Safety at Work (etc.) Act. UK/European legislation affecting health and safety practice. Appointment of first UK National Director for Work and Health.
Selected Milestones in the History of Occupational Health
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it may often be in low skilled poorly paid unsafe and insecure work environments.’ It seems logical then that occupational health nursing comes within the realm of public health nursing, as ‘the care of people with actual or potential health problems and manipulation of the environment to contribute to optimal health have been seen as the generic base of nursing practice for as long as nursing practice has been described’ (Fagin 1981). The definition for specialist community public health nursing used by the Specialist Community Public Health Nursing Committee is that it: aims to reduce health inequalities by working with individuals, families, and communities promoting health, preventing ill health and in the protection of health. The emphasis is on partnership working that cuts across disciplinary, professional and organisational boundaries that impact on organised social and political policy to influence the determinants of health and promote the health of whole populations (www.nmcuk.org/aSection.aspx?SectionID=29, accessed 22 June 2007). The determinants of health are broad (Figure 0.4) and occupational health nurses should always be aware of this when setting priorities for action. They have a unique opportunity to help people improve their health, including some difficult to reach groups such as migrant workers, because they have the opportunity to see people where they work.
Figure 0.4 The Main Determinants of Health From Dahlgren and Whitehead (DoH 1995a). Crown copyright is reproduced with the permission of the Controller of The Stationery Office
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Occupational health nurses, as the largest group of qualified health care professionals in the workplace, must ensure that they are fully involved with and contributing to the ground-breaking cross-departmental government Health, Work and Well-Being Programme (HM Government 2005). This programme, led by Professor Dame Carol Black (the National Director for Work and Health), has the same aim as we do, namely ‘to improve the health and well-being of people of working age’.
Maintaining Professional Standards Occupational health nurses must always keep in mind their professional duties and responsibilities. This is particularly important for the occupational health nurse who is working outside the traditional hospital nursing management structure. The occupational health nurse may be isolated and working as an independent practitioner and must be responsible for continued awareness of the need to maintain required professional and ethical standards. This should not interfere with the responsibility to the employer or client but diplomacy, negotiating and influencing skills are often required to ensure that, for example, a health surveillance programme is given priority over other, ‘less essential’ programmes. Upholding the core values of nursing is important: You are first and foremost a professional nurse with a duty to the public and your profession, and you must safeguard those interests and responsibilities (RCN 2003). Every nurse has an individual responsibility to reflect on their practice, to keep up to date, to ensure they are always working within professional boundaries, according to governing principles and the NMC Code of Professional Conduct (NMC 2004), and to consult and refer to others as appropriate. The NMC Code of Conduct: Standards for Conduct, Performance and Ethics may be used as a framework for ethical decision-making, together with other Council advisory papers, which may not be enforceable in a court of law but whose substance may contribute to minimum standard-setting for the registered nurse. Networking with colleagues and other experts and sharing best practice is a must. There are many occupational health groups around the country, which meet every few weeks after work and feature invited speakers, often focusing on topical issues such as forthcoming health-related legislation. There are active special interest groups such as the Society of Occupational Health Nursing (RCN) and the Association of Occupational Health Nurse Practitioners, both of which hold
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annual conferences. There are also many other relevant conferences and special training workshops. Finally, it is important to keeping up to date by reading professional journals such as Occupational Health (at Work), Occupational Health and Occupational Health Review and checking relevant authoritative web sites for ‘hot topics’ and information (e.g. government departments, the Health and Safety Executive, the Health Protection Agency).
The Craft of Occupational Health Nursing A report for the RCN Society of Occupational Health Nursing (SOHN) (Ballard et al. 2005), involving a survey of a sample of SOHN members, found that ‘communication and listening’ was the most highly rated competency for the job. Ballard (2006b) listed the five top functions of occupational health nursing as: confidential handling of health and personal data, assessment of fitness to work, health surveillance, disability management and assessing risks to mental health. Occupational health nurses should be a highly-trained and experienced asset to an organisation, doing preventive work, understanding people’s needs and advising on risks, hazards and environmental problems. They need to be enthusiastic and must be able to communicate their services effectively throughout the organisation, so that the benefit can be demonstrated to all. An experienced, confident and knowledgeable occupational health nurse who is a good communicator has much to offer to employers and employees in terms of providing costeffective, high-quality, practical help in the common aim of achieving a safer, healthier workplace. We see nursing as a craft developed over years of training and experience. Fischhoff (1995) described the process of communicating risks to patients as ‘craftwork’ requiring careful planning and implementation. This could be applied to the development of skills in occupational health nursing as we learn lessons from our experiences with people at work (both clients and colleagues), gradually building up a wealth of knowledge to improve our practice and that of others. Fischhoff states: ‘complex skills are acquired slowly e.g. aspiring musicians need to attend many concerts and practice before they can benefit from participating in master classes.’ Sharing good practice is important. This can be achieved by getting involved in professional association and local occupational health group activities and national strategies such as the aforementioned Health, Work and Well-Being Programme (HM Government 2005), and by researching and writing for publication. Nurses are practical people, trained to listen, observe and assess, to care for people when they are sick and to assist them with rehabilitation, to take responsibility when appropriate and work with patients to help
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them improve their health. In occupational health, they also need to be diplomatic and adaptable in a business setting to convince employers and employees of the benefits of good occupational health for them and their organisation. This means negotiating and influencing at all levels of an organisation, including the management board and union representatives. A week’s work may involve travelling to various sites, for example presenting to the board of a large company, facilitating a workshop for a community, running a clinic and advising on a health problem in a food processing plant. As with much public health work, the benefits are often long-term and difficult to measure and demonstrate. Getting results means assessing the key issues, listening to clients and learning from people using the service, working out what they want and assessing how that fits with the nurse’s own perception of the priorities in health protection and legislative terms, and negotiating an action plan.
Competence Occupational health nurses have nursing knowledge underpinned by physiological knowledge, and this is a useful support for the technical and scientific specialities of the hygienist and the health and safety adviser. Different approaches may be used in implementing the law, and the occupational health nurse can make an important contribution as a team member. Like all professionals, they need to have the confidence to be aware of their limitations and be conscious of their competencies, strengths and limitations and how to put these to the most effective use. The RCN publishes a benchmarking guidance document on occupational health nursing competencies (Bannister and Maw 2005). In this key document, Bannister and Maw, following extensive research and consultation, detail the competencies that should be expected at different levels of practice, moving from ‘competent’ through ‘experienced’ to ‘expert’. What is a competent occupational health nurse? Competence is a key issue whatever the task at hand, whether giving advice on healthrelated legislation, counselling employees who are experiencing stress or undertaking tasks associated with health surveillance and health screening. The term ‘competent person’ is used in the Factories Act 1961 and other legislation, but has been inadequately defined. There is no statutory definition of ‘competent’; the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC) report ‘Fitness for Practise’ (1999) describes competence as ‘the skills and ability to practice safely and effectively without the need for direct supervision. The concept of competence is fundamental to the autonomy and accountability of the individual practitioner . . .’ (UKCC 1999).
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‘Competence’ is included in the characteristics of a professional listed by Rogers (1994). The professional ‘possesses expertise, formal education or special technical competence; has a unique degree of autonomy that entitles her or him to exercise judgment; consciously conforms to a code or standard; feels a sense of service to humanity; acknowledges a higher responsibility for more than making a living; instils public trust.’ A competent occupational health nurse must keep up to date, not just with legislation, but with the changing workplace and emerging threats, such as pandemic influenza and bio-terrorism, and is involved in associated contingency planning and policy development. They are also involved in policy and practice development from the health perspective related to demographic changes and issues of equity, such as increasing retirement age, increase in temporary, agency and migrant workers, and teleworking. With changes in the type and pattern of employment, the hazards and risks of working have changed. There are still hazards from chemicals and substances, but there has been a great reduction in manufacturing and heavy industrial work. Risk management is an important part of protecting businesses and employees. The occupational health nurse, like everybody else, needs to be aware of change within the workplace and to try to foresee developments and potential hazards before problems occur. Teamwork and collaboration is key to workplace health (Figure 0.5).
Figure 0.5
The Occupational Health Nurse within a Multi-Disciplinary Framework
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General health promotion on issues such as healthy eating, alcohol and smoking on an individual or group basis has traditionally been a part of the occupational health nurse’s work, and obviously such issues can potentially affect work performance (see Chapter 10). There is little point, however, in addressing these issues alone without first tackling the hazards of the workplace.
Persuading the Employer Occupational health nurses can help employers and employees to understand their duties and responsibilities in relation to workplace regulations, codes of practice and publications which place occupational health practice high on the health and safety agenda. Employers usually want answers to the following questions: ‘Have I got to do it?’ and ‘How much is it going to cost?’ The occupational health nurse, in conjunction with others in the health and safety team, can help employers by explaining why measures are required in their organisation and the benefits of complying with the law. It is useful to point out estimated costings, including the potential effect of non-compliance on the company image. Quoting case studies related to the particular setting can help, e.g. to illustrate the importance of safe working systems in an X-ray department, the case of a radiographer who developed occupational asthma could be quoted. A radiographer was awarded more than £ 75,000 damages against the employer, who was found negligent (Ogden v Airedale Health Authority 1996). In his summing up, the judge said, ‘it is in my judgment incumbent upon an employer who requires employees to use chemicals in the course of their work to make inquiry as to the safety hazards which they present’ (see Chapter 9 for more details on health and safety matters).
More Legal and Ethical Issues, Including Confidentiality Chris Cox (2006) of the RCN legal department, in a presentation on indemnity insurance, legal accountability and the occupational health practitioner, listed core competencies for all health practitioners:
r A thorough grasp of fundamental legal principles around accountr r
ability and standards of care, the assessment of capacity and law of consent, confidentiality. A clear understanding of equal opportunities, disability, human rights and (if appropriate) mental health legislation, other relevant employment law. Knowledge of relevant professional codes of practice.
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Nurses may encounter conflicts arising from, for example, maintaining confidential records and reports. Since the second edition of this book an occupational health nurse has been awarded compensation for unfair dismissal in a case which involved refusing to divulge confidential information about an employee without consent (Tracey Cooke v West Yorkshire Probation Board). In relation to records and reports, decisions have to be made regarding who must know, who should know, who could know and who should not know (Downie & Calman 1994). The patient’s interest is paramount, and the burden of proof lies with the person providing the information. Occupational health nurses have a duty to ensure that reports and records are held in trust, and that the information retained is both clear and concise, as access to the information may be required by a court of law. Disclosure of information may also take place if the patient provides consent (preferably written), and if the information is required ‘in the public interest’. The occupational health nurse then has accountability under civil law and criminal law to all parties involved. (See Chapter 2, Appendix 2.1 for a sample policy on confidentiality.) If in doubt, seek advice from colleagues, other experts or your professional association. A key reference book on legal matters is the authoritative and user friendly Occupational Health Law by Diana Kloss (4th edn 2005). Professional negligence and duty of care, standard of care, the implications for practice of the Disability Discrimination Act 1995, the Human Rights Act 1998, health and safety legislation and much more are covered in this book. Conflicts may also be experienced in relation to patient advocacy. This is about upholding an individual person’s rights; acting in the best interests of the person; and acting as an intermediary on behalf of a person who is unable to articulate clearly his or her health needs to service providers. Empowering the individual to engage in personal target-setting is important here. The health professional is no longer perceived to be the sole expert, the ‘teacher’ or even the ‘victim blamer’. Power should be transferred to the client, creating a ‘partnership in care’, with critical appraisal of the relationship in terms of self-motivation and achievement. This is just as important in occupational health as it is in other aspects of health care, and involves special skills, diplomacy, experience and time to listen.
Case Studies The following case studies aim to give a flavour of the role of the occupational health nurse in a range of employment settings. The majority of occupational health nurses work in the independent sector (RCN verbal communication July 2007). The first case study relates to an independent OH service provider. This is followed by case studies on an NHS OH
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and safety service, a group OH service, an occupational health project and finally a self-employed OH nurse. Some general background on the type of service/organisation is given along with examples of work carried out in the specific case chosen.
Case Study 1: Independent Occupational Health Service Provider The head of nursing services at AXA PPP healthcare OHS Ltd says that ‘For nurses working within the private sector there are unlimited opportunities to develop and increase their portfolio of skills and competencies. The benefit of being able to experience such a wide variety of industry sectors, and have exposure to different client, employee, legislative and health and safety requirements is a great advantage to their professional development and progression.’ AXA PPP healthcare OHS Ltd is the second-largest medical insurer in the UK and is part of the UK business of AXA Group, one of the top four insurers in the world. AXA bought MIS, an occupational health service provider, in the late 1990s, and following this acquisition is now trading as AXA PPP healthcare OHS Ltd. Its staff includes over 85 occupational health workers, including nurses, physicians, health and safety staff and occupational health technicians. They all work closely with specialised teams of administrative and operational support workers. A senior management team made up of the leads from finance, operations, medical, nursing and business development operationally and clinically manages the company. The SMT meets monthly to develop and implement business strategy. The nursing team is managed by the head of nursing services, supported by the regional clinical managers in the north and south. Regional clinical team leaders, again in the north and south of the UK, support and assist them. The clinical leadership team has ownership of clinical governance, with responsibility for review, development, implementation and maintenance of clinical standards and policies and procedures. The heads of nursing services and medical services – with appropriate input and support from in-house and external clinicians with the specialist skills and knowledge for the specific projects ongoing at any one time – lead the clinical leadership team. The nurses can be home-based, work from client sites or AXA offices, or have a mix of locations. There is no particular service delivery model that AXA implements as its aim is to provide clients with a flexible approach to occupational health service provision, ensuring their needs are continually met. The skill sets and abilities of the nursing team include, but are not limited to, health surveillance, travel health, vocational rehabilitation, nurse case management, stress management,
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workplace risk assessment and audit, health education and promotion, sickness absence management, fitness for work assessment and training both in-house personnel and external clients.
Case Study 2: An NHS Occupational Health Service Many NHS trusts now provide occupational health programmes for commercial enterprises and businesses in their locality, targeting small and medium-sized companies. The occupational health department in this case study is a self-funding business unit within an NHS primary care trust based in south-east England. The head of occupational health services (a nurse) says, ‘working within an NHS setting, occupational health is driven by a business philosophy. This is further endorsed by the advice and standards set by the NHS Plus initiative which is an arm of the Department of Health.’ The government’s NHS Plus network aims to strengthen partnerships between the public and private sectors of the community (www.nhsplus.nhs.uk). As part of the health service business culture, income is generated by providing a service to non-NHS employees employed by outside agencies, ranging from charities to funeral directors. It is of utmost importance, however, that the service to trust employees is a priority. The philosophy of the department is captured in its mission statement: ‘We are a market leader in the provision of a professional quality and dynamic service tailored to the needs of the working environment.’ The aim of the department is ‘the promotion of positive health and fitness’. The service employs qualified and experienced occupational health nurses and doctors, who each have areas of responsibility in relation to all contracts within and outside the NHS. Other staff includes clerical/ administrative grades, a health and fitness adviser, a ‘moving and handling trainer’ and a psychologist who acts as a staff counsellor. Core occupational health activities are offered as part of a customer-focused service, plus a wide range of health programmes, which include workplace health surveillance, assessments and employment health screening. A gymnasium facility with supporting programmes is available for staff, as well as a comprehensive travel service. Members of staff are made aware of specific health topics on national awareness days. Both qualitative and quantitative auditing is carried out by the occupational health service, based on statistical returns, activity analyses and evaluations, following training courses and health-related programmes (including stress-management sessions). Innovations include developing specific projects, for example mental health services for staff; working with bullying and harassment advisers; and back care and rehabilitation programmes, which include a fasttrack referral system, clinical exercise programmes and a management case conference as part of return-to-work policies. Extensive work with
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three call centres is another development. Another separate unit based in a satellite hospital has a travel clinic, fitness suite, equipment for disabled users, stress-relaxing chairs and a steam room. There is a strong emphasis on rehabilitation.
Case Study 3: A Group Occupational Health Service The Gregson Report (1984) recognised the important contribution of group services, tracing their development and status and stating that ‘much depends on the zeal and proselytizing abilities of the staff’. The report recommended the extension of group services ‘especially in areas of primarily industrial development’. Group health services employ a skill mix of professionals, who usually operate from a central base but also provide on-site activities. Close liaison is maintained between the services and the regulatory bodies, including EMAS. Most services belong to an association of group occupational health services and have a common identity in that they all provide services that are ‘employer-led’, non-profit-making (having charitable status) and accountable to member companies. This case study is an example of a group service managed by an occupational health nurse and based on an industrial estate. Other occupational health nurses are employed, together with two qualified occupational health physicians and two other medical officers who work on a sessional basis. The medical officers carry out executive medical examinations for member and non-member companies. Ancillary staff includes a first aid supplies officer and a physiotherapist. Administrative support is provided by the company secretary/administrator, accounts clerk, two secretaries and two receptionists/clerks. First aid training is provided by a self-employed contract instructor. Around 100 small and medium-sized enterprises (SMEs) belong to the service. Subscription charges are invoiced on a per capita basis, and additional charges are made for specific services (at a subsidised rate), such as health surveillance (health and safety legislation), health promotion activities, lifestyle screening, first aid and health and safety training, manual handling training and vision screening. In addition, some 80 companies use the service on an ad hoc basis.
Case Study 4: An Occupational Health Project Occupational health projects (OHPs) have been in existence since 1978 and work with GPs and other health care staff to provide an independent occupational health advisory service to workers in a defined geographical area. Jackson (2004) provides an interesting and detailed summary of the work of two projects in his report of an evaluation research study conducted for the HSE.
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A national association has been established and project members meet regularly. The aims of the association include providing: mutual aid and benefit to member organisations (staff and committee members); pursuing a joint programme of exchange and activities; attempting to develop new methods of identifying emerging patterns of occupational disease; providing a national voice; developing awareness of occupational health . . . in primary and secondary health care and furthering the development and integration of occupational health services into primary health care in England, Scotland and Wales; emphasising the special value and strength of collective action to resolve health and safety problems; developing skills and capacities of workers and patients to solve problems for themselves. Other activities include creating models for the future development of occupational health services; establishing closer links with Europe; developing resources for public use; and identifying training programmes. Each OHP produces an annual report, and the projects are all at different stages of development. Funding for the projects comes from different sources, for example the Department of Health, health authorities and local authorities. Staff members are drawn from different backgrounds and include academics, scientists and nurses. A nurse working in a long-established project says: OHPs are ideally placed to plug a gap in occupational health service provision, with a particular remit to provide health and safety advice and information to small and medium-sized enterprises, particularly where no on-site occupational health provision is available, and where health inequalities need to be addressed. They appear to provide impartial help, whereas with on-site services conflicts of interest may arise, for example among managers, staff representatives and the work of occupational health practitioners. This particular project conducts research projects, e.g. on stress in taxi drivers and on health in self-employed ‘home-workers’. Several leaflets, available in different languages, are produced by the project – for example, on mothers at work. As part of expansion of their services, OHPs see themselves continuing to provide workplace health and safety advice, establishing new working partnerships with providers of community health services, as well as continuing to strengthen existing relationships with health purchasers.
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Case Study 5: A Self-Employed Occupational Health Nurse Some self-employed occupational health nurses specialise in key areas such as stress management and the management of back pain. Others may work through nursing agencies, providing relief cover on a temporary basis. Some nurses have developed a consultancy role, which might include, for example, combining teaching with practice and providing professional advice and support to organisations in other countries. Numerous opportunities exist for the self-motivated, multi-skilled and experienced occupational health nurse to provide a wide range of services (see Chapter 5 for a detailed discussion). An experienced and qualified occupational health nurse was prompted to become self-employed following redundancy. She has since used her knowledge, skills and abilities in a creative way and has developed a portfolio of skills that has wide appeal and involves both on-site and off-site activities. Such activities include lifestyle screening, workplace risk assessment and environmental survey, vision screening and first aid examining. This occupational health nurse is also actively engaged in health education on behalf of a women’s cancer charity organisation and is developing male health education programmes. Another important consideration for this nurse is the financial aspect of being self-employed. She has many expenses associated with, for example, ensuring adequate professional indemnity insurance, subscribing to professional journals and organisations, purchasing equipment and supplies (including those required to maintain a home office base) and marketing. As one should when setting up any business, she sought advice on writing business proposals and engaged an accountant. Changes in personal circumstances and a desire for freedom and more control over workloads may motivate nurses to become self-employed practitioners. The role of the occupational health nurse cited in this case study highlights the importance of practitioners keeping up to date clinically, in order to maintain competence and professional standards.
Conclusion Occupational health nursing aims to improve people’s health at work. Sometimes the effect of an occupational health intervention is obvious and measurable and this is satisfying for all concerned, for example following the introduction of a successful case management programme, or reducing the rate of back injuries amongst care workers following manual handling training and ergonomic interventions. More often, however, the effect is not immediately obvious or demonstrable as, in common with much public health work, it often involves preventing
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health problems in the medium and long term. An occupational health nurse therefore needs to be strongly committed to the discipline and believe that their work can make a difference. It is important to effectively balance sometimes competing demands and interests; remembering responsibilities and duties to the employer and the employee without compromising professional guidelines and code of conduct. Occupational health nursing practice is a synthesis of the study of the core values of community health nursing within the context of public health, combined with an in-depth knowledge of occupational health and safety and an understanding of the organisational and psychosocial factors affecting the workplace. Working with colleagues as a team member and in partnership with patients/clients is integral to any branch of nursing. Nurses must be competent at assessing and problem solving, but also at knowing when to refer on and to whom, e.g. occupational health physicians, safety professionals, ergonomists and hygienists. Occupational health nursing is a challenging, interesting and satisfying job. This chapter has tried to outline the role in order to set the context for the more detailed chapters which follow. In every aspect of the role, knowledge, qualifications, experience and contacts are not enough on their own; confidence, competence, adaptability and excellent communication skills, using language and methods appropriate to each setting, are essential for a successful and effective occupational health nurse.
References and Further Reading The Acheson Report (1988) Public Health in England: The Report of the Committee of Enquiry into the Future Development of the Public Health Function, London: HMSO. Agius R. and Seaton A. (2006) Practical Occupational Medicine, 2nd edn, Hodder Arnold. The Allitt Inquiry (1994) Independent Inquiry Relating to Deaths and Injuries on the Children’s Ward at Grantham and Kesteven General Hospital During the Period February to April 1991, London: HMSO. Association of Occupational Health Practitioners (UK) web site, www.aohnp .co.uk (accessed 16 July 2007). Aw T.C., Gardiner K. and Harrington J.M. (2007) Pocket Consultant Occupational Health, 5th edn. Ballard J. (2006a) Delivering OH Services Part 1: Performance Indicators and Benchmarking in OH Nursing, Occupational Health (at Work) 2(5). Ballard J. (2006b) Delivering OH Services Part 2: Nursing Competence and Performance Indicators, Occupational Health (at Work) 2(6). Ballard J. (2006c) Healthy Working (editorial), Occupational Health (at Work), October/November.
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Ballard J., Silcox S., Suff P. (2005) Performance Indicators and Benchmarking in Occupational Health Nursing, London: The At Work Partnership. Bannister C. and Maw J. (2005) Competencies: an Integrated Career and Competency Framework for Occupational Health Nursing, London: RCN. Black D. (1980) Inequalities in Health Report, London: DHSS. Calman K.C. and Department of Health (1995) On the State of the Public Health. The Annual Report of the Chief Officer of the Department of Health for the Year 1994, London: HMSO. Chadwick E. (1842) The Sanitary Condition of the Labouring Population of Great Britain (republished 1965, M.W. Flinn (ed)), Edinburgh: Edinburgh University Press. Charley I.H. (1978) The Birth of Industrial Nursing, London: Bailliere Tindall. Commercial Occupational Health Providers Association web site, www.cohpa .co.uk. Confederation of British Industry (CBI) (2001) Focus on Absence Survey, London: CBI Publications. Data Protection Act 1998. Cox C. (2006) Presentation for the RCN Society of Occupational Health Nurses Annual Conference (unpublished). Department for Work and Pensions (2004) The Framework for Vocational Rehabilitation www.dwp.gov.uk/publications/vrframework/.DoH (1993) Targeting Practice: the Contribution of Nurses, Midwives and Health Visitors, London: HMSO. Department for Work and Pensions (2007) Information on Health and Employment. Corporate Medical Group www.dwp.gov.uk/medical (accessed 15 July 2007). DoH (1995a) Variations in Health: What Can the Departments of Health and NHS Do?, London: HMSO. DoH (1995b) Making it Happen: Public Health – the Contribution, Role and Development of Nurses, Midwives and Health Visitors. Report of the Standing Nursing and Midwifery Advisory Committee, London: HMSO. DoH (2003) Taking a Public Health Approach in the Workplace: a Guide for Occupational Health Nurses, London: DoH. Dorward A.L. (1993) Managers’ Perceptions of the Role and Continuing Education Needs of Occupational Health Nurses. Research Paper 34, Sudbury: HSE. Downie R. and Calman K. (1994) Healthy Respect, 2nd ed., Oxford: OUP. English National Board for Nursing, Midwifery and Health Visiting (1996) Occupational Health Nursing. Leaflet, February. Faculty of Occupational Medicine (2006) Guidelines on Ethics for Occupational Physicians, 6th edn, London: FOM, Royal College of Physicians. Faculty of Occupational Medicine, Society of Occupational Medicine, Royal College of General Practitioners, supported by Department for Work and Pensions (2006) The Health and Work Handbook: Patient Care and Occupational Health: a Partnership Guide for Primary Care and Occupational Health Teams, www.facoccmed.ac.uk/library/docs/h&w.pdf.
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Fagin C.M. (1981) Primary Care as an Academic Discipline. In: Mauksh I. G. (ed), Primary Care: A Contemporary Nursing Perspective, New York: Grune & Stratton, 172. Fischhoff B. (1995) Risk Perception and Communication Unplugged: Twenty Years of Process, Risk Analysis 15(2), 137–45. The Gregson Report (1984) House of Lords Select Committee on Science and Technology. Occupational Health and Hygiene Services. Vol. 1, Report Session, 1983–84. Griffin N. (1992) Occupational Health Advice as Part of Primary Care Nursing, London: HSE. HSC (2000) Securing Health Together: A Long-Term Occupational Health Strategy for England, Scotland and Wales, Sudbury: HSE. Human Rights Act 1998. Information Commissioner’s Office (2005) Employment Practices Data Protection Code: Part 4: Information about Workers’ Health. Wilmslow: ICO. Jackson C.A. (2004) The Evaluation of Occupational Health Advice in Primary Health Care, Sudbury: HSE, www.hse.gov.uk/research/rrpdf/rr242.pdf. Kitson A. (1997) Using Evidence to Demonstrate the Value of Nursing, Nursing Standard 11(28(2)), 121–7. Kloss D. (2005) Occupational Health Law, 4th ed., Oxford: Blackwell. Health Protection Agency web site, www.hpa.org.uk. Lewis F. and Batey M.V. (1982) Clarifying Autonomy and Accountability in Nursing Services, Journal of Nursing Administration 1, 2, 12(9) and (10), 13–18 and 10–15. McGrath B.J. (1946) Nursing in Commerce and Industry, New York: The Commonwealth Fund. National Library for Health web site, www.library.nhs.uk. NHS Plus web site, www.nhsplus.nhs.uk. NMC web site, www.nmc-uk.org. NMC (2004a) Standards of Proficiency for Specialist Community Public Health Nurses, London: NMC, www.nmc-uk.org/(abygbo55blig2cvrbubkdw45)/ aFrameDisplay.aspx?DocumentID=324 (accessed 25 July 2007). NMC (2004b) The NMC Code of Conduct: Standards for Conduct, Performance and Ethics July 2004, www.nmc-uk.org/aFramedisplay.aspx? documentID= 201 (accessed 25 July 2007). Ogden v Airedale Health Authority (1996) unreported case. Rogers B. (1994) Occupational Health Nursing: Concepts and Practice, Philadelphia: W.B. Saunders. Royal College of Nursing (RCN) web site www.rcn.org.uk. RCN (1992) Powerhouse for Change: a Manifesto for Community Health Nursing in the 1990s, London: RCN. RCN (1994) Public Health: Nursing Rises to the Challenge, London: RCN. RCN (1995) Factsheet 6: Guidance on Employment of an Occupational Health Nurse, London: RCN. RCN (2003) Information for Would-Be Nurse Entrepreneurs: Turning Initiative into Independence, 3rd edn, London: RCN.
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RCN (2004) Integrated Career and Competency Framework: Occupational Health Nursing, London: RCN. RCN (2005) Confidentiality: RCN Guidance for Occupational Health Nurses, London: RCN. Townsend P. and Davidson N. (1982) Inequalities in Health: the Black Report, Harmondsworth: Penguin. Tracey Cooke v West Yorkshire Probation Board (2004) ET 1800941/04. TUC Worksmart web site, Health at Work section, www.worksmart.org.uk/ health. UKCC (1992) The Scope of Professional Practice, London: UKCC. UKCC (1996) Guidelines for Professional Practice, London: UKCC. UKCC (1999) Fitness for Practice: The UKCC Commission for Nursing and Midwifery Education, London: UKCC. Waddell G. and Burton A.K. (2006) Is Work Good for your Health and WellBeing? London: TSO. Westerholm P., Nilstun T. and Ovretveit J. (2004) Practical Ethics in Occupational Health, Oxford: Radcliffe Medical Press. Whitaker S. and Baranski B. (eds) (2001) The Role of the Occupational Health Nurse in Workplace Health Management, Copenhagen: WHO. WHO (1982) Evaluation of Occupational Health and Industrial Hygiene Services EURO Reports and Studies 56, Geneva: WHO. WHO (2002) Good Practice in Occupational Health Services: a Contribution to Workplace Health, Copenhagen: WHO. Wright F.S. (1919) Industrial Nursing, New York: Macmillan.
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Setting Up Services Anne Kennaugh
Introduction This chapter covers the key points involved in setting up an occupational health service across a range of settings. A standard ‘off-the-shelf’ package cannot be slotted into any organisation – the service will meet the needs of the employer and employee only if care and attention is paid to their particular requirements while implementing the health-related legislation relevant to the workplace in question. A systematic appraisal of the needs of particular organisations is required, which should involve consultation with them. This can be followed by the development of individualised services. A structured approach is essential when setting up a new service or changing the focus of an existing service, and this chapter gives some guidelines and practical suggestions for achieving this. Good diplomacy and communication skills, coupled with expert knowledge and experience are crucial in establishing a successful occupational health service. As organisations become leaner and are affected by rising costs, such as employers’ liability costs, sickness absence and claims on pension funds for early retirement due to ill health, they are beginning to look more critically at their occupational health service: how is it resourced, what is it doing and, most importantly, how is it benefiting the organisation? The occupational health department will increasingly be measured in the same way as any other department within the organisation and will have to demonstrate the quality of the service it provides; the speed with which it delivers its service, i.e. responds to its customers; the dependability with which it delivers the service it has promised; Occupational Health Nursing Edited by K. Oakley. C 2008 John Wiley & Sons, Ltd
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the flexibility that may be demanded to respond to the organisation’s changing needs; and the cost of delivering the service.
Understanding Organisations Most organisations still do not have an occupational health service. Whether you are setting up a new service or changing the focus of an existing one, a structured approach will assist in achieving this. Organisations may vary in size, culture and structure, but the initial approach to establishing the type of occupational health service appropriate to a particular organisation is often the same. Some essential questions need to be asked to ensure that an occupational health service meets the needs of the organisation. What are the business objectives of the organisation? What are the business objectives of individual departments? What are the key health and safety legislation issues? Are there any litigation concerns? How can employee health affect the foregoing? It is also important to understand the culture of the company, along with how it is structured to achieve its objectives. The culture of the organisation affects the style of communication – formal written communications or oral contact; the dress code – formal or casual; decisionmaking – whether through committees and senior management or individuals retaining some autonomy; management style – whether they expect obedience or individual initiative; and so on. The culture is also likely to affect the structure of the organisation; it may have many levels of management or it may have achieved a ‘flat’ structure. Irrespective of the style of structure, it is important for the occupational health professional to understand the lines and levels of communication. As already mentioned, it is important that an occupational health service understands and is subject to the same business criteria as the rest of the organisation. All too often an occupational health nurse can be heard to say: ‘My manager does not understand what occupational health does!’ Should not that nurse instead be asking, ‘Do I understand what the organisation needs?’, it being all too easy simply to implement a programme because ‘it seemed like a good idea’ as it follows the broad principles of occupational health. Therefore, it is essential that the setting up of an occupational health service is carefully planned and communicated. This is equally important whether the organisation is a large multinational or a small local family firm, with the approach remaining the same. One approach discussed in this chapter has separate elements involving five stages: assessment, planning and control, endorsement, implementation and monitoring.
Assessment This is a critical element in the setting-up of an occupational health service, and needs to be carried out by occupational health staff whether
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1. Meet the key personnel on-site and obtain a family tree, e.g. general or senior manager/director; human resources director/manager; health and safety manager; reporting manager; senior management team; trade union convenor; wages/salaries manager; company secretary/legal manager. 2. Obtain a breakdown of the workforce by age, sex, white/blue-collar workers and job category, e.g. display screen equipment workers; fork-lift truck drivers; food handlers. 3. Obtain sickness/absence policy and determine procedures. Specific details should include:
r r r r r r
sickness/absence rate number of employees on long-term absence procedure for frequent short-term absence procedure for return from illness procedure for ill-health retirement procedure for monitoring work-related illness and injuries.
4. Determine current pre-employment procedures. 5. Arrange a site visit to understand the working processes and obtain a list of products on-site. 6. Assess exposure to health hazards and obtain any relevant risk assessments, e.g. under Control of Substances Hazardous to Health and Manual Handling Regulations. Hazards may include:
r r r r r
chemical biological physical mechanical psychosocial.
7. Assess compliance with health and safety legislation and hygiene standards: wearing of personal protective equipment; training; notices. 8. Identify health related benefits provided to employees, e.g. Private Medical Insurance (PMI). 9. Assess first aid facilities. 10. Obtain details of compensation claims against the company for the past ten years. 11. Determine expectations of managers and employees for an occupational health service.
Figure 1.1
Occupational Health Assessment Checklist
they are commencing a new service or taking over or developing an existing one. The staff needs to ascertain where they are now, where they need to be and how they are going to get there. To gain this understanding, many questions need to be asked and a knowledge of the culture of the organisation acquired. This involves much discussion with all areas of the organisation and may be quite time-consuming. It is therefore useful to have a checklist to assist in the process of assessment, and an example can be found in Figure 1.1.
Key Personnel Key personnel must be identified as a priority to ensure that nothing is missed when investigating the needs of the organisation. To assist in this, the construction of a ‘family tree’ of the organisation showing the organisational structure can be an invaluable
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aid; key personnel include the human resources manager, health and safety manager, general manager, reporting manager and union representatives. Initially, close cooperation is likely to be required with the human resources department to investigate the organisation’s health-related policies, and subsequently to operate effective health-related programmes. Such programmes may include policies on smoking, alcohol and drugs, AIDS and health surveillance. An important issue for most organisations is the absence-management policy, and the way this is operated needs to be established. Is there a formal written policy? Who is responsible for managing it – managers or the human resources department? How is occupational health seen in respect of supporting it? Is the practice of proactive intervention supported? Early contact with those responsible for health and safety is also necessary to establish the organisation’s approach to health and safety, the existence of health and safety policies, and to provide access to existing risk assessments under health and safety legislation. It may also be necessary to clarify areas of responsibility, as occasionally these may appear to overlap in the areas of safety and occupational health. For the majority of occupational health services the reporting manager is likely to be within the human resources or health and safety department. In either case it is preferable that this person should be a member of the organisation’s board or have direct access to the board. Discussions with senior and middle managers provide an opportunity to understand the business objectives of the organisation, and to initiate an understanding with the managers about how an occupational health service can benefit them. Similarly, discussions with union representatives promote an understanding of the benefits that an occupational health service brings to their members. Support from all levels of the organisation is crucial for the success of the occupational health service, and the various expectations need to be identified. Other personnel within the organisation may also be able to provide valuable information. The wages and/or salaries manager may shed light on absence-recording issues, whereas someone in the insurance or legal department may be able to advise on compensation claims that have been taken against the organisation by employees. This can be an important measurable benefit to the company, as health programmes can be put in place to minimise the risk of claims; for example, if there are claims for noise-induced deafness it is important to ensure that there is a functioning hearing conservation programme in place.
Structure and Demographics of the Organisation The family tree has already been mentioned as a useful tool for providing the occupational health professional with an understanding of the organisation; however, this needs to be broken down further to obtain information about certain specifics of its profile. The family tree includes
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demographic information such as age, sex and ethnic minority distribution along with the types of workers, i.e. white or blue-collar, and their job categories. Decisions can then be made on the health programmes that will be most suitable and most effective for the organisation, including health surveillance and voluntary health screening programmes. For example, there is little point in investing time and resource in a ‘well-woman’ programme if 95 % of the workforce is male.
Absence Management It is important to understand how the organisation sees the role of human resources, line managers and the occupational health service in this procedure; therefore, the existence of any formal written policies needs to be established before recommendations can be made. Knowledge of specific details includes: absence statistics and procedures for recording absence; procedures for employees reporting absence; procedures for managing employees on long-term absence (e.g. over two or three weeks); procedures for managing employees with frequent short-term absences; procedures for seeing employees returning to work after absence; procedures for ill-health retirement (discussions will likely need to take place with the pensions manager); and procedures for monitoring work-related illness and injury. This is an important area for the involvement of the occupational health service, as it can again provide some measurable benefits to the organisation. However, it also has to be recognised that these benefits cannot be delivered by occupational health alone, but only in cooperation with managers and/or human resources departments. Pre-Employment Procedures An understanding of the organisation’s recruitment procedures is required. In some organisations the process allows forward planning, and the procedure can be well controlled; whereas with others the process may require mass recruitment within 24 hours. The occupational health service must be able to respond to these requirements while ensuring the company is not laying itself open to future litigation related to health issues. Therefore, careful consideration needs to be given to the style of questionnaire to be used, the point at which the prospective employee needs to complete it (before or after a job offer) and who sees it. In addition, the requirement for a full medical examination – depending on whether there are any pension issues involved – or baseline screening needs to be ascertained. Site Visit The occupational health staff needs to have a good understanding of the working processes of the organisation, which can only be gained through visiting all areas of operation with personnel who understand the process and are able to explain it. Through this, an understanding of the extent of machinery and equipment used on-site, along with any products, is gained, and a start made on determining
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the presence of health hazards. Where a site is extensive or contains many different processes it is useful to obtain a site plan. While undertaking site visits, hazard and risk identification may be carried out, along with assessment of compliance with health and safety legislation and good hygiene practice.
Hazard and Risk Identification A structure is provided under the Management of Health and Safety at Work Regulations 1999, which requires all organisations to carry out a general risk assessment to identify health and safety hazards in their workplace. This provides an excellent format for looking in more detail at the health hazards in the workplace and for deciding the requirement for health surveillance, health education and other health programmes. Where risk assessment is not available, the issue of non-compliance must be highlighted to the organisation. The general risk assessment should highlight the need for further detailed risk assessment under other health and safety legislation, including: Control of Substances Hazardous to Health Regulations 2004; Workplace (Health, Safety and Welfare) Regulations 1992; Health and Safety (Display Screen Equipment) Regulations 1992; Provision and Use of Work Equipment Regulations 1998; and Manual Handling Operations Regulations 1992. When carrying out a risk assessment it is necessary first to identify the presence of any hazards, which may be chemical, biological, physical, mechanical or psychosocial. Once the hazards have been determined, the risk of their actually causing harm can be assessed – which is where an in-depth understanding of the products and processes is required. If a risk has been established then a full programme must be instigated, starting with elimination of the hazard where at all practicable. The initial part of the programme is likely to be under the control of safety and/or operations staff – where elimination of the hazard has proved impossible this involves control measures, maintenance of control measures, staff training and the monitoring and recording of training, control and maintenance measures. Generally ‘historical’ hazards such as noise and asbestos are well controlled, but have been replaced by ‘new’ ones such as vibration and stress, for which programmes for control are still being evaluated. Where appropriate, health surveillance is carried out to monitor the health of the employees, which will be managed by occupational health. They may also be involved in training. Compliance with Health and Safety Legislation All qualified occupational health staff must be fully conversant with current health and safety legislation, so that when carrying out an occupational health assessment they are able to identify where there may be non-compliance and to advise management, particularly in respect of health issues.
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Non-compliance may be identified where there is poor hygiene practice, including the non-wearing of personal protective equipment, and lack of warning notices, inadequate training programmes and the absence of risk assessments and safe systems of work. Reporting of work-related illness and injury under RIDDOR (Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995) is likely to require the input of occupational health. It must be ensured, therefore, that the organisation’s procedure for this includes occupational health.
First Aid In many organisations the management of first aid in the workplace is often the responsibility of the occupational health service, so a full assessment of the current facilities and procedures needs to take place, including whether there is a formal first aid policy in existence. The assessment should look at the following areas in relation to the organisation’s full first aid risk assessment required under the Health & Safety (First Aid) Regulations 1981: the numbers and distribution of first aiders; whether all first aiders are in possession of an up-to-date First Aid at Work certificate; the number and location of first aid boxes and eye-irrigation facilities; the contents of the first aid boxes; the location and contents of a first aid room, if this is required; the procedures for recording the treatment of illness and injury; and the procedures for the disposal of casualties. Report Once the assessment is completed, a full report needs to be compiled, which forms the baseline for the service and provides the basis for decisions when producing the occupational health strategy. This remains an important historical document, as it provides findings and makes recommendations that, once priorities have been defined, may have to wait for some time before being implemented if resource is limited.
Planning and Control Some occupational health services within organisations today appear to lack focus, such that resources are often under-utilised or ineffective, leading to a lack of credibility with both senior management and the workforce. This generally derives from a lack of planning and control. Planning is normally the act of setting down expectations of what should happen, whereas control is the process of coping with changes when they occur. After the assessment has been carried out, and a better understanding of the organisation achieved, the planning stage of the approach to setting up an occupational health service can proceed, which aids decisions on the strategy for the service. This is developed by looking at the available resources and deciding on the service requirements and
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SERVICE RESOURCES
Figure 1.2
PLANNING AND CONTROL
SERVICE REQUIREMENTS AND CUSTOMERS
Planning and Control
number and type of customers, so that the service is able to respond to the demand (see Figure 1.2).
Resources This is the most important factor in planning and control, as resources automatically impose constraints on any decision-making. These include numbers of staff, available equipment and the facilities for the occupational health department. When setting up an occupational health service, resources may already have been fixed by the organisation, or else there may be an opportunity to start with a ‘clean sheet’, although the former situation is more common. If this is the case then resources are more likely to influence priorities; however, in the case that there is a ‘clean sheet’, priorities may be able to influence resources. When looking at staffing, the correct skill mix needs to be assessed according to the size and culture of the organisation, the presence of identified hazards, the structure for managing health and safety, and any specific requirements of the organisation. Where there is an occupational health team or an occupational health nurse working in isolation, the nurse in charge will hold an occupational health qualification and, preferably, will have management experience. The occupational health team may be led by the occupational health nurse or an occupational physician, with the rest of the team comprising other qualified occupational health nurses, occupational health nurses in training, clinical nurses, occupational health technicians, physiotherapists and administrative assistants or secretaries. Many services these days are managed by an occupational health nurse, with an occupational physician providing the medical expertise and guidance on policy matters. In the past, services had an emphasis on the delivery of treatment, so many existing occupational health departments have given considerable space to clinical areas. Although there may still be a need for this, in order to be a part of a service the role of treatment has been reduced significantly and thought needs to be given to how to adapt these areas for the delivery of a more proactive service. It is often necessary to convert these facilities to allow for such activities as health screening and surveillance and provide suitable surroundings for counselling sessions, while ensuring that all members of the occupational health team have adequate office provision to allow them to perform their administrative activities effectively. The provision of equipment is of course essential, and appropriate screening tools are required, depending on the findings of the assessment. Often in a manufacturing environment the need for such items
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as sterilising equipment has been superseded by sterilised packs, often used by confident, well-trained first aiders, and specific information technology tools have replaced the need for day sheets.
Information Technology Information technology must be considered as a basic management tool that needs to be used by occupational health services, although there has been nervousness from the medicolegal profession about moving away from hard-copy medical records. Information technology assists the service in producing effective statistics for the monitoring of trends in the health status throughout the organisation, along with achieving a better understanding of the costs and benefits of delivering the service. This provides valuable information to ensure that the service remains focused on the important issues and is able to talk convincingly to management about them. In addition, e-mail has become a basic tool for communication and it is important that all OH personnel have individual e-mail addresses, along with access to the Internet as a valuable source of reference. Priorities The assessment has identified a list of needs associated with health issues in respect of health and safety legislation, litigation concerns and business objectives. Occupational health can cover such a wide area, with all health issues appearing to be of equal importance, that it is easy to fall into the trap of trying to respond to all the needs as they present themselves. The danger of this, of course, is that nothing is delivered effectively, leaving management confused as to the value of the service that it is receiving. While acknowledging the extent of the issues that need to be addressed, it is now necessary to prioritise according to the importance of the impact each will have on the organisation. This is why it is essential for the occupational health service to understand the business objectives of the organisation, so that it can focus its activities to respond to these and avoid working in isolation from the rest of the company. In order to set the objectives for the service, therefore, the questions that again need to be asked are: Where are we now? Where do we want to be? How do we get there? Setting Policies and Procedures Once the priorities have been decided, policies need to be set for the occupational health service so that the occupational health team, management and workforce are clear on what the service is aiming to achieve. Policies are likely to be set for such areas as fitness-for-work health screening – including pre-employment health assessment; health surveillance – for employees exposed to health hazards; case management of ‘ill’ employees – to provide advice to human resources/line managers on their effective return to work; first aid – to ensure compliance with legislation; counselling – to enable a
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response to employees’ concerns; and health promotion – to promote employee awareness relating to health issues. The above list is not definitive, and the policies included will depend on the identified priorities or objectives. Each document should include an explanation of why it is included, what it is going to do and how it is going to do it (see Figure 1.3). It should be written in such a way that it is suitable for general distribution throughout the organisation if this is desired. Finally, it is important that policies are discussed and agreed to by key personnel within the company before being implemented. In addition to policies, protocols and standards for delivery need to be agreed. Standards identify how occupational health activities are to be carried out and protocols determine what needs to be done given a specific set of circumstances. For example, vision screening may be available and a protocol needs to ascertain under what circumstances it will be carried out and what constitutes an unacceptable level requiring referral to a specialist, for example an optician, occupational physician or the individual’s GP. Indeed, there may be levels at which an employee can no longer continue in his or her present position. Consistency in approach is important, to ensure accurate advice is given to employees and to avoid the confusion of two employees with the same results being given different advice. How the analysis is carried out is also important, as it will be worthless if the data collected have not been gathered using a systematic or consistent method (this subject is covered in detail in Chapter 2).
Programme The activities of the occupational health service have now been agreed and resources have been identified. The next stage is to devise a programme that enables staff to visualise the purpose of the service – necessary for any successful endeavour – and ensures that the standards are achieved. Many strategists will promote the need to remain focused on long-term objectives, but although this is important for remembering the lower priorities that may not be addressed immediately, the majority of occupational health services are judged on short-term achievements. Twelve months is felt to be the most acceptable time span to meet this criterion and to maintain the motivation of the occupational health staff by setting them achievable targets. The programme must specify clearly what needs to be achieved, while maintaining flexibility in delivery to allow for any change of requirements within the organisation. This subject is discussed in more detail in Chapter 3 and a sample programme is illustrated in Figure 3.6. It is important that a system be set up to monitor the results of the programme, check the effectiveness of the implementation and see how it has coped with short-term changes in circumstance. This is covered more fully later in the chapter.
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Fork Lift Truck (FLT) Purpose The health assessment will be to ensure that persons selected to operate fork lift trucks are free from physical and mental defects that might pose a threat to their own health and safety and the health and safety of others. Frequency r on appointment (minimum age 17) r age 40, 45, 50, 55, 60, 65 r annually after 65 r after sickness exceeding four weeks (or shorter if illness is significant in the operation of FLT) r when the operator or manager is concerned about fitness to operate FLT. Documentation r OH8 Lift Truck Operators Health Questionnaire to be completed by individual r OH13 Audiometry Questionnaire if indicated r OH3 Medical Examination Form to be completed by OHA r OH4 Fitness for Work Assessment Form to be completed by OHA. Assessment Preliminary assessment to complete OH3 questionnaire: r general assessment r urinalysis r visual acuity r depth perception r audiogram if indicated – need to hear alarms r mobility assessment. Medical Referral Criteria Visual Acuity: The minimum standard required for vocational driving is: r uncorrected – no worse than 3/60 in each eye for driving r corrected – no worse than 6/9 in one eye and 6/12 in the other eye r applicant must have binocular vision r colour vision should be normal but failure will not preclude individual from work that allows positional recognition of light signals. Health Fitness: The BMI of the individual should not normally exceed 30. Individuals with a BMI of 31–35 with any associated medical abnormality should be referred to the medical officer. Urinalysis: Screening of urine for pre-employment purposes is usually done to gather information about the physical status of the person being screened. Any positive results should be referred as per WI 001–Urinalysis. A decision on fitness may need to be deferred until the results of further investigations are known. Other Conditions: Referral to the medical officer is required: r after detection of any abnormality which could result in sudden loss of consciousness, impaired concentration or impaired exercise tolerance r pre or post declaration of any sickness absence/hospital admission/treatment which affects mobility, sight, hearing, cardiovascular fitness or central nervous systems function r if there is any concern by management r after accident or incident. Record OH4 Fitness for Work Assessment form to be sent to the individual’s line manager. Standards HSE publication HS(G)6 Safety in Working with Lift Trucks.
Figure 1.3
An Example of an Occupational Health Standard
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Education and Training Requirements While the strategy of the occupational health service is being developed, the training requirements of the occupational health staff must also be assessed to ensure that the correct level of expertise and skill-mix is achieved. It is important that services have nursing staff with a high level of knowledge of occupational health, which is normally gained through undergoing a course of training resulting in an occupational health nursing qualification. However, it may not be necessary for all staff to have this level of expertise, as nurses without an occupational health qualification can be trained up in certain skills and work under the supervision of a qualified occupational health nurse. The skills required by an occupational health nurse are many and varied, and can include computer skills, presentation skills, use of specialised equipment such as audiometers and spirometers, along with good communication and organisational skills. All nurses must remember their responsibilities under the NMC’s Code of Professional Conduct (2004), which requires individual nurses ‘to acknowledge the limits of your professional competence and only undertake practice and accept responsibilities for those activities in which you are competent.’ Where knowledge and competence are issues, it is likely that employers will expect the nurse to resolve these. Communications This is a critical issue for any department, not least for the occupational health service. During the assessment a knowledge of the structure of the organisation will have been obtained, which will aid the occupational health staff in identifying the key people who should be informed in a variety of situations, including project work, policy implementation, incident investigation and feedback on the implications of an individual employee’s state of health. Poor communications can, and often do, lead to misunderstanding and misconception of what the service is trying to achieve. Some extra time spent ensuring that people understand what is going to happen and listening to their comments can save considerable effort at a later date trying to recover credibility lost through poor communication. It is the belief of this writer that, where at all possible, the vast majority of communications should be made verbally in the first instance, followed by written confirmation.
Endorsement This, again, is an important stage in the setting-up process of an occupational health service. In order to implement either a new service or a change in service it is important that people are persuaded to support it. Whole books have been written and full training courses run on the management of change and suffice it to say here that, in relation to setting up an occupational health service, if it is to be successful, endorsement must be addressed as part of the implementation process.
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Those whose support is needed must be identified, and these will vary from organisation to organisation, to a large extent depending on the culture of the organisation. Generally speaking, the key personnel whose support is required are senior management, those who provide the service and those for whom the service is provided.
Senior Management Senior management’s endorsement is important, not only because it is they who hold the purse strings but because they set the organisation’s overall objectives. When the organisation is setting these objectives, occupational health strategy needs to demonstrate how it can support and contribute to their achievement so that it becomes an integral part of the organisation’s strategy. Careful planning is needed to demonstrate the long-term financial benefits that can be brought to an organisation through an effective occupational health service. Providers It is important to consult all those involved in the delivery of the service at the planning stage, if their commitment is to be gained. Along with personnel in the occupational health department itself, others include those where close liaison is necessary for certain aspects of management, for example health and safety personnel where compliance with legislation is an issue, or human resources personnel where support on absence management is required. It hardly needs to be said that if people are not convinced of the value of what they are doing then they are likely to be less than effective. Recipients of the Service Finally, those who are going to receive the benefit of the service must believe it is worth having or else it is likely to be a non-starter. Middle management and supervisors also have their targets to achieve and they need to be shown how occupational health can support them. This may not be obvious to managers if there is a low emphasis on health and safety issues and their targets are based solely on the number of products they produce in a day. However, if there is a high incidence of accidents or absence in the department then this can be related to productivity levels and the need for support in managing accidents and absence can be shown. Hence the original requirement to understand the organisation’s overall and departmental business objectives before setting the occupational health strategy. The employees must also feel it will be a benefit to them – it is no use preparing a sophisticated health screening programme if no one attends it. The unions are generally supportive of health and safety programmes, and again every opportunity should be given for consultation and communication on proposed occupational health activities.
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Implementation The success of the implementation process largely depends on how well the assessment, planning and endorsement processes have been carried out; indeed, it commences with the endorsement process by ensuring that everyone is aware of what is involved in the occupational health service, how they can use it and what benefits they can gain from it. Presentations at various committee meetings and management meetings are the most likely means of achieving this. The launch of the occupational health service may also be assisted by an advertising campaign, which could involve a special issue of the organisation’s newsletter, posters (it is particularly useful if it is a new service to print photographs of the occupational health staff) or e-mail (or equivalent) notices. The in-house newsletter is particularly useful for ongoing communications, as is an OH web site on an organisation’s intranet.
Monitoring When setting up an occupational health service, a system for monitoring how the implementation process is progressing must be addressed to ensure that the overall agreed objectives are being achieved. Management often looks for performance measures to assess the achievements of the occupational health service. In a proactive service this can be difficult to demonstrate, as a successful service may minimise the number of problems being found. However, this should not deter a service from establishing a system to demonstrate its achievements. Management needs to be aware of what the implications could be if the correct occupational health programme were not in place. This needs to be identified and documented when the initial assessment takes place. An example of this would be an organisation with noise levels above 80 dB(A) LEPd failing to implement a hearing conservation programme, including health surveillance where noise levels exceed 85 dB(A) LEPd, which could leave them exposed to claims from employees for noiseinduced deafness. Therefore, with the occupational health requirements for the organisation having been established and the priorities identified, the objectives and subsequent standards for the service can be set and a programme for delivery planned. A report for management on the progress of the service should be made at regular intervals, and it is recommended that this is at least six-monthly, with a full report on the occupational health status of the organisation annually. While recording the achievements of the service, these reports should also highlight any problems that require intervention and procedures that could be improved, with recommendations for action.
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Where possible, specific data should be analysed to demonstrate the progress of managed programmes; for example, an audiometry programme would identify the number of employees showing continued deterioration in their hearing levels. It is expected that where there is a well-regulated hearing conservation programme in place, these numbers would decline, and possibly achieve zero. Other performance measures depend on the available statistics, with the main focus being on absence rates and causes, and compensation claims. Specific performance measures can also demonstrate the effectiveness of the occupational health service, giving an indication of the service’s ability to respond promptly. This may take the form of guaranteeing a response to pre-employment health screening or a management referral within a specified time.
Conclusion The setting up of an occupational health service therefore requires several steps. These should include the carrying out of an assessment, identification of priorities, careful planning of the occupational health strategy, taking account of the structure and culture of the organisation, setting of policies, procedures and standards, arranging the programme for delivery, obtaining endorsement from key personnel within the organisation and monitoring the implementation of the programme to ensure that the organisation is getting what it expected. The structured approach and attention to detail in setting up a service will pay dividends, resulting in the establishment of high-quality, responsive and successful occupational health services.
References and Further Reading HSE (1981) First Aid at Work Health and Safety (First Aid) Regulations. HSE (1992a) Manual Handling Operations Regulations (as amended). HSE (1992b) The Health and Safety (Display Screen Equipment) Regulations (as amended). HSE (1992c) Personal Protective Equipment at Work Regulations (as amended). HSE (1992d) The Management of Health and Safety at Work Regulations (as amended). HSE (1992e) Workplace (Health, Safety and Welfare) Regulations. HSE (1995) The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations. RIDDOR web site: www.riddor.gov.uk. HSE (1998) The Provision and Use of Work Equipment Regulations (PUWER). HSE (2004) Control of Substances Hazardous to Health Regulations, London: HSE. HSE (2005) Guidance for Employers on the Control of Noise at Work Regulations www.hse.gov.uk/pubns/indg362.pdf.
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Humphrey J. and Smith P. (1991) Looking After Corporate Health, London: Pitman Publishing. Johnson G. and Scholes K. (1993) Exploring Corporate Strategy, Text and Cases, Hemel Hempstead: Prentice Hall International. NMC (2004) The NMC Code of Conduct: Standards for Conduct, Performance and Ethics July 2004, www.nmc-uk.org/aFramedisplay.aspx? documentID= 201. Slack N., Chambers S., Harland C., Harrison A. and Johnston R. (1995) Operations Management, London: Pitman Publishing.
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Writing Policies and Procedures Andrea Mummery and Katie Oakley
Introduction The main focus of this chapter is on making policies and procedures into working tools to improve an occupational health service. It looks at the rationale for having policy and procedure documents and defines the terms. It gives guidance on how to write them and also makes reference to the use of standards to audit policies. Practical examples are referred to and samples included.
Defining the Terms We start by defining the terms, as this in itself can cause confusion. Terms such as guidelines, standards, policies, protocols and procedures are used sometimes interchangeably and so a useful starting point is a dictionary definition (Concise Oxford Dictionary 1995) of these terms: Policy: ‘a course or principle of action adopted or proposed by a government, party, business or individual, etc.’ Procedure: ‘a series of actions conducted in a certain order or manner.’ Protocol: ‘the rules, formalities, of any procedure, group, etc.’ Guideline: ‘a principle or criterion guiding or directing action.’ Standard: ‘an object or quality or measure serving as a basis or example or principle to which others conform or should conform or by which the accuracy or quality of others is judged.’
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No wonder people find the terminology confusing. The word ‘principle’ is a common theme in the above definitions of policy, guideline and standard and is defined as ‘a fundamental truth or law as the basis of reasoning or action’ (Concise Oxford Dictionary 1995). There are many competing demands needing attention, many opinions and different ways of working, and in order to do ‘what is best’ it makes sense to write policies and ensure that they are implemented and updated. The policy acts as the statement of intent and the procedures linked to the policy give details on how it will be implemented. Standards are derived from policy and provide the link between the policy and the procedure. An example of a standard is given in Figure 1.3. Standards are also used to audit policy and are discussed in detail in Chapter 4. ‘Protocol’ is an American term often used instead of procedure and is so similar that we shall not use it (except when quoting other authors). We decided to restrict ourselves to the terms policy, standard and procedure, as these are all we need in a practical sense when running an occupational health service.
Why Have Policies and Procedures? Occupational health plays an important role in helping create a safe and healthy working environment but it is rarely a core function within a business. Occupational health nurses will need to demonstrate the contribution and value the service brings. Written policies and procedures, which are linked to the business needs, play a clear role in this process. They provide a framework in which to operate and enable nurses to know what they are expected to do in various situations. Once written, they can be audited and their effectiveness evaluated to further improve the service. Some occupational health nurses work without policies and procedures – perhaps they are sole practitioners and feel they do not need them, and can use their experience to make decisions. Maybe they work for large occupational health service providers where there has been a reluctance to write things down for commercial reasons. Perhaps they are reluctant to commit to paper where they feel there is not sufficient ‘evidence-based’ research behind the topic in question. Some occupational health nurses contribute towards policies and procedures ‘owned’ by others in the organisation, such as human resources (HR), but fail to have local procedures for the aspect of work that is solely in the occupational health domain. For example, they may help HR write a recruitment and selection policy for the company which states that all staff will have pre-employment health screening, but not have an internal written procedure detailing how the occupational health service will carry out this screening.
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Nurses working without policies and procedures place themselves in a vulnerable position from a medico-legal perspective and also from a clinical perspective. Tingle (1995) argues that ‘Legal advantages can be gained from adopting guidelines and protocols. Their presence in the care environment shows that health care professionals have thought proactively about the care they give and there is written evidence of the standard of care. Guidelines and protocols can also help avoid one of the principal causes of healthcare litigation: communication failure.’ The author goes on to caution, however, that, ‘They should not be applied slavishly or automatically and they are no substitute for professional judgement. The nurse owes the patient an individual legal duty of care and each case requires an individual assessment.’ The dilemma between following procedures rigidly and using professional judgement will occur occasionally, although less frequently if the policies, standards and procedures are well written. The nurse is professionally accountable for their actions and must be able to demonstrate that they have explored all the possible options and can justify the reasons for a clinical decision. It is particularly important to document clearly in the occupational health records why a course of action has been followed, especially if it is different from standard practice.
Clinical Effectiveness In occupational health nursing, as in other nursing disciplines, we are aiming for clinical effectiveness, and working with good policies and procedures helps us to achieve this. ‘Clinical effectiveness is about doing the right thing in the right way for the right patient at the right time. This involves getting evidence of what works into everyday clinical practice and evaluating its effect on patient care’ (RCN 1996 p. 3).
So Where Do We Start? Occupational health policies should be based on detailed knowledge of the subject matter, but also take into account the operating environment. To be successful they need to be practical and realistic. Guidelines can help policy formation in relation to occupational health nursing and are likely to come from professional bodies, textbooks and nursing journals. Such guidelines are developed following expert consultation and a systematic review of research findings. In legal settings, to help decide what is reasonable, courts will look at what is common practice amongst similar organisations. This is something that occupational health nurses can do to determine best practice
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when formulating policy. This process, known as benchmarking, is one that the lone practitioner may find of particular value, even if it just serves to reassure them that their current practice is correct. It can, however, be difficult to achieve in competitive environments, where occupational health colleagues may be reluctant to share information. Avoiding professional isolation and ensuring that one keeps up to date is a particular challenge for the lone occupational health nurse, who will have to actively look for opportunities to ensure their practice is not outdated. Nursing groups such as the Association of Occupational Health Nurse Practitioners (AOHNP(UK)) and the Royal College of Nursing (RCN OH Forums) provide a good means for networking and sharing best practice.
Are There Any Disadvantages in Having Policies and Procedures? The main perceived disadvantages of having written policies, standards and procedures are that they could encroach on the qualified nurse using their professional judgement and that they do not allow sufficient input from the clients (employers and employees) or a tailoring of service to the individual. These criticisms, however, really apply only to poorly written or inadequate policies, standards and procedures. Another criticism of writing policies, standards and procedures is that the process is time consuming and takes the nurse away from providing a service. It is true that good documents take time to prepare and that not all nurses are confident in writing such documents but these are not valid arguments. In many working environments there will be help available in formulating policy; this may come from other occupational health nurses, the occupational health physician, the HR department, training and development departments, etc. Some larger organisations run management training programmes, which, although not specific to occupational health, will help the occupational health practitioner develop necessary skills and cover issues such as research, quality and audit skills. If in-house courses are not available, a number of companies provide short courses. Some feel it is difficult to write policies, standards and procedures where there is no evidence base available. Evidence should be used where it is available but in its absence the nurse should continue with producing documents. Indeed, there has been some criticism of an overemphasis on the evidence-based approach. Illingworth (1999) says: ‘Evidence based cost cutting will not bring about a more compassionate and caring profession. The challenge of demonstrating that nursing is a scientific discipline is still one many are taking up. But I believe it is wrong. Some qualitative feedback from
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the service users is needed . . .We can, however, use qualitative methods to seek users’ opinions and perceptions. This is the evidence to use in nursing education, practice, research and service development.’ He was writing in relation to mental health nursing, but the ideas could equally apply to occupational health nursing. Not having the evidence base is no reason to avoid writing documents. It does not make sense just to work as individuals doing things the way we think best, without audit or review to check that we are achieving what we set out to do and that it meets our clients’ needs. Smith et al. (2001 pp. 184–5) also argue that other factors apart from evidence-based thinking need to be taken into consideration in policy making. Referring to social changes in the 19th century, they say: with an evaluation group implementation of the Factory Acts could have been resisted since there was a lack of evidence, for example from ‘controlled intervention studies showing the health benefits of e.g. stopping children under 9 from working in cotton mills . . .’
How to Produce the Documents So how do we start writing documents for use by an occupational health nurse? Some possible steps are displayed in Figure 2.1 and described below. STEP 1: Identify Priorities Agree list of policies and procedures (link with risk assessment) Prioritise Agree a lead person for each Issue interim guidance notes if necessary
STEP 2: Research Literature search Consultation with multidisciplinary experts as necessary STEP 3: Format Agree format Draft
Figure 2.1
Framework for Producing Documents
STEP 5: Documentation Control System Authorise Implement under documentation control system STEP 4: Consultation Send out for comment Redraft/reconsult as necessary
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Job-specific fitness standards Health interview procedure and associated forms, e.g.
r r r r
Pre-employment health questionnaire form Food handlers’ questionnaire Health interview record form Request for information from former occupational health department form
Sample letter requesting medical report Consent form for medical report Letter to manager (pending GP reply) Pre-employment health screen report form Occupational health notes record sheet Occupational health notes record continuation sheet Standard for referral to occupational health physician Note: There may be other documents that relate to the pre-employment process depending on the industry, e.g. health surveillance and immunisation policies, standards and procedures
Figure 2.2 Sample Section from an Occupational Health Operational Manual Showing Documents Relating to Pre-Employment Health Assessment
Step 1: Identify Priorities Agree the list of policies, standards and procedures that need to be written, prioritise them and identify who will take the lead for each. A sample section taken from an occupational health operational manual (Figure 2.2) illustrates examples of documents relating to one area of occupational health practice. It may be that the senior nurse or occupational health physician takes the lead, or else a member of the team with specialist knowledge or a particular interest in a subject matter. It is important that the person who takes the lead controls the process, even though the work itself may be shared amongst others in the team. A useful way of prioritising policies in occupational health nursing is to link in with risk assessments. Where a high risk is identified, documents on how to control the risk should follow. Compliance with legislation will also help to prioritise the work. Where there are many conflicting priorities, it may be necessary to produce some brief guidance notes on key subject areas that can be used to help promote consistency of service delivery while the more detailed policies and procedures are being written and authorised.
Step 2: Research Carry out any necessary research. This may involve a literature review and asking experts in the field or related disciplines for their opinion. Examples of those whom you may wish to consult include other members of the occupational health team, health and safety experts,
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Examples of external sources of information:
Examples of internal sources of information:
The Internet, voluntary body publications, newspaper articles, professional journals, research projects, professional body publications, health service circulars or guidance notes, codes of practice, national guidelines, NICE and SIGN, legislation, case reports, clinical examples, systematic reviews, randomised controlled trials.
Accident statistics, incidents and near misses, complaints, client feedback, sickness absence data, staff turnover rates, litigation/tribunals, PHI, ill-health retirements, internal projects.
Figure 2.3
Sources of Information in Relation to Step 2
occupational hygienists, environmental health officers, microbiologists, etc. Consulting and involving all concerned takes time but the benefits should not be underestimated, especially the benefit of involving other members of the occupational health team, who will often be able to make a significant contribution and are likely to be more committed to the final document. The literature review should be broad. There are many sources of information; examples are given in Figure 2.3. Care needs to be taken to ensure that any information used is from a reliable source. The task can appear quite daunting. Clearly not every policy will require extensive research; however, the examples are intended to help the reader think about the sources of information that might, in the wider context, be relevant to their subject matter.
Step 3: Format Agree the format for the documents (in line with the organisational house style if necessary) and be consistent in applying it. Attention must be paid to the wording of documents; statements should be clear and not open to misinterpretation (Figure 2.4). We have already established that policies may at times come under scrutiny in industrial tribunals or courts and the wording of the policy may make a considerable difference to the outcome of a case. For example, the case of Angus Council v Edgely highlights the dangers of an employer’s failure to apply a policy on alcohol abuse to an employee. Edgely was dismissed through the disciplinary procedure because of a longstanding alcohol problem. He was not given the opportunity to seek diagnosis and specialist help as he was supposed to under the council’s policy. The wording of the policy was crucial. It stated that where a person was found to have an alcohol problem he/she would (not may or might) be given the opportunity of assessment and treatment, pending which the disciplinary process would be suspended. The tribunal held that the council’s policy on alcohol abuse lay at the heart of the case and its failure to apply its own policy was a factor that entitled the tribunal
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Title: Name of document. Number: Number. Policy Statement/Purpose: This is where the policy statement is made or the reason for the procedure is given; it may only need to be one or two lines or may extend to an explanatory paragraph. Example: ‘This procedure describes the arrangements for managing a case of acute anaphylaxis following vaccination.’ Example: ‘This policy explains how the organisation will comply with Department of Health Guidelines on protecting health care workers and patients against hepatitis B. It will ensure, so far as possible, that health care workers who may be at risk of acquiring hepatitis B infection during the course of their occupation are protected by immunisation and that as far as possible patients are protected against the risk of acquiring hepatitis B from an infected health care worker.’ Scope: To whom does this procedure apply? Is it just the occupational health nurses, or is it wider than that? Example: ‘This procedure applies to all occupational health nurses who have demonstrated their competence to give vaccinations and have the appropriate written instructions.’ Example: ‘This policy applies to all health care workers who provide direct patient care.’ Definitions: Explain the terms used in the document and any abbreviations that you may wish to use. Accountabilities: Explain who is responsible for what, e.g. the occupational health nurse/doctor’s responsibilities, the manager’s responsibilities, the employees’ responsibilities. Policy or Procedure Detail: This is where the body of the policy or procedure is included and explains how the purpose will be achieved. It does not have to be lengthy and may refer to other documents. Example: ‘All clinical staff will have their hepatitis B status checked on employment and will be offered vaccination as appropriate. See procedure no. X for details on safe administration of vaccines.’ References: Give details of all references used. Include references to other in-house documents as necessary. Appendices: Attach any related documents or flow charts as appendices. Name of Author: All policies should have the author identified; this may be by department, named individual or both. Date: It is important to include the date and the revision number. Authorised By: Include the name of the person who has approved the policy/procedure with signature and date. Review Date Due: Most policies are reviewed annually, unless there is a specific reason to do so sooner.
Figure 2.4
Suggested Format for Writing a Policy or Procedure
to conclude that the dismissal was unfair. This case demonstrates not only the importance of the wording of the policy, but also the problems that can occur when a policy is not followed.
Step 4: Consultation The documents should be sent out in draft form for consultation and comment, with a cut-off date for return of written comments. This is much better than telephone comments as the contributions can all be
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kept and compiled for future reference. Consider the validity of comments received, take further advice if necessary and amend the document. Send the second draft out for comment, with a new deadline. When the document is finalised it must be authorised and distributed. All policies and related documents should be dated, and a version number and the author’s name added. Before becoming operational, policies will need to be authorised. Some organisations may also want to authorise the related procedures but this will depend on local arrangements. Authorisation may be a simple matter of agreeing internally an implementation date. However, in many cases where the policy impacts on others in the organisation or where there are financial implications, ratification may be required by someone at a senior level such as a director, or by a committee with responsibility for an area of work, for example a health and safety committee. All documents should be reviewed on a regular basis; annual reviews are standard unless circumstances necessitate a change sooner, for example the publication of new national guidelines that affect practice. When documents are reviewed, even if no change to the text has been made, the date of the review should be added.
Step 5: Documentation Control System It is important to ensure that there is a robust system in place for document control. There may already be established systems in place within an organisation. If there are no such company-wide initiatives, the occupational health service must develop a local procedure. This applies regardless of the size of the occupational health service, but is especially important where nurses are working in a peripatetic environment or where there are multiple sites. The system must ensure that when new policies, standards or procedures are properly issued, all superseded documents are withdrawn. There should be nominated people responsible for reviewing documents (usually the author) and distributing them. Within one national occupational health service, for example, the senior nurse required the nurses at each site to sign and return a simple document acknowledgement form stating that they had received an updated document and destroyed the old one. A master copy was retained at head office for possible future reference, together with the distribution lists and signed acknowledgement forms. There are a number of computerbased systems now available to help with document control. These systems usually incorporate a system for logging that documents have been received and also ensure that old versions of documents are removed and archived. It is useful to have whatever system is used explained in the foreword in an occupational health operational manual (Figure 2.5).
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1. Introduction This manual has been produced by ............. All policies and procedures have been approved by the team of occupational health nurses. The aim is to provide guidance to occupational health nurses and a consistent approach across the service. 2. Forms and Checklists Forms and checklists have been provided where appropriate and may be copied and used on all sites. The pre-employment health questionnaire forms are available from ............. 3. Issue, Revision and Control Controlled copies of the manual are numbered and a register of the holders is retained by ............. Revisions and re-issues to the manual are distributed by ............. All registered holders of the manual are responsible for updating the manual assigned to them and for destroying obsolete copies. 4. Transmittal Note All amendments will be forwarded to each registered holder under the control of a transmittal note system. The holder will be responsible for returning the transmittal note to ............., confirming safe receipt and that the amendments have been made to the manual. 5. Review The Occupational Health Policy and Procedure Manual will be reviewed on a quarterly basis by ............. to ensure that the information it contains is relevant and up to date. 6. Improvements/Suggestions Please contact ............. if you have any suggestions for improvement of this manual or if there is a subject that has not been covered.
Figure 2.5 Manual
Sample Foreword from an Occupational Health Policy and Procedure
It is important that master copies of old policies, standards and procedures are kept, although they need to be clearly dated to show when they have been taken out of use to ensure that they cannot accidentally be confused with the current document. Evidence of old documents may be required in tribunals or courts. Staff who make claims against their employer may do so several years after an injury, and the occupational health service may be required to produce evidence of practice at the time. For example, a manual handling policy which precedes the Manual Handling Operations Regulations 1992 may be very different from the type of policy in place today, but may have been acceptable practice with the knowledge available at the time. The court, however, will be able to make that judgement only by seeing the evidence of the working arrangements at the time of the injury. IT systems are used to distribute documents, either through access to shared drives or through e-mail. While this is a quick and effective way of distributing information and enables updates to be incorporated easily, it is important to ensure that every member of the workforce who needs a document has computer access and the necessary computer skills to enable them to read it. It is also important to make such policies readonly, so that only authorised individuals can change the text. Computer policies must also be stored for possible future reference.
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Sample Policy: Confidentiality Confidentiality is crucial to occupational health nursing and the confidential handling of health and personal data has been described as one of the top five functions of occupational health nursing (Ballard 2006). We have therefore included sample documents as an appendix, which are being used effectively, and are presented here as templates that can be adapted to meet individual needs.
Conclusion In this chapter we have discussed the reasons why policies, standards and procedures are necessary, have looked at the importance of the wording of such documents and have discussed in detail how to produce, authorise and distribute them. Good occupational health practice begins with the development of such documents, which, if correctly implemented, help to ensure that a high-quality occupational health service is delivered.
References and Further Reading Angus Council v Edgely, IDF 647. Ballard J. (2006) Delivering OH Services Part 2: Nursing Competence and Performance Indicators, Occupational Health (at Work) 2(6). The British Occupational Health Research Foundation web site, www.bohrf. org.uk. The Cochrane Database web site (occupational health section), www.cohf.fi. Dale A.E. (2006) Determining Guiding Principles for Evidence Based Practice, Nursing Standard 20(25), 410–46. HSE (1992) Manual Handling Operations Regulations (as amended). Illingworth P. (1999) Nursing Times, 95(38), 27–8. NHS Executive (1996) Promoting Clinical Effectiveness: a Framework for Action in and through the NHS, Heywood, Lancs: BAPS Health Publications Unit. National Institute of Health and Clinical Excellence web site, www.nice.org.uk. RCN (1996) Clinical Effectiveness: an RCN Guide, London: RCN. Scottish Intercollegiate Guideline Network (SIGN) web site, www.sign.ac.uk. Smith G.D., Ebrahim S. and Frankel S. (2001) How Policy Informs the Evidence: ‘Evidence Based Thinking can Lead to Debased Policy Making’, British Medical Journal, 7280, 184–5. Tingle J. (1995) Clinical Protocols and the Law, Nursing Times, 91(29), 27–8. Verbeek J. and van Dijk F. (eds) (2006) A Practical Guide for the Use of Research information to Improve the Quality of Occupational Health Practice: for Occupational and Public Health Professionals, Protecting Workers’ Health Series Number 7, Geneva: WHO.
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Appendix 2.1: Occupational Health Confidentiality: Sample Policy 1 Introduction Occupational health (OH) nurses have a legal duty to ensure that any personal or sensitive data obtained during the course of their work are treated confidentially. This policy and associated standard operating procedure (SOP) explains the principles surrounding confidentiality and provides guidance for OH nurses in relation to disclosure of confidential information. It is not possible to cover every aspect of confidentiality within this document and therefore references are given to supporting documents where further detailed guidance and examples of case law can be found.
2 Scope This policy applies to all staff working within occupational health.
3 Policy 3.1 OH staff will ensure that personal or sensitive data obtained during the course of their work are treated confidentially. 3.2 Only required information should be collected and it must only be used for the purpose for which it is obtained, e.g. information gained for the purposes of pre-employment screening cannot be used for another purpose (e.g. insurance, pension, legal claims) without permission of the individual. 3.3 Medical information contained within occupational health records must not be disclosed to third parties including managers, human resources or health care professionals outside the OH team without the permission of the individual, except in exceptional circumstances. Guidance on releasing information is given in standing operating procedure (SOP) 1. 3.4 OH records must be stored securely and access to records restricted to OH staff. OH administrative support is not usually provided within the company, however where administrative support is provided, staff must be made aware of their responsibility and asked to sign a declaration not to disclose information to anyone outside of the OH team. 3.5 If the OH nurse/provider should change, arrangements for the secure transfer of OH records must be in place. Guidance is given in SOP1.
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3.6 To prevent unnecessary duplication and to allow continuity of care, if staff during the course of their employment move sites within the company, their OH records will be transferred to the OH nurse at the new location. As this is a transfer of information within the OH team, individual consent is not required. 3.7 Records are archived when an individual leaves the companies’ employ. Archive records must be kept securely for a minimum of eight years unless there is a requirement to keep them longer, e.g. health records made under the Control of Substances Hazardous to Health Regulations should be kept for 40 years after the last entry. OH nurses should develop written procedures regarding the local arrangements for secure storage of archived records, especially if they are to be stored off-site or transferred to microfilm, CD, etc.
4 Legal Framework There are several key pieces of legislation that deal with confidentiality and disclosure with which OH nurses must ensure that they are familiar. A brief outline of the legislation is given in Appendix 2.3. Detailed guidance on the interpretation of the legislation can be found in the documents listed in the References.
5 Ownership of OH Records OH records are the property of the company. However, there is a clear distinction between ownership of records and control over their content. The information contained within the OH record belongs to the OH nurse/doctor making the record. In data protection this is referred to as the ‘data controller’. The data controller has a duty to protect the confidentiality of the data subject, the employee.
6 References DoH (2002) National Minimal Standards and Regulations for Independent Health Care. DoH (2003) Confidentiality: NHS Code of Practice. Faculty of Occupational Medicine (1999) Guidance on Ethics for Occupational Physicians, 5th edn. Healthcare Commission (2005) Code of Practice on Confidential Personal Information. Kloss, D. (2005) Occupational Health Law, 4th edn, Blackwell Publishing. RCN (2003) Confidentiality: RCN Guidance for Occupational Health, publication code 002043.
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Appendix 2.2: SOP1: Guidance on Disclosing Occupational Health Records Staff Access to Their Own OH Records Staff have the right to view or have copies of any information held within their own OH file providing the information does not disclose information about a third party. If a third party can be identified then that person’s permission should also be sought. This does not apply when the third person is another health care professional involved in the individual’s care, unless disclosure is likely to cause serious harm to that health professional’s physical or mental health. A request by an employee to view their OH file must be arranged by appointment. On arrival at OH the employee must provide proof of identity, including a signature which can be compared to the signature on their health questionnaire. Viewing of any medical information held on file will be under supervision of the OH nurse or doctor. There is no charge made for viewing their record. A request for a copy of the file or a report held within their file must be in writing and signed by the employee (with a printed name below). It should also indicate their date of birth, job title and the address where the information is to be sent. A charge of up to £ 10 can be made to staff wishing to receive copies of their OH record. Requests to view or have copies of OH records should be dealt with in a reasonable time frame, which should not usually exceed 40 days.
Disclosing Information with Consent to a Third Party An employee may request that OH sends information from their OH file to a third party such as a solicitor or another OH provider. Information will only be sent with the employee’s written consent, stating what information is to be sent and to whom. The consent must include their name printed, their signature, their date of birth and the name and address of the person to whom the information is to be sent. The OH nurse will only release the records when they have satisfied themselves that the consent is that of the individual concerned. Information will not be released if authorisation is in the form of a photocopy or faxed authorisation; an original signature is required. On occasions human resources or line managers may request access to an individual’s occupational health record, perhaps as part of an investigative hearing. The person requesting the information must obtain the individual’s written consent before information can be disclosed.
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What Information Can Occupational Health Nurses Share? The following areas of OH nurses’ work are not confidential, providing medical information is not included in the reports:
r r r r
Issuing of fitness-to-work certificates. Giving advice about work adjustments. Confirming attendance at an OH appointment. Confirming inclusion in or attendance at a health surveillance programme.
During OH assessments the OH nurse may be given information that they would like to share with a line manager for health and safety reasons or to allow reasonable adjustments to be made. Information about the health issue can only be given to the line manager with the individual’s permission. In most cases if it is clearly explained to staff what information would be shared and why, it is rare for permission to be denied; however, where this is the case the OH nurse must respect the person’s wishes and give information about adjustments without disclosing the reason why. The Healthcare Commission (HCC) expects HR or line managers to have evidence that staff are protected against infectious diseases such as hepatitis B. This is to allow appropriate and timely follow-up should an exposure incident occur, without access to the OH records being required. In some cases it is also to ensure patient safety. Sharing the outcome of vaccination programmes/screening with HR or line managers in these circumstances is not considered confidential. The information shared, however, must be strictly limited. For example, it would be acceptable to share that an exposure prone worker must have an annual surface antigen test; however, the reason that this is required (e.g. refused vaccination, unable to receive vaccination because of a preexisting health problem or non-responder to vaccine) should not be shared.
Disclosing Information Without Consent to a Third Party In exceptional circumstances OH records can be released to third parties without consent. These circumstances are:
r It is required by law. r If disclosure is clearly in the patient’s interest but it is not possible or is undesirable to seek consent.
r It is in the public interest.
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r It is necessary to safeguard national security or to prevent a serious crime.
r It will prevent a serious risk to public health. r In certain circumstances, for the purposes of medical research. In these cases the OH nurse will have to make a judgement about when it is appropriate to release information and this will depend on the specific circumstances of each case. The nurse remains accountable for any disclosure and must therefore be able to justify that disclosure. OH nurses are advised to seek advice from the OH manager and the company’s legal advisers before disclosing information. Advice can also be sought from professional bodies such as the RCN or NMC.
Legal This includes:
r In the course of legal proceedings or where legal proceedings are pending.
r The reporting of notifiable infectious diseases, although this will usually be reported by the GP/treating doctor.
r RIDDOR reporting of accidents/dangerous occurrences; however, reporting of occupational diseases does not fall into this category and consent must be obtained before informing the employer. HSE inspectors have extensive powers, including the right to inspect and take copies of any documents for the purposes of any examination or investigation. OH records are not exempt from this. The Healthcare Commission also has the power to inspect and take copies of documents, including health records, and to remove them from the premises without consent. However, the HCC code of practice on confidential personal information states that they will obtain information that identifies individuals only when necessary to progress a complaint and/or inspection and that as far as possible they will seek consent from individuals before using personal or confidential information related to them. A police investigation does not give automatic right of access to OH records; the OH nurse should seek advice before disclosing. In many cases disclosure will be justifiable because it is in the public interest.
Disclosure in Patient’s Interest For example, in the case of sudden acute illness in a member of staff at work requiring immediate assistance by ambulance/A&E services it would be in the patient’s interest to disclose relevant health information to the treating doctor.
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Public Interest Disclosure in the public interest is where a failure to disclose information may expose others to the risk of death or serious harm.
Public Health For example, if a member of staff were found to have a blood borne virus and there was evidence to suggest that they had deliberately continued practices which could put others at risk.
Procedure for Disclosing Records Without Consent It is considered best practice to, as far as is practicable, seek consent for disclosure from the individual before releasing the OH records. As a request may be ignored, a time interval for responding should be given. Consideration should be given to including a pre-paid return envelope to facilitate a response. If consent is not given, the nurse must tell the individual that information will still be disclosed. The letter should include:
r On what grounds information will be disclosed, e.g. public interest, public health risk, etc.
r Specifics about what will be disclosed as it may not always be necessary to disclose all of the OH record.
r To whom this information is being given. Any disclosure must be strictly limited to those who need to know. The OH nurse must keep a written record of all action taken.
Change of Occupational Health Provider OH records should be stored in such a way that they can be easily transferred to another OH provider. It is the responsibility of the current OH provider to ensure that the records are only transferred to an appropriate health professional. Where external providers are used and the service is being transferred to a different provider or being brought in-house, a letter should be sent to all staff advising them of the change and that unless they object, their OH records will transfer to the new provider. It is not necessary to get individual consent for transfer of records. Attaching the letters to payslips is one way of ensuring that all staff are informed. If there is an internal change of staff and another OH nurse or doctor is providing the service, they can assume responsibility for the OH records. It is not necessary in these circumstances to write to staff individually.
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Where OH staff are being made redundant and no replacement service is planned, the RCN recommends that records are transferred with individuals’ consent either to each employee’s own doctor or to another medical adviser. Records must not be destroyed before the recommended archive time has elapsed.
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Appendix 2.3: Relevant Legislation: Key Points Human Rights Act 1998 Article 8(1) of the Human Rights Act gives a right to respect for private and family life. It is generally accepted that private life includes information about physical and mental health. Article 8(2) allows for some exceptions where the state may interfere with the individual’s right to privacy, e.g. in the prevention of crime and disorder, the protection of health and the protection of the rights and freedoms of others.
Data Protection Act 1998 The Act came into force in March 2000, repealing the 1984 Act. It is concerned with the collection, storage, use and disclosure of data and applies to paper records as well as to data processed electronically. Individuals have a right of access under the Act to personal data held on them by the OH department. The definition of personal data includes any expression of opinion about the individual and any indication of the intentions of the data controller or any other person in respect of the individual. Sensitive data is defined as information about an individual’s physical or mental health or condition. There are restrictions regarding the processing of sensitive data, such as:
r An individual has given consent. r It is necessary for medical purposes. r It is necessary to perform any obligation that is imposed by law on the data controller in connection with employment.
r It is necessary to protect the vital interests of the individual or another person (provided that certain conditions are met). The Secretary of State has the power to make provisions for exemptions. Under the Data Protection (Subject Access Modification) (Health) Order 2000, access may be denied if it could cause serious harm to the physical or mental health of the data subject or any other person or would breach the confidences of third parties. With regard to health records, access may not be refused on the grounds that the identity of a third party would be disclosed, where that person is a health professional who has compiled or contributed to the record or care of the data subject, except (which must be very rare) where serious harm is likely to be caused to that health professional’s physical or mental health.
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Information must be communicated in a form that is capable of being understood.
Access to Medical Reports Act 1998 The Access to Medical Reports Act 1988 gives patients right of access to reports prepared for insurance or employment purposes. OH staff may from time to time need to obtain medical reports, either pre-employment to help with making a decision about fitness to work or because of sickness or performance issues. Staff have certain rights under the Act. The key points are detailed below:
r The employee must give their written consent before the medical report can be applied for.
r The employee must understand what information is being sought and why, i.e. consent must be informed.
r The employee has the right, within a given time frame (currently r
r
21 days), to see their medical report and comment on it before the employer receives it. The employee may request the medical practitioner to amend any part of the report which the employee considers to be incorrect or misleading, or to have a statement attached setting out the employee’s views if the practitioner cannot accede to the employee’s request. Having seen the report, the employee may withhold consent to its being supplied to the employer.
Further details, together with consent forms, can be found in Section E of the Human Resources Manual, General Employment Policies, Absence from Work.
Access to Health Records Act 1990 This Act has now been superseded by the Data Protection Act and remains relevant only in relation to deceased patients, whereby the deceased’s personal representative and any person who may have a claim arising out of the patient’s death can request access to health records.
The Computer Misuse Act 1990 This Act came into force to secure computer programs and data against unauthorised access or alteration of data. Reading information
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displayed an a screen that one is not entitled to see, without interaction with the computer, would not be a breach of the Act.
Health and Social Care (Community Health and Standards) Act 2003 The 2003 Act provides the Healthcare Commission with its statutory powers. The HCC also has functions and powers under the Care Standards Act 2000 (as amended by the 2003 Act). The revised Act includes clauses that allow inspectors access to personal health records. Section 31, 1A states: The power under subsection (1) to require the provision of information includes: (a) The power to require the provision of copies of any documents or records (including medical records and other personal records); and (b) in relation to records kept by means of a computer, power to require the provision of the records in legible form.
NMC Code of Professional Conduct The professional and ethical obligations for nurses are set out in the Nursing and Midwifery Council’s Code of Professional Conduct (2004) (www.nmc-uk.org). There are specific clauses that relate to confidentiality. The GMC has similar codes of practice for doctors.
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Appendix 2.4: Sample Letter Notifying a Change of Occupational Health Provider Dear Colleague, Re: Change in Occupational Health Provider I am writing to inform you about a change to your Occupational Health (OH) Service. (Insert name of company) currently provides the OH service to the hospital. From (insert date) the service will be provided by (insert name and any supporting information about the company/person). OH records are held in the strictest confidence and access is strictly limited to the OH nurses providing the service on-site. Access to your OH records will therefore be transferred from (name of current provider) to (name of new provider). You do not have to do anything, however if you do not want your records to be transferred or have any queries then please contact (insert name) by (date). Details about the new service, including contact numbers and dates that (new provider name) will be at the hospital will be circulated shortly. Yours Sincerely,
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Managing Services Cynthia Atwell; Updated by Anna M. Cosgrove
Introduction This chapter will concentrate on the day-to-day management of an occupational health service, focusing on the practical aspects with reference to theoretical models that can be used by the reader for further reading and educational development.
Who Should Manage an Occupational Health Service? Historically, the management of an occupational health service has been the domain of an occupational physician in large organisations and a personnel manager in smaller companies. Doctors and nurses who practice occupational health have a wide range of professional experience and qualifications and at times may experience difficulties in establishing the management roles and responsibilities of their departments (Lunn & Waldron 1991). All nurses are managers (Sullivan & Decker 2005). Most nurses will have considerable experience of organising and running departments even before they specialise in occupational health. Nurses’ unique skills in communication, negotiation and collaboration position them well to manage in a constantly changing environment. But it cannot be assumed that if a person is at the top of their ‘professional ladder’ they can automatically take over the management of their service; in practice, they may not have the relevant skills, talent, Occupational Health Nursing Edited by K. Oakley. C 2008 John Wiley & Sons, Ltd
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motivation and ability. The best person to manage is the individual with the necessary management skills and business acumen.
Leadership and Management Management involves an individual’s efforts to influence the behaviour of others. The manager sets goals that represent some level of growth for a particular group in a particular environment. Management is not based on seat-of-the-pants thinking. Managers have formal authority to direct work, and are formally responsible for the quality of that work and what it costs to do it. As manager you will have responsibility to accomplish an organisation’s goals. The concept of leadership is broader; it can be defined as a process of interaction in which the leader influences others toward goal achievement. Effective leaders enable people to move in the same direction, toward the same destination and at the same speed – because they want to. As leader, the primary tasks are to: help people develop a sense of direction and purpose through goals and vision, build a group’s commitment to its goals and face challenges through innovation and change. Leadership is an essential part of effective management. You do not have to be a manager to be a leader, but you do need to be a good leader to be an effective manager. A working definition of management is ‘the art of getting things done through people’ (Torrington et al. 1989). This is a somewhat limiting definition, however, as it implies that management is simply getting other people to do things. It also implies that these people have a subordinate relationship to the manager. In the context of occupational health practice this is a poor definition, as management style needs to reflect the skills of the people in the team and acknowledge that they will often be peers or superiors in terms of qualifications in their own specialties. A nurse or doctor, for example, may manage a service that employs a range of other professionals such as nurses, physiotherapists, safety advisers and doctors. The most appropriate management approach is thus based on a team concept, acknowledging the skills and experience of the team as a whole rather than simply managing through power.
Management Style The managerial style adopted should take account of the people being managed. Blanchard et al. (1994) outline four basic leadership styles: directing, coaching, supporting and delegating. The style used will be developed to suit the circumstances of the person and the situation. People with little experience may require directing until they have grown into the job, whereas someone with a lot of experience may
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require a style that is supporting and delegating in order that they can grow and do not feel restricted in their role. A good manager will need to coach individuals through close supervision of tasks, explaining the reasons for decisions, soliciting suggestions and giving support in order to encourage individual development. This supporting style helps to facilitate and support individuals in their job, sharing in the responsibility and decision-making process. There is no rigid style for every person, and a good leader will change style and tailor their approach to differing circumstances, to meet the needs of a particular situation with a particular person. At times, the manager will have to take control and be directing when normally they would consult and involve others. This is acceptable, providing the manager explains the decision, takes full responsibility for the outcome and is not too proud to admit when they get it wrong. The misconception that ‘the boss is always right’ is perpetuated by the boss’s never admitting to being wrong, and this attitude inevitably leads to resentment and mistrust. People who never make mistakes are either not doing anything or are not being honest with themselves. Mistakes are part of the learning process and, providing the mistake is not repeated time and time again, should not be used to discipline people, unless of course it is on a major issue. The style of management developed when managing a group of professional people must reflect and utilise the skills of the individuals. In occupational health practice this is paramount if the team is to be developed and structured so as to use its skills, knowledge and experience to best advantage. As mentioned earlier, occupational health teams may consist of nurses, doctors, hygienists, safety advisers and others, all of whom make a unique contribution. They can work as autonomous practitioners or as part of the team, and the value of their expertise should be recognised and acknowledged. In this way, they are encouraged to give their best, and a relationship of loyalty and trust is developed, which is fundamental to any successful organisation.
The Management Process Management requires methodical problem solving that is based on a conscious, identifiable strategy for achieving goals at a particular time and place and with identified individuals. Managers are required to develop strategies for reaching organisational goals that are based on the highest probability for success. There are four distinct functions of the management process:
r r r r
planning organising motivating controlling.
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It can be said that planning is the first and most important step of the management process: what, why, where, when, how and by whom. It involves identifying problems, setting and specifying short and longterm goals, developing objectives and mapping how the goals will be accomplished. It needs to involve the whole team so that the members can work together toward identified goals. The planning stage can be divided into ‘contingency’ and ‘strategic’ planning. Contingency planning will include ‘what ifs’, for example, ‘what if there is a pandemic flu outbreak?’ Strategic planning (2–5 year plans) will involve long-term objectives and what is needed to implement them. Organising involves bringing together systems, resources, people, capital, equipment, etc. to accomplish the organisational objectives. Organising is an ongoing process that systematically reviews the use of human and material resources. As a manager you are more likely to accomplish your objectives if you are able to sell ideas, projects and proposals to staff members, rather than telling them what to do. Professional staff members are autonomous, requiring guidance rather than directions. As manager you will need to motivate staff to achieve their objectives. Motivation is an important aspect of enhancing employee performance, as motivated employees are more likely to be productive than non-motivated employees. Individual staff members will bring to the workplace different needs and goals. Motivation describes the factors that initiate and direct behaviour. Motivation theories are useful because they help explain why people act the way they do and how a manager can relate to individuals as human beings and workers. Controlling will involve the mechanisms for ongoing evaluation. Obtaining feedback of results will enable you to compare results with plans. Examples of control involve quality control systems, quality assurance, audits, etc. The controlling function will normally involve staff members, who will review, monitor and identify ways to improve the service and delivery of care. As manager you will constantly attempt to improve productivity through evaluating outcomes and performance, and instituting change as necessary.
Developing the Team What is a team and what makes a good team? The Concise Oxford Dictionary defines a team as ‘a set of persons working together’, and teamwork as ‘combined effort, organised co-operation’. Hastings et al. (1986) discuss the qualities of ‘superteams’, using words such as persistent, creative, flexible, inventive, committed, driven by success and action-oriented. They state that teams work best ‘with principles and guidelines as procedures rather than rules’. This is particularly pertinent to the success of the occupational health team (see Figure 3.1).
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Common Purpose Members know the part they play. Applied Talents Members aware of each other’s abilities. Appropriate Leadership and Clear Roles Clear direction and defined roles. Shared Responsibility Not jobsworth’ mentality. Goal Focused and Results Oriented Know the precise goals to be achieved. High Communication Everyone knows what is going on. Responsive to Opportunities Go for all opportunities. Highly Innovative Looking to do things better and better ways of doing them.
Figure 3.1
The Characteristics of a High-Performing Team
There is no room for the ‘that’s not my job’ attitude; everyone needs to work together towards a common goal and be prepared to take responsibility for any problem that may beset the team; it is all too easy to blame others for poor performance. A successful team member will take on a problem for the team and use all his or her skills in projecting a positive outcome, and will be prepared to be accountable for and with the team. This level of team success does not happen overnight, but requires effort and commitment from everyone, and, most of all, trust. This trust is built up when team members allow others to take control without feeling that they are being undermined or that the leader is taking all the credit for the team’s success or abdicating responsibility when things go wrong. Teams will succeed only when there is mutual trust between all the members. Outside the occupational health team itself, good team relationships with others in the workplace are also crucial to achieving healthier and safer working environments. So even in a small company, where the occupational health nurse is the only health-trained professional, the same principles apply, only the nurse will develop a team with others such as the engineer, the human resources manager and those who have responsibility for health and safety. By working together, better results can be achieved.
Managing Change Change is inevitable if we are to progress. If occupational health services do not change their approach to providing services then they will disappear. Change is a continuous process, not something that happens once, or even once every few years. Occupational health services must be in a continuous mode of change, adapting to meet the needs of the business to which they are supplying their service. The introduction of new technology has been a major factor in this, bringing about changes in work from labour-intensive to fully
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mechanised, which requires none of the skills developed through the traditional apprenticeship. Many people have been retrained in computer and similar skills, which have brought their own occupational health problems. Occupational health services have been greatly affected by the changes in organisations, employment trends and the changing emphasis on health care. The recent major developments in the NHS, alluded to in the Introduction to this book, have had an impact on the provision of health care in the community, and occupational health has been identified as being part of the community. The government’s 10-year strategy Securing Health Together (HSC 2000) outlines a long-term strategy for managing occupational health provision. In particular, it provides a challenge to all occupational health and safety professionals, and others, to develop ways of ensuring that occupational health care is available to all, including small and mediumsized enterprises (SMEs). With this in mind, it will be necessary for all occupational health services to look at their specific operation to see where they could help in the development of this strategy, for example could they provide services to SMEs in their neighbourhood? If so, how would this be managed? What would be the benefits to the community and the employer in doing this? This type of initiative would need to be included in their business plan. There is competition for the provision of occupational health services through the development of occupational health providers and through local GPs, who are seeking to offer occupational health care through local health centres. This is very innovative as, with changing patterns of employment, more people are employed by small businesses, which do not have in-house occupational health services. Therefore a massive market exists for these services, which provides income for the GP practice health centre and helps to subsidise its resources, which in turn can be of benefit to the rest of the community. Some occupational health services are being sold off or put out to tender, while others are growing. Companies are buying occupational health provision on an ‘as and when’ basis, which they see as more costeffective than retaining an in-house service. By buying in occupational health, companies know that if they do not get the service they want, they can choose not to renew the contract, which gives them control over the service provided. It also means that occupational health providers must supply services tailored to meet a company’s specific needs, and, above all, services that contribute towards the overall success of the business. There are potential pitfalls in this approach. Clearly, the client’s needs must be met, but the occupational health professional has a duty to advise their clients, based on a risk assessment approach, on meeting health-related legislation relevant to the particular company. It would make little sense, for example, for an employer in an organisation using recognised respiratory sensitisers to offer staff
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general health-promotion sessions while ignoring their legal obligations to provide health surveillance of exposed workers. As is discussed in Chapter 16, employers may look to occupational health services to provide ‘competent’ advice under health-related legislation and will welcome guidance in this area to help define their needs. There is nothing new about change. What is different in the modern world is the speed at which change occurs, and we must be quick to adapt. Successful organisations recognise the need to keep changing to survive, as standing still means going backwards. Organisations that succeed will invest in equipping people to prepare for and respond to change, and will have developed the skills to deal with this. One major problem for the occupational health service is moving fast enough within the organisation even to maintain the status quo. As mentioned previously, employers are looking at reducing overheads, and many are putting occupational health services out on a contractual basis, perceiving it as an overhead rather than a benefit. In doing this, the company can control the costs, buying only what it wants, when it wants it. In order to manage that change, occupational health professionals must develop skills which to many are alien and go against the very essence of their values. This entails approaching occupational health as a business, developing business plans with targets that will contribute to the overall strategy of the organisation. In so doing, occupational health will become an integrated part of the organisation and be seen by managers as supporting their objectives in making the company successful. Whether the occupational health professionals like it or not, the service is there to support the bottom line. Gone are the days of occupational health being there because ‘it is a nice thing to have’; it must now demonstrate that it adds value to the organisation. This creates some difficulties in the ethical field and, as mentioned elsewhere in the book, good diplomatic skills are now a prerequisite for effective occupational health practice. Whitaker (2001) provides some good examples of ethical dilemmas in which occupational health nurses may find themselves. Management requiring the support and involvement of a nurse in managing sickness absence is one such situation. However, with the proper policies and procedures in place and with agreed professional standards for practice this should not be an issue. The secret is to pre-empt the problem and manage it in a positive way. Occupational health services must provide services that are appropriate, by identifying needs through the risk assessment process and developing services to address those needs. More detail on this aspect was given in Chapter 1. Core services need to be clearly defined, following which the occupational health team must ensure that the right skills are available to carry out those services. The approach to pre-employment screening is one example of identifying need and tailoring a service to suit an individual organisation.
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This core function of occupational health services often involves a lot of time and resources if a blanket approach is to be undertaken. Research shows that this time can add little value. For instance, Whitaker and Aw (1995) found that there was no difference in rejection rates of employees screened by a multi-staged process compared with those who were medically examined. This raises the question of whether this is a good use of resources and if it is cost-effective to spend a lot of time on pre-employment screening. If an assessment of the needs of the organisation has been made then the requirements for pre-employment screening will have been identified. From this, fitness standards criteria can be produced, which will set out the fitness requirements for the various jobs, and an appropriate system for screening can be developed to ensure that the standards have been met. The result is an efficient way of tailoring the service to meet the needs of the organisation while also taking into account relevant legislation. It ensures that screening relates to the risks involved in individual jobs and aims to help both employer and employee.
Business Planning In establishing the management style and structure of the occupational health service, it is necessary to take account of the type of business and its culture and philosophy. A business plan can then be developed, which will set out the overall plans for developing and improving the occupational health service. The first step is to produce a ‘Purpose and Values’ statement, in order to provide the service with direction. This will also define the business, determine its long-term goals, set the context for business development and form the basis of the corporate identity. Prior to producing a ‘Purpose and Values’ statement, the occupational health service must identify the factors that will influence its development. These might include the following: 1. Environmental factors (legislation, policies, workplace hazards). 2. The future (European legislation, customer base, audit results, policy). 3. Competition (external companies, services provided, experience of the occupational health team, commitment of the team). The benefit of stating your service’s purpose is that it helps to unify the service, focuses the marketing strategy, simplifies decisions on investment and spending, and improves performance. Every successful business will have a stated purpose, and occupational health services must be no different if they are to succeed. The statement of purpose must be succinct, a statement of what you want to be in no more than one line. It must be memorable and something to which all staff can relate, with which they all want to be associated
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and which they want to ‘own’. The best way of achieving this is to get all staff involved in developing it, which will help them understand the occupational health service objectives and alleviate some of their anxiety about change. Defining the values of the service provides a common frame of reference – everyone will understand the behaviours that are expected of them. It assists with setting the rules for business practice and clarifies relationships with customers, shareholders, suppliers and employees. Perhaps more importantly, defining values provides a focus for those employed by the occupational health service, providing performance criteria, guiding people’s behaviours and actions, enabling effective delegation and empowerment, and giving a basis for performance assessment. The statement of values must address four main areas of the occupational health service’s commitment (see Figure 3.2). Once the ‘Purpose and Values’ statement has been developed and agreed, the business planning process can begin. The business plan sets out how the purpose and values are to be implemented in practical terms and how the statement is to be made active. The planning process begins with identification of goals and objectives, measurement of performance (part of quality) and a report on business results. For example, the goal may be related to customer satisfaction; the objective is to be customers’ chosen supplier of services; and the measurement criterion is for 95 % of customers to say that their requirements are met. Developing the business plan will require a critical analysis of the occupational health service’s strengths and weaknesses,
The Client e.g. Who is the client (employer/employee)? Understanding, identifying and meeting their needs. Delivering services on time and to agreed standards. Developing services to meet their present and future needs. The Occupational Health Service Staff e.g. Recognising and respecting the contribution they make to the success of the service. Providing opportunities for career development and equipping them with the necessary skills to contribute to the development of the business. The Suppliers e.g. Understanding their constraints and ensuring they understand the needs of the occupational health service. Being loyal and fair, honouring obligations to them (e.g. paying bills!) The Investor (The Employer) e.g. Achieving a return on the investment (providing value for money). Developing the service, new ideas and ways of working. Contributing towards the profitability of the company.
Figure 3.2
The Occupational Health Service’s Four Main Areas of Commitment
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Strengths What you are good at and need to capitalise upon e.g. expertise of staff, location, knowledge, quality. Weaknesses What you are not good at and need to improve e.g. not commercially minded, inflexible, not business focused. Opportunities Changes and/or influences that can be taken up and developed to grow the service e.g. impact of European Union legislation, present supplier, high cost of sickness absence to companies. Threats Those things that threaten the survival of the service e.g. outsourcing, competition, company downsizing and cutbacks.
Figure 3.3
SWOT (Strengths, Weaknesses, Opportunities and Threats) Analysis
opportunities and threats (SWOT analysis). This helps to focus on the issues that are most likely to affect the success (or failure) of the service, and needs to be carried out fairly ruthlessly so that all issues are examined objectively (see Figure 3.3). In carrying out this exercise, it is important not to become demoralised and focus overly on weaknesses and threats. With a positive attitude, both of these can be turned to advantage and re-focused as ‘opportunities’. Once you have identified weaknesses in and threats to the service, you can immediately take action to minimise them. But it is more dangerous not to identify them and to continue in the same old way, becoming complacent, and then one day wondering why the service has crumbled. The SWOT analysis having been completed, the next stage is to build up the occupational health service’s business profile. This requires identifying what the occupational health service can offer – the skills and experience of the team – and from that deciding what services you can offer and what staff and budgetary resources will be required to deliver these services. It will be important to decide on the core activities of the occupational health service and what the major activities will be; these can be itemised in a priority list that targets the needs of the company receiving the service. For example, if, in agreement with your client, managing attendance is identified as a major problem, that will be the priority activity for your service to target. This should be documented with details of the type of activity the occupational health service will undertake in order to support and help the client, together with the measurable outcomes you hope to achieve. By so doing, the occupational health service will be able to monitor its progress and contribution, and feed back to the customer information on the evaluation of the services provided. This provides a means for continually monitoring and updating what the
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service is doing to ensure it meets the needs of the customer, and begins the quality control process. The business plan provides support for the development of performance appraisal systems in that it provides a way of identifying what each team member can contribute and allows for this to be used to set objectives for individuals and for the team as a whole. The next stage in the business planning process is the development of critical success factors (CSFs). These are the essential outcomes that must exist in order for the purpose to be accomplished; in other words, those things that are vital to the survival and development of the occupational health service. CSFs should be written as a commitment, such as ‘we must have/be’, and should be discrete elements with a mixture of tactical and strategic outcomes. It is vital to involve the occupational health team in their development and to obtain consensus; again, ‘ownership’ is paramount. CSFs should be few in number, no more than eight, and must target the areas of the occupational health service that most need to be addressed in order to move on. An example of a CSF might be: ‘We must have services that are delivered efficiently which meet our clients’ needs.’ To achieve this, it is necessary to examine the image of the service; a customer satisfaction survey should be carried out to obtain information on how the client rates the service. This will provide a basis for development and a focus for bringing about changes in the way the service is delivered. Another example might be: ‘We must have effective and relevant business systems.’ This will require a review of existing systems and a definite commitment to improvement, with the necessary investment as required. The main purpose of developing CSFs is to focus effort and commitment in a structured way to support the overall business objectives. They are very powerful tools for improving the service.
Budgeting Management accounting is vital to management. Hartley (1994) states: ‘Management must have monetary information if it is to guide the course of the business successfully.’ Budgeting is a management planning technique, not accounting, and must be part of the total management process. Regardless of how expert, creative, collaborative and altruistic a health care system may be, it cannot function without money. Budgets should be developed by areas of responsibility and incorporate controllable items necessary for the successful management of the service. Those responsible for managing the service must be involved in setting budgets; they must take ownership and control of the budget and be prepared to implement it. Most importantly, budgets should
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not be imposed from above, although it is accepted that there will be a certain amount of control and direction from those who have the final responsibility for the financial state of the business. Budgets should be set with clearly-defined objectives that are understood and reasonably attainable; they must also be reviewed and monitored – it may sometimes be necessary to move the goal posts in order to accommodate fluctuations in predicted workloads/productivity. Once the budget has been approved, this fact must be communicated down the line to indicate to all concerned management’s acceptance. Progress on achieving budget targets should be communicated to everyone on a regular basis, as staff need to know how well (or otherwise) they are doing. Without this information they cannot measure their success in relation to the overall profitability of the occupational health service. Budget planning should be a dynamic process of continuous monitoring and improvement. Budgets must not be seen as a ‘reason to spend’; they must be controlled, but the controls should be directed towards action and not recrimination. A simple process is shown in Figure 3.4. Involving staff at all levels in budgeting is important in order to avoid negative attitudes developing towards controls, particularly on spending. It is easy for staff to blame the lack of money on inactivity and poor performance, and therefore they need to understand what is happening in the occupational health service business and why restraint and control are necessary. Historically, occupational health service budgets have been controlled by others, such as personnel directors, which has led to a dissociation with the financial side of the service. Budgets have been imposed from above, with the occupational health service manager having little control over or say in what was agreed. When the occupational
Development of the financial objectives/strategy of the occupational health service Review objectives Revise forecast
Long-term financial plan
Resource planning: a. human resources b. capital
Detail department/centre annual budget – profit and loss – cashflow
Figure 3.4
Evaluate/monitor results
Take action to make plan happen
A Sample Budget Planning Process
Measure actual results
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health manager was asked to plan a budget their work was often totally ignored, which meant there was little incentive for their full involvement in the final outcome. If occupational health is to be part of the business it must also be accountable for its finances and develop cost-effective services that will add value to the business as a whole. Companies in the business of providing occupational health services must control their own budgets and plan and develop strategies to grow the business or they will not survive.
Information Technology The need for information technology (IT) to support occupational health practice is paramount. Not only do customers require more information about the services they are receiving, the occupational health service is required to provide statistics on such topics as attendance at the occupational health centre, accidents, the fitness profile of the organisation and much more. With the emphasis on cost-effectiveness, the use of IT systems to provide such information is essential. It is invaluable to demonstrate the added value provided by the occupational health service. The original outlay of capital expenditure to acquire IT must be considered and will be an important factor in budget preparation. This cost must be examined in relation to the efficiencies that may be achieved, as well as the improvements in the quality of the service and the information thereby provided. An IT system should be introduced to meet the needs of the occupational health service and it will be necessary for staff to be consulted. Until the question ‘what do we want the information for and how are we going to use it?’ has been asked, there will be little point in progressing. Too many IT systems have been introduced to suit the IT manager, without consulting the people who need and use the information. Examples of information that may be required to assist with the successful management of the occupational health service are listed in Figure 3.5. It is impossible to state the type of IT system that should be used, as there are many ready-made packages available. However, before purchasing such an expensive item, the package should be given a trial to ensure it is what is wanted and does what it claims to do. It is advisable to shop around and not to be hurried into purchasing without being fully convinced of the product’s value; once it is purchased, the occupational health service will have to live with it. It may be possible to get programmes specially written to meet particular needs; however, these can be expensive and often cannot easily be updated.
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1. Types of medical/health assessment carried out. 2. Numbers found to be unfit or unsuitable for employment and why (pre-employment and in service). 3. Numbers and reasons for employees taking ill-health retirement, including age and gender profile. 4. Numbers and reasons for referral to occupational health service. 5. Ill health and accident statistics – causes, age and gender profile. 6. Statistics on statutory medicals, e.g. lead, asbestos, ionising radiations, Control of Substances Hazardous to Health Regulations. 7. An automatic invoicing system (an option whereby customers are invoiced per item of service). 8. Information on risk assessments, which could provide data on major risks in certain areas. This would form part of the occupational health information available to staff prior to making workplace visits. 9. Automatic medical review recall diary system. This brings up all medicals due, allowing for forward planning and control over workloads. This would alleviate sudden unexpected demands on resources (e.g. the manager telephoning to say they need 20 medicals carried out before a certain date). It would give the occupational health service control over its operation. Note: This list is not exhaustive; the most important thing is to ensure that the statistics used meet the needs of the particular service.
Figure 3.5 Useful Information (from Software Systems) for Occupational Health Services Management
Prioritising Service Delivery As mentioned previously, occupational health must be an integral part of a business, and the services provided must be tailored to meet the needs of that business. Occupational health should contribute to the profitability of the business and to the economy of the community and country as a whole, by maintaining and improving the health of the working population. In order to achieve this, services must be prioritised on the basis of an assessment of need. For instance, if a company is having serious problems with sickness absence it will be necessary to help management to develop a managing attendance policy as well as to identify the causes of the absenteeism. Likewise, if a company is experiencing severe difficulties associated with the implementation of a new piece of health and safety legislation, the occupational health service should make that the priority. As mentioned earlier, the fact that for example some promised health promotion programme on healthy eating has been neglected will be of little importance to the manager who is concerned about the possibility of a visit from the health and safety inspector. To ensure that the client’s needs are being met it is advisable to agree priorities and target objectives with management. This can be done quite simply, using a few major headings setting out what will be done, by whom and by when, programmed over a given period with review dates. An example is given in Figure 3.6.
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Figure 3.6
Prioritising Service Delivery: Key Objectives
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Assist managers in identifying the need for health surveillance. Provide on-site health surveillance. e.g. commence audiometry programme.
Health Surveillance
Support managers in complying with statutory obligations.
Proposed Outcome Assist the business’s aim to lower long-term sickness rates and minimise time off sick. Identify main causes of sickness absence.
Raise awareness of the benefits of a healthy lifestyle. e.g. well person assessments, such as BP, Weight, lifestyle.
August e.g. meeting to review sickness absence statistics/ policy and performance to identify needs and service provision
e.g. plan for smoking cessation, promotional material, locations, advertisina material, etc.
e.g. undertake/ refresh/review own departmental risk assessments.
July
Health Promotion
June e.g. run managing sickness absence training course for new managers.
Time (e.g. weeks/months)
Identify need. Plan and implement training.
e.g. run two health and safety refresher courses for managers.
May
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Training
e.g. commence spirometry health assessment programme.
April e.g. two case conferences with personnel and depot manager.
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Objective Managing for Attendance
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Quality and Audit Quality is a way of conforming constantly to the standards that have been agreed with the client. This means that occupational health services must be client-focused at all times (see Chapter 4 for more on quality and audit). Quality is paramount, whether the client is an employee visiting the occupational health nurse or doctor for a health or medical assessment, or the employer who is paying for the service. Each will have different expectations. The employer will be looking for a service that responds to their needs, perhaps in getting people seen and reports issued quickly, whereas the employee will measure the quality of the service provision by the way he or she is received by the nurse or doctor and the time and empathy given. To start the process of quality, the occupational health service should do the following: 1. Decide what services it has to offer and target the market. 2. Find out from customers what it is they want from an occupational health service. 3. Employ the right people to provide the service. 4. Provide the services to the agreed standard – ‘get it right first time’. Quality control procedures are implemented through auditing. Auditing is a method of looking critically at what is being done and objectively comparing the findings with an agreed standard. By so doing, standards can be improved and changed in order to improve the quality of service provision. The occupational health service must set the standards that it wishes to achieve, thereby providing a base from which quality can be assessed. This will be founded on the needs of the client, taking account of health and safety requirements, legislation and professional practice standards. The business planning process will identify the overall occupational health policy and objectives, and will be linked to the critical success factors in defining the purpose. It is important to select services for audit that are common, high-risk or costly in terms of human and monetary factors. Examples of services to be audited might include return-towork health assessments, ill-health retirement procedures, reasons for ill-health retirement and health surveillance. The audit process will require that objectives be set. These should identify what is important about the quality of the service and what will be achieved by the audit. For example, for return-to-work health assessments the service standard to be achieved could be: 1. That the manager has access to occupational health advice as necessary on weekdays from 9 a.m. to 5 p.m.
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2. That individuals are seen within two days of referral to the occupational health service. 3. That a report is sent to the referring manager by the occupational health service within 24 hours. Clearly, this example is aimed at standards of response times that would have been agreed in the contract. It is important to realise that the other aspects of audit will be aimed at quality in relation to clinical audit, which is a professional activity to ensure that standards are met in line with latest research and current best practice. In this chapter, audit is discussed in relation to the management sphere and does not include clinical audit. Some occupational health services have achieved BS5750/ISO 9000 quality standards. This is a set of requirements for quality management systems. It is based on a process approach requiring documentation and control of what is done, of how it is to be done and of records (supporting information). The areas to be considered are: document control; purchasing; maintenance of equipment; process control; corrective action; handling, storage and packaging; records; and training. Each is discussed in more detail below.
Document Control This requires a procedure to be introduced that will ensure that the staff is working from the latest documents. For example, a new work instruction on carrying out audiometry tests will need to be controlled so that it is known that all staff members are working to the same instruction; likewise, all staff members will need to be made aware of a new piece of health and safety legislation and understand the implications of it for the occupational health service and the business.
Purchasing This means getting the supplies that will comply with requirements delivered when they are wanted, and will be particularly significant for occupational health services purchasing expensive equipment such as audiometers, lung function testing equipment, etc.
Maintenance of Equipment If equipment has been purchased or is on loan it is necessary to have a system for regular maintenance and calibration as appropriate. This must be documented to ensure that the equipment is working to the agreed specification. This will be vital to the service as most screening work is carried out to an agreed standard. Audiometry results, for example, could have grave consequences if not accurate.
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Process Control This is to make sure that work is carried out in the correct way. For example, if different people carry out health/medical assessments it is important to know that the assessments are being carried out to the same standard by all those concerned, so a written work procedure will be necessary.
Corrective Action When something does go wrong, procedures are needed to ensure it is not repeated and that the reason for the problem is identified and put right. Action should then be taken to identify the cause, and corrective action implemented to ensure it does not happen again. This then needs to be monitored. Corrective action can be applied to all types of problems, including complaints that are usually dealt with as isolated incidents; it would be better to learn from such experiences in order to take preventive action and avoid mistakes happening in the future.
Handling, Storage and Packaging This requires controls on all items and materials used in the occupational health service. The most important of these will be health/medical records and consumables such as vaccinations, which have special storage needs. Records must be kept securely and for a given length of time. The Control of Substances Hazardous to Health (COSHH) Regulations 2004, for example, require health/medical records to be kept for 40 years. Vaccinations have special temperature storage requirements and a shelf life. These and other similar situations must be properly controlled, with the supporting documentation demonstrating and proving the control methods.
Records Records must be kept of all quality control systems; these records must demonstrate that the systems are working effectively. They must be comprehensive, with enough detail to trigger any need for corrective action. However, it is important not to let quality be consumed by paper; this is not a paper exercise, and should be used to ensure that it is known what is happening. A good quality system will support the management process, be a monitoring tool and highlight problem areas that can be addressed before things get out of hand.
Training Training for quality will be an integral part of staff training and development. All occupational health service staff members will need to
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be trained regarding the quality system that is being implemented. As well as being committed to making it work, they will need to understand what is expected of them and how the system operates.
Staff Development and Training A vital component of all good businesses is a well-trained staff, and occupational health services are no exception. To attract and keep good staff, potential employees will need to see that the service has a high commitment to staff training and development. As mentioned earlier in this chapter, when developing the business plan cognisance of staff skills and knowledge will be important for deciding on the type of service that can be provided. The first step is to identify what skills and experience are available within the team. This can be discovered through a simple questionnaire. Experience outside the work setting should be included as this will identify skills which are often forgotten or deemed not to be relevant. Activities that people pursue in their spare time can equip them with numerous abilities, for example, secretary or treasurer of a club; leader of a scout, guide or other group. These activities will develop organisational, leadership and financial skills, to name but a few. Once the skills in the occupational health team have been identified the next stage will be to make an assessment of training needs – both organisational and individual needs. This should be done by carrying out a job analysis, which should have been part of the original business planning process. From this, specific training needs will be identified, which need to be set out as specific training objectives, including educational and behavioural objectives. Occupational health nurses and doctors are usually seeking to obtain higher medical and nursing qualifications in order to enhance their professional skills or to maintain their registration on the professional registers (this is a statutory requirement for both nurses and doctors). Other training needs, however, must be examined and linked to the skill mix required in the team to enable the services outlined in the business plan to be executed. Too often, occupational health services have people too highly qualified carrying out routine tasks that would be more appropriately performed by others. In the past, services recruited staff with recognised occupational health nursing and medical qualifications even when many of the skills those people had were not to be utilised. This led to staff becoming bored with the job and leaving, which was very costly to the business. Getting the skill mix right is vital and needs careful planning. According to Artus (1995), occupational health practitioners of the future will require safety skills and will provide an advisory service, with much of the routine work being carried out by others. The focus of any occupational health service must be on getting the job done
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(delivering the service) to the agreed standard and in the most economical way; therefore, it will be paramount to success to ensure that the service has the right skill mix of practitioners and support staff. It could be argued that a major part of occupational health screening work could be carried out by non-specialist practitioners, leaving the highly-skilled occupational health nurses and doctors to monitor and supervise that work and develop the preventive strategy and policies to improve the health of the company. This develops the theme outlined in Chapter 15 on educational issues and occupational health nursing. It seems a practical and cost-effective way of providing essential routine services, and is in line with the changes taking place in other sectors of health care.
Competencies In 1999, the government published a paper ‘Agenda for Change: Modernising the NHS Pay System’. The proposal set out a single job evaluation scheme to cover all jobs in the health service to support a review of pay and all other terms and conditions for health service employees. The NHS Knowledge and Skills Framework (the NHS KSF) defines and describes the knowledge and skills that NHS staff need to apply in their work in order to deliver quality services. It provides a single, consistent, comprehensive and explicit framework on which to base review and development for all staff. The NHS KSF has impacted on the career and pay progression of occupational health nurses working in the NHS and in the private and independent sectors. The RCN has produced ‘Competencies: an Integrated Career and Competency Framework for Occupational Health Nursing’. This framework, through consultation with occupational health nurses and allied professions, has mapped identified competencies against the NHS KSF. The RCN framework is a guide to occupational health nurses and their employers for decisions on practice competency, personal and professional development, and career and pay progression.
Performance Appraisal Performance appraisal must be part of good management and is a means of supporting staff development. Appraisals are frequently dreaded by staff, as, by reputation, they tend to be a critical analysis, often very subjective, of the performance of an individual. An appraisal is a formal, two-way process between the manager and a team member to enable progress to be reviewed against agreed objectives. It will also summarise past performance and agree action for the future, which will include training requirements and the new objectives
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Set and agree objectives
Monitor progress of the individual
COACH
Give formal feedback appraisal Measure performance
Give informal feedback Implement necessary corrective action
Figure 3.7
A Sample Performance Management Process
to be achieved. Furthermore, there should be no surprises. If someone is not performing satisfactorily then that should be dealt with at the time, not left for the formal annual appraisal. Appraisal should be ongoing and monitored continually, so that progress or otherwise is followed up. Any appraisal system must be based on agreed criteria, must be measurable and must be a means of motivating, not demoralising, staff. Therefore, objectives should be set that are specific, measurable, achievable, relevant and have agreed time-scales. Appraisals act as a formal check by bringing together all aspects of the work: objectives, special projects, personal development and values. Another important aspect of staff development and appraisal is coaching, which is ongoing and should support objectives and guide behaviour to achieve those objectives. An example of a performance management process is set out in Figure 3.7.
Conclusion A successful occupational health service must be integrated into the business and be part of the human resource strategy. Only then can the service’s value to the business be demonstrated and a positive contribution made to the overall health of the workforce and therefore the community as a whole. Occupational health services must be operated as a business. There must be a business plan that clearly sets out the objectives of the service, with a planned budget and a management philosophy that develops the team concept of operation. The most successful occupational health services use the skills and expertise of the people they employ, and value the contribution made by everyone.
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References and Further Reading Artus K. (1995) Is Multi-Skilling the Future?, Occupational Health 47(8), 275–7. AOHNP(UK) (2000) A Quality Pathway for Occupational Health, Leicester: AOHNP(UK) Publications & W. Mercer. Blanchard K. and Johnson S. (1994) The One Minute Manager, London: HarperCollins. Blanchard K., Zigarmi P. and Zigarmi D. (1994) Leadership and the One Minute Manager, London: HarperCollins. DoH (2004a) The NHS Knowledge and Skills Framework (NHS KSF) and the Development Review Process. DoH (2004b) Agenda for Change. Handy C. (1994) Understanding Organisations, 4th edn, London: Penguin Books. Hartley W.C.F. (1994) An Introduction to Business Accounting for Managers, 5th edn, Oxford: Pergamon/Elsevier Science. Hastings C., Bixby P. and Chaudhry-Lawton R. (1986) Superteams: a Blueprint for Organisational Success, London: Fontana. HSC (2000) Securing Health Together: a Long-Term Occupational Health Strategy for England, Scotland and Wales, Sudbury: HSE. HSE (2004) Control of Substances Hazardous to Health Regulations: Approved Codes of Practice, Sudbury: HSE. Kelly-Heidenthal P. (2004) Essentials of Nursing Leadership and Management, United Kingdom: Delmar Learning. La Monica Rigolosi E. (2005) Management and Leadership in Nursing and Health Care: an Experiential Approach, 2nd edn, New York: Springer Publishing Company. Lunn J.A. and Waldron H.A. (1991) Concerning the Carers: Occupational Health for Health Care Workers, London: Butterworth-Heinemann. RCN (2005) Competencies: an Integrated Career and Competency Framework for Occupational Health Nursing. Sullivan E.J. and Decker P.J. (2005) Effective Leadership & Management in Nursing, 6th edn, New Jersey: Pearson Prentice Hall. Torrington D., Weightman J. and Johns K. (1989) Effective Management: People and Organisation, London: Prentice Hall. Whitaker S. and Aw T.C. (1995) Audit of Pre-Employment Screening by Occupational Health Departments in the NHS, Occupational Medicine 45(2), 75–80. Whitaker S. (2001) Ethics and Ethical Dilemmas in Occupational Health, Occupational Health Review 89, January/February, 13–15.
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Quality and Audit Linda Maynard
Introduction The concepts of quality health services and audit are now well accepted in occupational health practice. Whether you are a student of occupational health or a qualified occupational health nurse, it is still often confusing to unravel what is meant by ‘quality’ and the practice of ‘audit’. Getting started on ensuring that quality services are provided can feel like an onerous task. There are numerous books on the subject, with associated jargon, detailing different methods of audit and giving various definitions of the nebulous term ‘quality’. It is the aim of this chapter to demystify the quality and audit process to guide the reader through the subject. The chapter starts with some simple definitions of quality and audit. Following that, some answers are given to the questions: Why audit? What are the different types of audit? How can audit be done? Quality is: ‘Knowing what outcome you want and being sure you get it, every time, for as long as you want it’ (Lilley 2001) or ‘the degree of excellence of a thing’ (Oxford Concise English Dictionary). Audit is: ‘a systematic review’ (Oxford Concise English Dictionary) or ‘a method of looking critically at what is being done and objectively comparing the findings with an agreed standard . . . in order to improve the quality of service provision’ (see Chapter 3, this volume). Perceptions often differ, but in this summary a quality service ‘is the capacity of a product or service to satisfy specified requirements or expectations’ (Menckel & Westerholm 1999 p. 82). This includes reliability over time as well as the ability to continually improve. The Occupational Health Nursing Edited by K. Oakley. C 2008 John Wiley & Sons, Ltd
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first step towards assuring and improving quality is to define and measure it. This means translating ideas about quality into standards that can be measured. Information can then be collected by various methods, such as observation, interviews, questionnaires (e.g. a questionnaire survey for people attending an immunisation clinic to evaluate the quality of the clinic) and analysing existing information (e.g. occupational health records). Development of quality services should be a continuous process and integrated into everyday practice. The quality assurance procedures need to fit with the company model on quality, or the organisational quality framework if one exists. This will ensure that the occupational health service is following the company culture as well as maintaining professional, legal, ethical and clinical standards.
Why Audit? The Royal College of Nursing (1999a) paper on audit in occupational health clearly summarises the benefits (Figure 4.1). These benefits are important for developing the speciality of occupational health. Monitoring the management and delivery of services is necessary for ensuring accountability in today’s society and business climate. Occupational health nurses should, with appropriate competence, training and experience, be involved in identifying and prioritising standards, as well as developing audit tools. This involves monitoring the potential negatives of audit. For example, some ‘mandatory’ company or organisational audits, such as the externally-formulated NHS Health Quality Service Audit, generally contain broad standards and can become bureaucratic. They tend to concentrate on the superficial structure and process of the service rather than focus on fundamental issues or outcomes of activity. Occupational health professionals need to be vigilant that whatever the type of audit, it does not become a paper exercise, and must remember to ‘audit the audit’, especially if some aspects seem
r r r r r r r r r
Audit is a tool for continuous improvement. It is a tool for quality assurance. It provides documented evidence of the value and quality of the OH service. It can provide evidence that the OH service is meeting the needs of the business. It can be used for benchmarking internally and externally to achieve best practice. Audit results may identify trends and help focus and prioritise actions to improve the OH service. It can benefit individual OH nurses, the business and customers. It can raise the profile of OH in an organisation. It allows the OH service to meet national standards of clinical excellence through clinical governance.
Figure 4.1 The Benefits of Auditing the Occupational Health Service Source: RCN (1999a)
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irrelevant to the service. Feedback from the occupational health service, on either organisational or internal audits, will make the exercise more applicable and therefore more useful in the longer term.
Types of Audit Many organisations now have a quality framework that encompasses the different systems working towards providing and developing quality services. This is a way of organising the different departments to continuously improve together, to increase the effectiveness of the work and its results. The occupational health service will be expected to work within this management culture to develop the quality of its own services. Every organisation will use some or all of the following types of audit or self-assessment activity. The two broad main types of audit relevant to occupational health are, first, those where the framework standards have already been set (e.g. ‘top-down’ management audits or third-party audits) and, second, those where the occupational health team organises the audit itself, usually developing its own standards and criteria. There may be some overlap between the two types (Figure 4.2).
Audit Type 1: Standards Already Set Organisational Management Audit An example of a selfassessment tool used to assess standards (and also used as a framework for quality) is the European Foundation for Quality Management (EFQM) business excellence model. This is gaining popularity, particularly in the NHS, where the government has commended its use (Jackson 1999). Approaches for achieving ‘excellence’ (e.g. meeting targets and national standards, comparing well with other organisations) are defined and then assessed and reviewed. The key components of the business excellence model contain further sub-criteria to address different areas in the organisation (Figure 4.3).
Type 1 Audit framework standards already set
Type 2 Audit standards set by OH
EFQM BS5750 ISO 9000
Clinical audit User satisfaction Cost-effectiveness Baseline service audit
Figure 4.2 be Relevant
Occupational Health Services: Examples of Types of Audit which may
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Enablers
Results People Results 9%
People 9%
Leadership 10 %
Policy & Strategy 8%
Partnerships & Resources 9%
Processes 14 %
Customer Results 20 %
Key Performance Results 15 %
Society Results 6% Innovation and Learning
Figure 4.3 A Diagramatic Representation of the EFQM Excellence Model c EFQM. The EFQM Excellence Model is a registered trademark Source: EFQM (1999).
EFQM Business Excellence Model A summary of the model shows how all the elements of the organisation are included. The model starts with leadership. Commitment to continuously developing quality is considered vitally important and leaders should be able to demonstrate by their behaviour that they are involving all staff, communicating to internal and external customers, and recognising the input of motivating and supporting their staff. People management follows, as the contribution and empowerment of staff is important to improving the service. Criteria include areas such as performance review, training and development, improving retention of staff and decreasing sickness absence rates. Policy and strategy reviews the mission, values and strategic direction of the organisation. Policy and strategy should be based on the present and future needs of stakeholders, using relevant information and research. These areas should also be regularly developed, updated, communicated and implemented effectively. Resources looks at how the resources required to run the organisation are managed, from financial resources to buildings, equipment and technology. The processes element analyses the design and management of all activities to review how they can be improved. This includes all the processes involved in an occupational health service that incorporate clinical best practice, benchmarking standards and customer needs. Other
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national standards can also be absorbed into the model within this component, for example the Investors in People Award. The above elements are considered under the ‘enablers’ part of the model, which concentrates on running the organisation. The remainder of the model looks at achievement, measurement and targeting of ‘results’. People satisfaction examines achievements by measuring the perceptions of staff and reviewing customer satisfaction, i.e. the perceptions of external customers. Impact on society is monitored by looking at how the needs and expectations of people affected by the organisation are met, for example, the impact of being a local employer. Lastly, business results or key performance results measure what is being achieved by the organisation, comparing financial, non-financial and operational aspects with targets (Jackson 1999). All these activities are linked and depend on networking and overcoming practical barriers. Building and developing a quality organisation means ensuring that the total quality ethos is at the heart of everything. It can take a long time for this ethos to be integrated into a company.
Other Examples of Organisational Management Audits Management audits tend to be formulated outside the occupational health service and use broad standards to review the organisation. These audits take a general look at systems and processes, including auditing occupational health services and seeing how they interact with other services in the organisation. External auditors will periodically attend for planned audits, normally undertaken with representatives from the organisation. The Health Quality Service Audit, previously known as the King’s Fund Audit, where it originated, is an example of an organisational, general accredited audit used in the NHS. There is a dedicated section on occupational health, as well as other core activities of a Trust. There is a checklist of standards, for example ‘Is there a health screening policy in existence?’ and ‘Is there access to a qualified occupational health physician?’ A commonly used organisational audit is the internationally equivalent family of standards, ISO 9000. As with the NHS Health Quality Service Audit, the standards relate to broad management activities and are used as a marker to indicate that a system of monitoring and audit exists. Health and Safety Audit Health and safety audit should be an integral part of the organisation’s quality framework, rather than an isolated section. Regular audits, viewing the corporate health and safety system or separate individual parts of that system, are used to monitor and evaluate risk management standards as part of the general
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management responsibilities. This involves working with health and safety colleagues to look at areas of potential overlap or dual responsibility, in particular the risk assessment and control process, health surveillance activity, accident/incident reporting, policy and procedure writing including review, first aid organisation, health and safety training and the level of legislative compliance. As above, there may be an external organisational audit that has a health and safety section to monitor corporate activity, or this type of audit may be designed internally.
Audit Type 2: Occupational Health Staff Set the Standards Baseline Occupational Health Service Audit This type of audit reviews the existing resources, facilities, equipment, procedures and policies in a service and how they may be improved or reorganised. Such audits are performed when there is new management, the viability of the service is being questioned, or to adapt to major changes in the host organisation. Some companies use external occupational health experts for this, as they will give an objective look at a service. There are professional standards available to help design this type of audit, for example, those from the Royal College of Nursing on setting up an occupational health service. Many occupational health service providers use this as a first step when taking over a service (for more details see Chapter 1). User Satisfaction Audit The ‘users’ are either the company (purchasers of the service) or its employees. Each user will have a different concept of what quality means to them. The employees are not involved in payment for the occupational health service and will normally base their perception of quality on the advice and care they receive on a oneto-one basis or as part of a group. The company, however, will usually have a broader perspective on quality, such as wanting to ensure a range of services, value for money and accessibility. One way in which to audit the users is to slot their perceptions of service received and their expectations into one of five ‘gaps’. Parasuraman et al. (1985) developed a model of service quality based on interpretation of qualitative data from executive interviews and consumer focus groups. The study was not health care related but can be usefully adapted. The model identifies gaps in perceived service quality between the executives and consumers, i.e. service providers and service users. The model is adapted to fit an occupational health service in Figure 4.4. It provides a useful breakdown of the different gaps in customer service and could be used to formulate ‘bottom-up’ criteria against which to audit user satisfaction.
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User expectation–management perception gap: Occupational health management may falsely believe that it understands the users’ expectations and without any feedback it will continue to do so.
Service quality expectation–service delivery gap: A department may have established quality standards but it relies on all members of staff to maintain them; a shortfall in delivery will reflect on colleagues and the overall service.
Management perception–service quality expectation gap: Quality specifications are set by the occupational health managers without their understanding what the users’ priority is, for example the occupational health service allows several days for typing a detailed report to management, when the advice contained within the report could have been communicated by another means.
Service delivery–external communications to consumers gap: The standard of service delivery as communicated to clients is not met, for example a sign in the waiting room informs clients that they will not be kept waiting longer than five minutes without being informed of the reasons but this is not put into practice. Expected service–perceived service gap: Users’ subjective expectations of service may not match that which is received and a single event may influence their views of the entire service.
Figure 4.4 Quality Model for an Occupational Health Service Source: Adapted from Parasuraman et al. (1985)
The occupational health service may adopt the organisational standard on customer services and use measures such as encouraging feedback in structured questionnaires or reviewing the number of complaints received. Each service level agreement or contract the occupational health service holds needs to specify how this area of customer satisfaction can be audited effectively. Appropriate measurement tools may need to be developed. It is important to remember that the employees need an opportunity to offer feedback as well as the employers or managers, and an occupational health monitoring group can be established, allowing representatives from management and staff to give their views. A simple example of a questionnaire based on an internal standard for customer service following referral is included in Figure 4.5.
Internal Occupational Health Audit This type of audit is to measure internal clinical and non-clinical standards in the occupational health service and involves looking at either a separate process or a group of processes that function together, for example the wider effects of how accessible the service is, or how the occupational health service communicates with managers. Many occupational health services, particularly in the NHS, will fall within the organisation’s clinical audit process. Clinical audit involves all members of the occupational health team reviewing care in a systematic way and assessing whether it meets standards. This means taking part in clinical audit projects, which will need to be submitted and
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Aim to evaluate how the occupational health service is meeting user needs 1. Have you come to occupational health today at the request of: Your manager Self-referral 2. Were you offered an appointment date and time convenient to you? Yes No 3. Was the service easy to find? Yes No 4. Were you made to feel welcome? Yes No 5. Were you seen within five minutes of your appointment time? Yes No 6. Are you happy with the quality of advice and any actions planned by the nurse/doctor with you? Yes No Comments .......................................................... 7. Was this advice/action explained clearly? Yes No Comments .......................................................... 8. What was the most useful aspect of your appointment today? 9. What was the least useful aspect? Please add any other comments/suggestions below. ....................................................................................................................................... .......................................................................................................................................
Figure 4.5
User Satisfaction Survey
approved. Again it is important that the occupational health professionals guide the project, with the help of internal audit experts if required. In the occupational health context, this means auditing the quality of care to the client when assessing, treating or advising an individual and their manager. It may also require examining the outcome measures of the advice given. Medical audit is the evaluation of care: diagnosis, treatment, resources and outcomes carried out by doctors. It is normally performed by doctors looking at their own work or that of medical colleagues.
Documentation Review This type of audit can be conducted as a joint effort, with doctors and nurses looking at a random sample of notes to see how the cases were handled. In occupational health there is normally only one set of notes for each service user, making audit much easier. One occupational health service has regular multi-disciplinary team audit meetings, and reviewing notes is one of the topics. Figure 4.6 presents a case study looking at record keeping following a referral.
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Method: compare with internal clinical operating guideline standards on this subject by a retrospective review of a sample of records as follows:
r r r
Selection of records made randomly within a set time frame. Audit questions formulated using measurable criteria, for example the standard states that all records must contain information concerning how and why the individual was referred, and that an appropriate assessment should be made, containing at least four essential areas of information. Audit questions such as:
r r r
Do the notes contain the mode of referral? Response yes or no. Do the notes contain the reason for referral? Response yes or no. Do the notes contain information on the assessment made: Present problem Occupational history Symptomatic review Clinical assessment Responses to above: yes, no or not applicable.
Results and action points: if the results are not 100 % compliant with the standard this must be discussed and acted on. The fundamental details to be included in all records of an assessment may be adjusted as necessary after reviewing individual cases used in the audit.
Figure 4.6
Documentation Review of OH Case Notes Following Referral
Cost-Effectiveness Audit/Financial Analysis This type of audit, often done in conjunction with other auditing approaches, is described as a means of justifying why any activity is being delivered and its financial cost (staff time costs, client time costs, equipment and other overheads), and looks at how to make the activity more economically efficient. It is also used to identify priorities for action, such as research activity. Our starting point for any audit is to observe practice compared with a standard. The standard or outcome of any activity under audit can be set to satisfy specified requirements, but evaluating the actual health value in cost-effectiveness terms can be complex. There are methodologies for calculating costs, both direct and indirect, and the audit results depend on what method is used. In auditing the cost-effectiveness of, for example, a back clinic that sees workers with back pain and provides preventive advice, the parameters for cost analysis will include direct costs such as occupational health staff time, client time, drugs and equipment. Further indirect costs such as lost working time or intangibles like counselling costs required for an anxious worker whose back pain is continuing might also need to be included. A source of potential error in the results is disagreement over definitions, such as what should be included under the ‘back pain’ description. Activities that have purely occupational causes are rare but are easier to audit, as opposed to activities that have multi-factorial elements. This
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type of auditing is therefore better termed financial ‘analysis’, as, to ensure services are really cost-effective, comparison of the costs of one or more interventions may be necessary. Each organisation will have its own financial advisers, normally situated in the company finance department, who can help with this type of audit.
The Quality and Audit Process Any occupational health service must be focused on the business’s needs. It should add value by contributing to the maintenance and promotion of the health of employees. This must be the basis on which the service business plan and service level agreements (the level of occupational health services agreed between purchaser and the providing occupational health department) are written. There is also the need to demonstrate effectiveness and efficiency, particularly in a competitive environment, either internally or against other occupational health units if selling services externally. Quality services should follow from meeting and exceeding standards that reflect the professional and purchaser expectations of practice. But what do we mean by quality ‘standards’? The Royal College of Nursing defines a standard as: a statement which outlines an objective, with guidance on how to achieve it including required resources, activities and predicted outcomes. It is also a representation of care which all [clients] should receive – either as the basic minimum or for use as a measure of excellence (RCN 1997). Criteria to measure standards used in audit are defined as: variables which enable the achievement of a standard and evaluation of whether it has been achieved or not. In medical audit, criteria are systematically developed statements that can be used to assess whether specific health care decisions, services and outcomes are appropriate. Once criteria have been selected, a desired standard of performance must be defined (RCN 1997). The aim of audit is therefore to measure how effective agreed criteria are against set standards. These abstract terms can appear to be peripheral to everyday practice but audit must become a regular part of service activity, with the involvement of the whole multi-disciplinary team as necessary. In a perfect world each occupational health service should have a standard or target for all aspects of service, from the facilities provided to clinical advice given. In reality all these standards would be impractical to measure unless there were full-time auditor posts in each service. Audit activity must therefore concentrate on the
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priorities agreed with the purchaser (ideally contained in the service level agreement), elements of service raised by the professionals and any mandatory organisation-wide audits. Deciding on the priority of activities to audit can present a challenge. In the case of health professionals, one of the main priority areas will be the quality of care and advice given. It is widely recognised that there are currently inadequate written standards of clinical practice in occupational health care and as yet few are evidence based (Agius 1997). Research has shown that occupational consultations and occupational rehabilitation have hardly been studied and that scientific evaluative research is needed to provide more evidence-based care (Hulstof et al. 1999). Occupational health practice can be very diverse and exists over many different industries, creating a further problem for consistency of standards of care and advice. Identifying the objective of any audit can be problematic. This raises the question of whether audit is a control function only to evaluate standards or whether the information generated is going to be used to develop and improve standards. Most occupational health professionals would agree that audit should be a dynamic process, not just a control function, and that the indications for change should be acted upon as far as is possible.
Prioritising Quality Assurance Activity and Ethical Considerations It is important to use any existing quality organisational framework as a starting point from which to base the way systems are used to control and develop quality. Audit activity in the occupational health service, defined as ‘observing practice and comparing it to a standard’ (Faculty of Occupational Medicine 1995 p. 9), should be steered by occupational health professionals, with company (purchaser) and employee input. Priority areas for audit include the general organisational systems, activities where the occupational health staff have concerns over a shortfall in practice and areas where improvement is needed or changes in clinical practice are proposed. It is worth remembering that when prioritising audit activity, the values of individuals working in the team or buying occupational health services can influence the subjects or methods chosen, as well as the interpretation of the results. Menckel and Westerholm (1999 p. 207) recommend that a good starting point for any specific audit area is the question, ‘Which issues in this evaluation are ethical?’ This involves looking at ‘actions planned and undertaken, and in what ways their underlying motives involve the value criteria of beneficence, non-maleficence, respect and justice.’
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Setting Standards and Criteria The audit process starts with setting of standards. Standards need to be identified and it is useful to divide them between external standards that can be translated into operational standards and existing standards already in use. External standards are those that have been formulated by international bodies, government, professional bodies or the organisation the service is contracted to. They include customer charters, health and safety legislation and codes of practice, guidance notes and classifications (see Chapter 2 for information on writing policies and procedures). Some health and safety legislation contains statutory levels of compliance, while codes of practice and guidance notes describe best practice. Other existing standards are the respective professional codes of practice, which describe standards, for example, on record keeping. National clinical guidelines that are evidence based are available from different sources and include systematic worldwide literature reviews (e.g. www.library.nhs.uk/Default.aspx). Professional guidelines such as those published on the management of acute low back pain (Carter & Birrell 2000) and the evidence-based guidelines for the prevention, identification and management of occupational asthma (Nicholson et al. 2005) will be useful in any occupational health setting. Examples of internal standards, developed within the occupational health service and already in existence, may be clinical procedures such as a vaccination policy, medication guidelines and response times to management or waiting times in the department. If a new standard needs to be written, it should be:
r r r r r
Agreed with professional or management colleagues. Desirable and appropriate to the customer base. Observable. Measurable. Relevant to the occupational health needs of the organisation (RCN 1999a).
Any standard written concerning clinical performance must include the minimum level of safe practice to be considered ethical. Before a new standard is constructed there may need to be further data collection to help inform the level of practice. For example, it might be useful to carry out a user survey of occupational health customers and clients to understand current expectations before writing the standard of customer service. Other necessary standards may require more detailed research methods in order to gather data. It is also worth noting that the jargon of audit may be confusing here. Some ‘audits’ are really methods of data collection, as they do not have a ‘standard’ to audit against. For example, collecting information
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about a type of occupational health practice across a region is useful as a benchmarking exercise, which in turn can be used to help formulate standards, but for an ‘audit’ there need to be standards to audit against! Benchmarking involves comparing practices with other occupational health services and adopting those considered to be the best. Once standards are in place, the next step is to agree measurable criteria. Review criteria should clarify whether the standard is being met, so statements need to be formulated to achieve this. For example, the ‘if–then’ format is useful. To illustrate, if a manager refers a staff member for advice then they should be seen within the defined time standard for making appointments. Or if a client informs us they are working with blood then hepatitis B immunisation should be offered, as stated in the local policy. The various approaches to audit described earlier are the main types in use and the majority start from the basis of a standard or target describing the level of quality expected, and audit criteria to measure the standards. The AOHNP(UK) (1999) produced a general framework for auditing occupational health practice. This pathway or audit process starts with the ‘outcome’ or expectations, in terms of what is decided with the purchaser, and looks at setting standards, measurement and review. This framework is useful in any occupational health setting, but particularly in organisations that do not have general established quality assurance. Whatever audit tool and checklist is finally used to record the responses, it should be kept as simple as possible, with either yes/no, numerical figures or short responses systematically collected. As a further simple example, the occupational health service may want to audit the response time to managers after a referral and will use as the standard the existing service statement, describing the level of service expected. Elements of the standard may be converted into measurable criteria, such as recording how quickly an appointment was sent, waiting times for an appointment and how long it took the occupational health service to respond. The results can then be analysed by the team and compared against the agreed acceptable level of service, for example that each referral is offered an appointment within one working week and that the manager is informed in writing within five days. If this is not being met, the standard can be changed to, for example, contacting the manager by telephone within one working day to speed up communication. This is a fairly simple retrospective audit but can still be time consuming. It is therefore vitally important to ensure that relevant, logical measurement criteria are formulated to save time. Descriptive audits are the most commonly used; analytical types, usually to evaluate outcomes, require more detailed design. It may be more appropriate to undertake such an audit as a research project as outcomes may be difficult to measure. Analytical audits still need standards to measure against to avoid becoming pure data-collection or benchmarking exercises.
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Other variables used to formulate measurement criteria are the data sources in the service, such as daily activity figures; historical data; benchmarking data from other occupational health services; and national statistics. Data should be from a reliable source, be as accurate as possible and be relevant to the population being audited. Internal policies, legal requirements, peer-reviewed research evidence, clinical practice guidelines and the experience of the occupational health professionals can all help in establishing measurable criteria, as well as in writing the standards in the first place.
Carrying Out the Audit Who performs the audit will vary between organisations and types of audit. In most circumstances it should be a team effort, if there is an occupational health team, not only to aid in designing the audit and collecting data but to increase everyone’s experience and understanding. The audit leader or co-ordinator, normally the lead doctor or nurse, should have knowledge of the audit process and be competent and experienced. This person will ensure that the audit tool design is practical, that a time frame is set and that the results are analysed, collated and communicated to the relevant people. The collection of measurement data will either be retrospective or recorded during a procedure, depending on how the audit tool has been designed. This may entail information being collected at different times, perhaps to fit in with the department schedule, or at repeated intervals if procedures (or different aspects of a procedure) are being monitored over time. Sampling strategies may be required to ensure that, for example, when auditing records, a representative selection is chosen. Internal auditors in the organisation may be involved, although issues of confidentiality must be remembered, and external auditors in the form of occupational health experts may be brought in to carry out the process. Donabedian (Donabedian and Rosenfield 1968) developed a model that separates audit activity into structure, process and outcome. Structural elements include clinical equipment, facilities, reference materials, resources available and how the service is organised. Process measures are procedures such as sickness absence management, pre-employment screening and health surveillance activity. Outcome measures are the results of occupational health interventions, for example advising on acute back pain, the number of clients identified with an occupational disease compared with previous data and the impact of a health promotion project. In practice these can be difficult to separate, but the sections provide a useful reminder when designing an audit tool.
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Reviewing the Results The results need to be compared with the standard under audit, if necessary using statistical analysis of the data collected, and any gaps or areas for improvement must be identified. Previous audits for the same standard can provide comparison and help with prioritising recommendations in practice. The standard can be adjusted or rewritten as necessary. It is essential to show where and whether the standard is being met and to congratulate the team when they are delivering up to the standard. The audit tool should also be examined to see if it was valid, if the right criteria were chosen, whether the data were captured effectively and whether the standard and measurement criteria were pragmatic.
Making Changes This involves agreeing action plans to implement what has been highlighted in the reviewing results stage and may involve parties outside the occupational health service. Deadlines and responsibilities should be made clear, with review dates. As with any process of change, communication with the team and other stakeholders as required is important. The audit process will continue with a further date for re-audit and review of further standards.
Communicating Results It is important to use the results to improve the occupational health service, but why not share the knowledge? Sharing good practice and useful results is important. British Medical Journal editor Richard Smith says that ‘Those who work in quality improvement in health care have a poor record in publishing their articles.’ He goes on to recommend the structure introduced by the editors of the journal Quality in Health Care as a good format for communicating quality improvement reports (Smith 2000 p. 1428).
Conclusion The preceding outline has given an overview of the audit process, the types of audit commonly used in practice and how this work can help measure progress and develop the quality of the service that is being offered. It is essential to grasp the difference between audit and data collection, which is only part of the process. The use of existing standards, as described earlier, can be particularly useful when setting up a new occupational health contract or starting to introduce audit activity into practice. Careful planning of the audit process will save time and
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resources in the long term. As more experience is gained, the team will be able to construct effective audits and re-audit standards with less time required for planning. Audit is a useful marketing tool. From an external viewpoint, audit will be seen as an indication that the service is actively looking at continuous improvement. This should be one of the ‘selling points’ and a marker for a proactive service. General outcomes of audit and actions taken should be included in the annual business plan and service report to the customers, including results of any specific audits agreed with the purchaser of the service. This information will help inform the customer about using the occupational health service or adjusting the service level agreement when reviewed. It should also help inform business cases for increasing occupational health services in the future. The audit process should be incorporated when setting up any new occupational health contract, and time for audit activity must be built into any contract as an essential quality-control element. Well established audit systems can also help recruitment and encourage occupational health students to undertake training placements in the service. The quality and audit process must be integrated into practice and encompass all elements that go towards delivering a ‘quality’ service. Help to set standards, formulate criteria and start audit activity may come from within the occupational health service, from the organisation’s experts in audit or from external experts brought in to advise. Logical thinking and consultation are needed to ensure priority areas are chosen for standard setting and audit and that there is a consistent approach. Inability to demonstrate a quality service costs money. Customers may be lost, complaints may rise, recruitment and retention of occupational health staff may become difficult and time and effort will be wasted. The benefits of audit may not be obvious in the short term, especially as some occupational health practice may not show results for a long time. Other areas, such as audit of administrative systems, may demonstrate that progress has occurred in a quicker time frame. Overall, the quality assurance costs are repaid in quality staff and services, and satisfied customers and clients.
References and Further Reading Agius R. (1997) Quality and Audit in Occupational Health, Health Environment & Work, www.agius.com/hew/resource/quality.htm (accessed June 2007). AOHNP(UK) (2000) A Quality Pathway for Occupational Health, Leicester: AOHNP(UK) Publications & W. Mercer, available from PO Box 11785, Peterhead AB42 5YG. Carter J.T. and Birrell L.N. (2000) Occupational Health Guidelines for the Management of Low Back Pain at Work: Principal Recommendations, London: Faculty of Occupational Medicine, Royal College of Physicians.
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Donabedian A. and Rosenfield L.S. (1968) Criteria and Standards for Quality Assessment and Monitoring, Quarterly Review Bulletin 12, 1–6. Everitt J. (2000) Evaluating Clinical Supervision, Nursing Times 96(10), 47–9. Faculty of Occupational Medicine (1995) Quality and Audit in Occupational Health, London: Royal College of Physicians. Hulstof C.T., Verbeek J.H., van Dijk F.J., van der Weide W.E. and Braam I.T. (1999) Evaluation Research in Occupational Health Services: General Principles and a Systematic Review of Empirical Studies, Occupational and Environmental Medicine 56, 361–77. Jackson S. (1999) Exploring the Possible Reasons why the UK Government Commended the EQFM Excellence Model as the Framework for Delivering Governance in the NHS, International Journal of Health Care Quality Assurance 12(6), 244–53. Lilley R. (2001) Clinical Governance Toolkit, Oxford: Radcliffe Medical Press. MacDonald E.B. (1992) Audit and Quality in Occupational Health, Occupational Medicine 42, 7–11. Menckel E. and Westerholm P. (eds) (1999) Evaluation in Occupational Health Practice, Oxford: Butterworth-Heinemann. NHS Electronic Library, www.library.nhs.uk/Default.aspx. Nicholson P.J., Cullinan P., Newman Taylor A.J., Burge P.S. and Boyle C. (2005) Evidence Based Guidelines for the Prevention, Identification and Management of Occupational Asthma, Occupational and Environmental Medicine 62, 290–9. Parasuraman V., Zeithaml A. and Berry L.L. (1985) A Conceptual Model of Service Quality and its Implications for Future Research, Journal of Marketing 49 (Fall), 41–50. RCN (1997) Clinical Guidelines: What You Need to Know, London: RCN. RCN (1999a) Occupational Health Audit: a Practical Guide for Occupational Health Nurses, London: RCN. RCN (1999b) Clinical Governance: How Nurses Can Get Involved, London: RCN. RCN (2003) Clinical Goverance: an RCN Resource Guide, London: RCN. Smith R. (2000) Editorial: Quality Improvement Reports: a New Kind of Article, British Medical Journa1 321, 1428.
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Independent Practice Kit Artus; Updated by Katie Oakley
Introduction This chapter covers some general and practical aspects of independent occupational health nursing. The first issue for anyone considering independent practice is to recognise what is meant by the term. In the context of this chapter it means being self-employed or: Someone who uses their skills and abilities to create a successful business while assuming total responsibility and risk (RCN 2000 p. 5). It is recognised that being an ‘independent’ can in addition mean working with others who are also testing the commercial market.
Skills and Abilities The decision to launch out as an independent can at first glance seem the ideal. The idealist sees ownership of projects and freedom to choose the clients and work undertaken. The pragmatist will question what projects, what work and what skills they will need. A SWOT exercise is a good starting point. It may be old hat to some but it is a way to focus on the project of self-employment. The SWOT exercise needs to be specific to the independent (Figure 5.1). The SWOT exercise, if completed objectively, can assist the possible independent to decide whether self-employment is really a preference or Occupational Health Nursing Edited by K. Oakley. C 2008 John Wiley & Sons, Ltd
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Strengths: what you are good at and what you need to promote Independent thinker Innovative Like working alone Committed Good decision maker Quality orientated Provide best practice and not just what the client wants Good problem solver Can turn down work Know own capabilities Computer literate Can work to deadlines Weaknesses: what you are not good at and what you need to develop Need to refer problems for a final decision Like structure
Figure 5.1
Need the support of a team Not a self-starter Never been in a senior position Must generate a set amount of income Not certain of abilities Opportunities: to develop the company Work is available in the geographical region wanted Market research confirms opinion Experience to market Known in the area Network Threats: things that threaten the survival of the company Only one client has offered work Need regular income Not willing to take risks Bank loan not possible
The SWOT Exercise Applied to Independent Working: Some Ideas to Consider
an ability-based option. The same exercise can be used to assess projects, marketing materials and initiatives.
Steps to Independence
What Do I Want the Business to Be? There are basically three types of business: sole trader, partnership and limited company.
Sole Trader Most independents start out as a sole trader, which is the simplest form of business structure. Registering the business and, if relevant, obtaining licences is relatively inexpensive. The sole trader has complete control of finances and can decide when and how much to take out of or put into the business. Unlike other business structures there is little government control and there are no reports to be filed with government agencies or departments. The business and the sole trader are taxed as a single entity, i.e. the business-generated income is equivalent to the salary. There is a major risk as a sole trader: personal assets, house, property, car, investments or other valuables can be seized to pay outstanding debts and other liabilities.
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Partnership A partnership is an association of two or more people to carry on a business with the aim of making a profit. To enter in to a partnership you need a contract – oral or written – between all interested parties. The fees and legal expenses are lower than for an incorporated company but higher than for a sole trader. Being in partnership means sharing all decisions, profits and unlimited liabilities of the partnership. Changes in circumstances automatically end the legal identity of the partnership, for example the death of a partner. A partnership agreement, sometimes referred to as articles of partnership, is essential. The larger the partnership becomes the more complex the agreement. When more than one person is making decisions you need consensus management. A dependence on consensus management can lead to difficulties and result in partnership conflict. At the risk of sounding pessimistic: A friendship founded on business is better than a business founded on friendship (John D. Rockefeller, 1874–1960; see Gray 1996). Dissolving a partnership can result in expenditure of time and legal and administrative costs, as all partners need to agree the terms, which can result in trading difficulties. For example, the withdrawal of capital at termination of a partnership can result in the business being insolvent.
Limited Company A limited company is a legal entity, with or without share capital, which can be legally established by one or more individuals. The shareholders’ (or owners’) personal assets are separate from the business and cannot be seized to pay outstanding debts incurred by the business. It should be noted that there are various tax advantages available to limited companies that are not available to partnerships or sole traders. However, expert advice before making the decision is essential. Tax planning and annual returns will need to be undertaken with the help of a professional and qualified accountant. The selection of an accountant must be undertaken with care and a decision based on personal recommendation is advised. Investors find it more attractive to invest in a company with limited liability than to invest in a business whose unlimited liability could involve them in financial responsibility that is greater than the amount of the investment. Long-term financing from lending institutions is more readily available because lenders may use both corporate assets and personal guarantees as security. The limited company continues to exist and operate regardless of any changes in the shareholders. For example, the death of a shareholder does not mean the termination of the company.
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There are more regulations affecting a limited company than a sole trader or partnership. Companies must report to all levels of government. As can be predicted, it is more expensive to establish and operate a limited company than to operate as a sole trader or in a partnership, because of the additional documents and forms that are required. In general, it is probably better in tax terms to start a small business as a sole trader or partnership. Once the business is mature and profitable, professional advice may be sought and the needs and implications of becoming incorporated can be researched. This delay ensures a better chance of making an informed decision from an experience base and with some indicators of profit and growth potential. The choice between setting up as a sole trader or as a partnership is largely dependent on individual preferences and circumstances. Consultants who start as sole practitioners may, when they are established, form a partnership with one or more congenial people. In the final analysis professional advice is required when setting up independent practice.
What Do I Want to Offer? A key point when starting out as a self-employed person is to decide what services are to be offered to clients and whether the services can be offered within current resources. The range of options is varied and will depend on past experience and the type of work enjoyed. The work of the independent occupational health nurse practitioner seems to break down into several categories. The most popular is providing an independent occupational health nursing service, usually on a set number of days per week or month to a client or clients who contract for the service. The work often entails pre-employment and ongoing health surveillance programmes, training and, in some instances, a treatment service. Another area of independent practice is consultancy, working with senior managers to design strategies, policies and procedures and then managing the implementation of the agreed work. Both elements can be incorporated into a contract for services but the latter offers a greater opportunity to influence the client at a senior level and requires a range of management skills. Some independent occupational health nurses may have a contract to provide full-time services, which seems to follow a company downsizing or rightsizing. This type of contract ensures a sustained income but the benefits and security of continued employment are often less advantageous for the independent than for someone directly employed. Remember, if the contract is not renewed then the independent practitioner is unemployed and has to start finding new clients. If selfemployment is really a preferred choice, the pros and cons of being tied down to one client should be considered carefully – a single contract may be too high a risk.
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What Do I Need? An Office and Space A major decision is whether the office will be in the home or in rented accommodation. Both have their pitfalls and both need to be well thought out. To work from home has many advantages, such as no travel and tax relief for a room used as an office. However, working from home needs discipline – office hours are office hours. Ideally the office should be a separate room with desk, shelves for reference books, filing cabinets, computer with broadband Internet access, printer, telephone and fax/copier. To rent accommodation means the need for regular income to offset overheads before making a profit. But the rented office will not intrude on private space. In the end it is a matter of choice and may be based on projected fee earning. Therefore, another essential is capital to set up a functioning and efficient office. Administrative Support This is another overhead, which would need to be covered on a regular basis before a profit could be identified. The appointment of an administrative support worker will depend on the type of services to be offered and the independent’s computer skills. In consultancy the need is more apparent as there is usually a volume of written communications. The decision may be based on some or all of the following:
r What is the role of the administrative support worker? r How much time is spent by the income generator on routine adminr r r r r
istration, e.g. accounts, invoicing, chasing payment, writing reports, chasing clients, marketing, etc.? Could this freed time be used to generate more income? Is the independent paid for report-writing time? How much of the report writing could be done by a third party? Is it nice to have or essential? Would it enhance the image of the business?
Computers Buying the best within budget and with lots of memory will help avoid the need to upgrade later. Whatever you think you will need, you should get a system that will do more. Deciding which computer and what programs to buy will depend on your projected needs: this is not as simple as it sounds so it is essential to do some market research. The best advice will be from someone doing the type of work being considered. But remember, everyone has their own favourite. You should identify computer packages that can be upgraded and are flexible. Monitors are important; the bigger they are, the easier they are to use. Of course, all independents will complete their display screen equipment risk assessments and ensure compliance, which is easier to
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achieve at the set-up stage. Ensure the programs are user-friendly and buy a virus and computer systems checking programme. As the independent will need to prepare reports, and the reports are a window to the business, a colour printer and a good graphics package are serious considerations. Seek advice from several Internet suppliers and consider a system, ideally broadband, that best suits your needs. This can be part of a mobile and TV package – dial-up can be used in areas where it is hard to get broadband. There are some very user-friendly computer accounts packages on the market. Accounts are essential for invoicing clients, for keeping a record of the transacted business and National Insurance, and for the accountant to prepare tax returns. The accounts packages will also calculate VAT and assist in completing the VAT forms. The paperless office is a laudable objective that is not as easy to achieve as to talk about. Keeping client files and copies of reports is essential for reference and in case of complaints. External hard or flash (usually USB) disks have fallen rapidly in price and provide a good method for backing up the internal drive. Users can use synchronisation software packages to facilitate back ups with the same file structure as the internal drive, but if a good filing system is used it is easy to back up from the root directory. This requires an understood and consistent system for directories, folders and files: for example, a directory may be labelled ‘Clients’, and each folder constitute a named client, and within the folder the essential files are placed. Retrieving files can be a nightmare, so consistent titling of files going into the appropriate folder in the right directory can be a time saver. From experience, dating the files – for example 00.11.03 letter to Jane Doe re interviewdoc – tells you a lot, and the computer will show all files by date sequence.
References Good up-to-date and varied references are essential for the independent. You will need the latest editions of textbooks, subscriptions to the best occupational health journals and broadband Internet access for e-mail communications, research, receipt of e-bulletins and so on. The risks of making recommendations based on outdated information are real and can result in clients taking action for loss of or detriment to business. The purchase of data is a tax-deductible item, as are office equipment and consumables such as paper, folders, pens and so on.
Do I Register for VAT? At a certain level of income a self-employed person must register for VAT. Current information can be obtained from one’s bank or an accountant, or the local Customs and Excise office. The advice varies from accountants about when to register but in fact you can register at any time. The advantages of registering are that you claim back VAT spent on any purchases that are made solely for business purposes:
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petrol, stationery, equipment, etc. A disadvantage is that for non-VAT registered clients you must add VAT to all invoices, which for some clients such as charities can make the fees seem high. The Customs and Excise will issue a refund if you spend more on VAT for the running of the business than clients pay in VAT for your services, which is likely to be the situation in the early days of the business.
What About Finance? Bank managers can be sympathetic to small businesses and if there is doubt about cash flow in the first few months it is better to discuss setting up a business account at the start. Bank charges can be high; for example, for every transaction in or out of an account there will be a bank charge and so it is worth shopping around. There is merit in obtaining a business credit card, which will assist in keeping private expenditure separate from the business and reduce the number of transactions in and out of the business account. The bank manager may request a business plan.
What is a Business Plan? A business plan identifies the amount of financing or investment required and identifies when it will be required. It demonstrates that you have considered all aspects of self-employment and that you recognise the opportunities and threats to the business. It is also a means to persuade an investor or bank manager that you are a good risk. In the longer term, if the objectives identified in the business plan have not been achieved, you are in a better position to identify the financial needs of the moment and to take appropriate action. Discussing the business plan with your financial backer or bank manager will enable focused discussions. Banks, Chambers of Commerce, Business Link offices and the Internet may provide templates for use when preparing your business plan. Local Chambers of Commerce run short courses for people setting up their own business. Some sample topics are: accounting for small businesses, marketing and basic management skills. Various areas should be covered in a business plan (see Figure 5.2). Any business plan needs to be well laid out and cross-referenced for ease of evaluation.
What About Tax and National Insurance? The basic requirement is to inform the appropriate local Inspector of Taxes of your intention to be self-employed as soon as the decision has been made. The relevant notification forms can be obtained from the local tax office. If you are no longer employed at the time of informing the Inspector of Taxes, the tax office will require the last P45 provided by your most recent employer.
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Introduction: company name, contact details, nature of the business and markets in the region, securities, business loans sought, proposed use of funds Description of services to be offered: possible market and growth potential, trends that may affect the business, e.g. size of market (stable or expanding), national and legal trends Nature of the business: what is to be offered, method of operating, clients to be targeted, competitive advantages of your business concept, location in relation to the client market, etc.
Figure 5.2
Business goals: short and long-term Marketing plan: methods of informing people of the services to be offered and who is likely to find the services attractive enough to agree a contract Forecasts: essentially what your market research indicates you can achieve and by when Costing: how much it will cost to set up and how much will be needed to survive until fees are generated Action plan: where are you and how will you get to where you need to be?
The Business Plan: Topics Usually Included
It is imperative to consider the issue of National Insurance (NI). The independent must notify the Department for Works and Pensions, even if the self-employment is part-time. If employed while establishing independence you can be designated as employed and self-employed and the NI contributions can be deferred until you reach a certain level of income. Up-to-date information can be obtained from the Department for Works and Pensions. If the decision is made to employ staff in the business you may have to deduct Pay As You Earn (PAYE) and National Insurance. In general terms it is better to employ an accountant to address these regulatory requirements.
Do I Need Business Insurance? Employer’s liability insurance is a must if staff are employed. A pitfall to be aware of is when other independent consultants are sub-contracted to fulfil a client’s needs. It is prudent to check their professional insurance position and to seek legal guidance regarding the difference between contract for services and contract of services. Some client contracts will require the principal independent to obtain insurance for several million pounds as part of the contract requirements. This is then factored into the contract price. The independent professional must have appropriate professional indemnity insurance. This can be obtained either through the independent’s professional body or from an insurance company. If private insurance is needed, a reputable insurance broker can assist. Car and equipment insurance are also needed and once again insurance brokers are the best initial contact. It is recommended that several
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brokers be approached, as the cost of insurance can vary considerably. One issue that is becoming easier is to insure your office equipment when the office is home-based. An increasing number of insurance companies are now providing this cover, often as part of the home contents insurance. Sometimes there are restrictions to the cover – for example, clients visiting the home office – so the business plan should reflect this need. It is essential to notify the insurers that your car will be used for business purposes and there is merit in asking about cover for car contents, e.g. general equipment for service provision, laptop, etc. There are other insurance considerations, such as insurance for life and health, loss of earnings, cash and cheques, theft, fire and damage to buildings. It sounds a minefield but a reputable broker can assist, as can the professional bodies. The necessity is to obtain sound advice, make an informed judgement of actual needs and avoid the trap of gold star cover if the nature of the client work and services provided can be covered by professional indemnity and car and equipment insurances. All the overheads mount up before a profit can be made. It is easier to spend than recoup!
Personal Pensions This is another area where independent financial advice must be obtained. Remember that banks are likely to recommend to customers their own policies. You will need advice regarding your existing pension scheme(s). Is it better to freeze an existing pension or to transfer the cash to a personal pension scheme? The essence is to decide which of the many options is the best one for your particular circumstances. If you employ staff you may be required to offer pension advice and to consider whether the company will offer a pension to staff.
Independent Practice The decision is made, advice has been evaluated and required notifications have been completed. Now the hard work starts.
What Shall I Call the Business? What is in a name? Careful thought is required. Is the name of the business to reflect the independent themself, such as Jane or John Doe, or does the name of the business reflect that there are associates, such as J. Doe and Associates, or what the business provides, such as Essential Occupational Health Services (my apologies to all J. Does and any business of the name used as an example!). Once the name has been agreed, the question of a logo needs to be considered. It is not essential but it does give the feel of an established
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organisation and can be used on business cards, business headed notepaper and marketing brochures.
What will Be Offered to Clients? Working as an independent is very different from working as an employed person; the type of service offered to clients will dictate how different. If providing an occupational health service such as preemployment and risk-focused health surveillance programmes, the expectations of the client will range from sustaining existing programmes to creating programmes and then implementing them. If the latter work is required, the independent may have to create, tailor, recommend and then implement policies and procedures based on statutory requirements, risk or needs assessments and best practice. This is when the perils of self-employment become more easily recognised and where references, knowledge and experience come into play. Training may also be a service that clients require. The trainer is expected to be knowledgeable not only concerning best practice but concerning the client’s individual and specific needs. Prior to embarking on this type of work it is prudent to complete a training needs analysis – What do they have? Where does the client need to be? Preparation, supported course notes and lively presentations using computer-generated graphics are really the norm today. Remember: Good teaching is one-fourth preparation and three-fourths theatre (Gail Godwin; see Kelly and Kelly 1989). Consultancy is another type of service that can be offered to clients. A consultant is a person that other people or organisations ask for advice and look to for guidance, instruction and/or information. Again, there is a range of consultancy services that can be offered to clients, from working with company teams to improve the implementation of policies and procedures of an occupational health department, to assisting the client to turn the advice into action, to working at a corporate level and facilitating strategic planning, policy and procedure designs and methods to achieve progress. Other forms of consultancy are auditing, assessment of needs and helping companies to managing compliance. The real issue for a consultant is to identify what is needed and not just accept what the client believes they need; this is a form of specialised project management. Project management can be broken down into several steps or phases and each step should be carefully designed, tested and presented. Once presented, it can constitute a contract for services. Consider the steps outlined in Figure 5.3.
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r r r r r r r r
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Define the objectives: what objectives need to be set to meet the needs of the project and when is the project to be completed? Establish terms of reference: how can the objectives be met? Construct a realistic and achievable work schedule, breaking the project down into phases, identifying who will do what and by when, noting resource needs both hard and soft. Hard needs include computers, facilities, assistance, etc.; soft needs encompass experience, creative thinking, flexibility, strategic planning, etc. Plan for quality: demonstrable facts are important in every output and activity. Plan time scales: each phase of the project will have a time frame for completion. This is the means to drive the project forward. Deliver outputs to client specifications, with regular reports to clients to keep them abreast of developments. Conduct SWOT of project quality of delivery: constant improvement may be made by learning from success and failures. Consider the cost of the project: if the independent needs to provide the hard resources this will be a cost factor.
Figure 5.3
Project Management
In preparing a proposal, the detail can be broken down into the above elements. However, it is important to realise that not all elements of the project management list will be appropriate to all contracts.
How Will the Clients Be Found? Remember the golden rule: it is easier to spend than to recoup. So be focused and accept that marketing is expensive, and that general marketing such as a general mailshot is not usually cost-effective for the small, specialist business. Contracting a company to call possible clients is expensive and in general does not generate many leads. However, if a couple of leads are the targets then cold calling may be a considered approach. Cold calling simply means that you telephone and try to reach the right person to persuade them that, whatever you are offering, the prospective client cannot do without. Preparation is needed, such as:
r Identifying the types of companies in the area in which work is sought.
r Going to the library and researching the names and positions of key
r r r
managers or directors, purchasing directories of local companies or purchasing lists of companies of interest from the local Chamber of Commerce, for example. Preparing the introduction and sales pitch. Ringing to sell yourself and the services to be offered. Keeping comprehensive notes.
The aim is to get an appointment to meet. Be prepared for talented blocking manoeuvres by receptionists through to personal assistants.
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The business card and headed notepaper are forms of marketing. These tools must be used, so keep your pockets full of business cards wherever you go. Make sure your business card states clearly what you do. A carefully worded advertisement in carefully selected journals can result in leads. Whichever avenue is selected, it is important to remember that the lead-in time from contact to work can be months and in some cases years. Another method of working as an independent is to register with a reputable agency, which will do the marketing and put you in touch with clients. It is possible to obtain work from a range of clients, ensuring a full diary with a variety of companies or involvement in a variety of projects. The agencies must be registered if they are recruiting or placing nurses, and the agency will pay NI. It can be a low-risk way to real independence.
How Much is to Be Charged? If the work is found via an agency they will have a range of fees to offer, so be sure to negotiate. A golden rule is to remember that the independent is selling a service and aiming to run a profitable business. Occupational health nurses seem reluctant to be realistic about the fees to be charged and in essence offer services at a low rate and then regret the decision. If the services and the experience are to be valued they must be realistically costed. If working as a true independent, it is essential to sit down with a calculator and do some sums. There are some personally tried and tested golden rules for setting fees in Figure 5.4.
r r r r r r r r
General Points What do you need to generate to ensure the business is solvent? Identify overheads – rent, insurances, staff costs, telephone, etc. Work out a day and hourly rate based on the above, with a profit margin. Remember just covering costs is no way to run a business and make a profit. Find out what other independents are charging in the area (there seem to be regional variations in fees). Decide either to charge expenses separately or to make the fee inclusive (plus VAT if registered). Specific Points to Consider Is the work occupational health nursing or consultancy? (The latter tends to generate a higher fee.) What does the project management profile identify as the real needs and time commitments for the practitioner? When a contract for services is pending it is also worth considering the client and the length of the contract. Short-term contracts tend to be costed at a higher rate, as the independent needs to work and find other clients. If equipment is required, the cost of hiring it should also be included in the fees.
Figure 5.4
Setting Your Fees
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How to Keep Clients An independent must ensure they provide the services agreed to a standard expected by the client. It is prudent to agree the detail at the start of the contract for services. There are several issues that need to be considered before entering into an agreement to provide services, such as:
r The duration of the contract and terms of termination. r The fact that the independent contractor is not entitled or eligible r r r r r
to participate in any benefit programmes or tax-withholding obligations on the part of client. The detail of the services to be offered. Who will do what – ensure both parties agree. Confidentiality of information obtained during the term of contract. Liability to the business. This can be limited by adding a clause that states liability for loss or detriment to the client will be equal to the amount of the contract. The period of payment of invoices. Consider charging a penalty for late payment. Late payment of invoices sent to the client can have a serious impact on the business, as there will be companies and people waiting for payment from the independent.
Working as an independent occupational health nurse practitioner can be rewarding and certainly challenging, but it is not for everyone.
References AOHNP(UK) (1998) Information for Independent Occupational Health Practice, Leicester: AOHNP(UK). Gray D.A. (1996) Start and Run a Profitable Consulting Business, London: Kogan Page. Kelly F.J. and Kelly H.M. (1989) What They Really Teach You at the Harvard Business School, London: Piatkus. RCN (2000) Turning Initiative into Independence, 2nd edn, London: RCN. RCN (2003) Information for Would-Be Nurse Entrepreneurs: Turning Initiative Into independence, 3rd edn, London: RCN.
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6
Marketing
Janette Murray
Introduction This chapter introduces some basic marketing theory and terms, applying them to occupational health nursing. Practical examples are provided to encourage occupational health nurses to consider marketing an integral part of a quality service and an activity they actually carry out in practice every day. Marketing is about increasing awareness of what occupational health professionals do and the value they create. This is a key component in gaining a wider market for occupational health services. Marketing is no longer the remit of the ‘marketing dept’ in leading organisations; it is what everyone does. Marketing shapes the company, services and every client interaction (whether internal or external). Marketing skills can be utilised in all occupational health settings to allow occupational health nurses a means of reaching their target population and increasing access to services. Marketing is a process by which occupational health providers can examine the aims of their own service and plan to meet the needs of customers effectively. The marketing process is essential, not only in securing contracts and winning business, but also in ensuring that both employers and employees (all customers of the service) are satisfied and that contracts are well managed and retained.
Occupational Health Nursing Edited by K. Oakley. C 2008 John Wiley & Sons, Ltd
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Concepts of Marketing Occupational health nurses employed by commercial occupational health providers or working as independent occupational health consultants may already be familiar with the marketing process. Others may believe that marketing is not something they need to consider or implement, particularly if they are part of an integrated occupational health service within an organisation or are not involved in income-generation activities. Some occupational health professionals believe that evidence of professional competence, qualifications and experience will ensure that their skills are automatically recognised and appreciated (Chan 1992). However, if marketing is defined as A customer-centred process carried out with passion and enthusiasm throughout the service provider’s organisation (Clarke 2000 p. 32) we can begin to see that marketing is not just a function by which commercial occupational health providers win business but can, and should be, a means of ensuring customer satisfaction in all occupational health services. Jowett (1996) describes marketing as a process that ‘underpins daily working practices’, providing an opportunity to identify customer needs, explain and develop services and monitor the effectiveness of services and practice. Most occupational health nurses are involved in these actions on a daily basis, in assessing and meeting the needs of both employer and employee. Occupational health nurses are familiar with the challenges and ethical dilemmas posed by delivering a service to both employer and employee, both being ‘customers’ of occupational health services. In this chapter I have chosen to use the generic term ‘customer’ to include both the employer (purchaser of the service) and the employee (user of the service). This is to demonstrate that marketing is not just about winning business, but is a process that can be used to ensure best practice within quality service delivery; that is designed to meet the needs of all parties. Perhaps unwittingly, marketing has already become an integral skill for many occupational health nurses, as most will have been carrying out a marketing role, to some degree, throughout their practice. A form of marketing takes place every time the role of the nurse/department is explained to a new employee, whenever the team contributes to an in-house company newsletter and whenever a nurse makes a presentation to management on the utilisation rates of the service. The continuing need to explain the role and benefits of occupational health to employers, employees and even our peers has inevitably led to the development of marketing skills, which we may not even be fully aware of possessing.
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Clarke (2000 p. 48) says that marketing allows us to ‘recognise that we constantly need to review the services we give and how we give them so that they can be given in the most cost effective way.’ This description perhaps does not seem so alien to occupational health practice, given that a similar one might be given of assessment and audit. The need to review and audit services is well documented by a number of authors (Macdonald 1992; Widtfeldt 1992) and is covered in Chapter 4 of this book. The RCN 1998 Marketing Guide provides a useful summary on the concept of marketing as:
r A philosophy: without satisfied customers there is no business. r An ethos: planning to be exceptional, professional, efficient, effective and responsive to customers’ needs.
r A way of thinking: identifying what is wanted, the current position, where you are going and how you are going to get there.
r A process: identifying business goals, gaining market information, making strategic decisions, setting objectives and monitoring (RCN 1998 p. 3)
The Marketplace Workplaces continue to change within the UK, with heavy engineering and manufacturing industries being overtaken by the electronic, financial and communication sectors. New technology, work practices and the ever-changing nature of business have not only altered the types of physical, chemical and biological hazards that occupational health professionals deal with but in many cases have altered access to and delivery of occupational health services. Some large companies, which traditionally employed in-house occupational health services, are outsourcing services or expecting existing teams to ‘income-generate’ funds. Example of this are the incomegeneration activities of NHS Trusts and the launch of NHS Plus in England and Wales. This government initiative encourages NHS teams to market occupational health services to local small and medium enterprises (SMEs). There have also been increases in the numbers of independent commercial occupational health services established and nurses working as private, independent practitioners. The need for effective marketing of occupational health becomes increasingly evident if the HSC targets, set out in the long-term occupational health strategy for Great Britain, Securing Health Together (HSC 2000a), are to be met. This strategy set targets for the reduction of workrelated ill health and stated the need to create more opportunities for rehabilitation at work. UK statistics show that small-to-medium enterprises (those employing fewer than 250 employees) account for 99 % of private sector
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businesses and 58.9 % of total employment (Dept for Business Enterprise & Regulatory Reform 2007). The Occupational Health Advisory Committee report (OHAC 2000) clearly outlines the lack of provision within the SME sector and the challenges occupational health professionals face in accessing this sector of the workforce. Marketing skills will be required in order to reach this important sector of the working population.
The Nature of Services In a marketing context, the delivery of occupational health is a service, whether carried out in the public or private sector, in the NHS, in large multi-skilled teams or by independent practitioners. Kotler and Armstrong (1991 p. 110) describe a service as: An activity or benefit that one party can offer to another that is essentially intangible and does not result in the ownership of anything. It is important to outline the differences between goods and services in order that the core elements of marketing a service become evident. Occupational health services are intangible in that they do not produce goods but comprise processes and interactions between people; the exchange of information and advice; health gain for individuals; and aim to make a positive economic contribution to the business or organisation they serve. While these processes and interactions require the use of facilities and equipment and the creation of reports, the service is essentially the interaction between the occupational health professional/team member and the customer. The concept of ‘intangibility’ of a service means that it cannot be touched, heard, smelt or seen. Whilst we can see someone receiving a service, this is not the same as actually experiencing the service. It is the experience of the customer that remains crucial in service delivery. The customer is inevitably participating in the service interaction and must therefore be central to it. Clarke (2000) describes four crucial components of a service:
r r r r
intangibility customer is involved in it it is consumed whilst it is being provided the customer can be the arbiter of quality.
The customer is involved in the provision of a service throughout, as opposed to provision of goods, where production may have occurred at a different place and time. Recognising the intangible elements of a service and the restrictions these bring in demonstrating an effective operation leaves us with the problem of articulating the benefits of occupational health (to both
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employer and employee). This is an ongoing challenge. Artus et al. (1992) describe outcome measures as the most compelling method of describing occupational health, and these include benefits to employer, employee and society.
The Marketing Plan A written marketing plan provides a clear focus on the direction the service is taking and the contribution all members of the team can make. The marketing plan needs to have SMART objectives that are Specific, Manageable, Attainable, Realistic and Time bound. The marketing plan should not stand alone, but be an integral part of the service provider’s overall business plan, outlining the short, medium and long-term goals of the service. This ensures that the marketing plan is an active process that is regularly reviewed, and adapted when appropriate. Ideally all members of the team should contribute to the formulation of the marketing plan, to ensure that each individual takes ownership of the plan and is committed to following it through. As well as being a strategic business tool, marketing is essentially a process carried out at every level, and by each individual, in an organisation (Chan 1992). For example, the first point of contact for many customers will be the receptionist. A warm, friendly welcome to all contacting the department will set the tone and create a positive climate for the occupational health interaction. The impression created by each team member inevitably contributes to the successful marketing of the service. It is vital that all contact with potential and existing customers is courteous, prompt and professional. This creates a positive culture and ambience that will be communicated to customers. A satisfied customer will spread the message about the service in a positive way, which further contributes to successful marketing. Successful marketing (and a quality service) is achieved by paying attention to all aspects of service delivery, taking care of the relatively straightforward day-to-day contacts, as well as the more ‘formal’ marketing strategies. A SWOT analysis can be used to examine strengths, weaknesses, opportunities and threats within the service and the market it aims to serve (see Figure 3.3). Development of a marketing plan needs to start with some very basic questions: 1. What services are on offer? Service providers must be clear as to the range of services they can offer with the resources and staff available and within budget constraints. Services on offer will be dependent on the range of skill mix within the team and access to facilities and transport. There is no value in marketing services and raising
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customer expectations concerning services that cannot be delivered. The range of services marketed may need to be adjusted, or additional staff recruited, if the skill mix within the occupational health team changes. 2. Who are we offering services to? 3. How are we going to reach them? 4. Who are our competitors? Questions 2–4 can be answered by using the formal marketing concepts of segmentation, targeting and positioning.
Segmentation Segmentation is the process of separating customers into groups with similar characteristics. Segmentation provides a clear focus on the type of customer the marketing plan is aimed at and ensures that the service provider has addressed the practical implications of resources, location and equipment to meet customer needs. Customers can be divided, for example, by: Size:
r small enterprises – 50 or fewer employees r medium enterprises – 50–250 employees r large enterprises – 250 or more employees. Geography:
r companies within a 20-mile radius r companies within a defined geographical area r organisations with multi-site locations across the UK. Sector:
r industry/commercial r electronics r retail r financial institutions r manufacturing r transport r food and drink. r public sector r health care service providers r local authorities r fire service r colleges r police service.
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Segmentation allows the service provider to identify potential customers and to consider the occupational health requirements they are likely to have. Clearly, however, a full needs assessment can take place only when contact with the customer has been made. Occupational health professionals must not compromise professional ethics, for example by delivering a service such as lifestyle health promotion if they are aware that statutory requirements such as audiometric testing under the Control of Noise at Work Regulations 2005 are not being carried out (HSE 2005). The following case studies demonstrate market segmentation and will be continued later to show market targeting:
Case Study A An NHS Trust occupational health team planned to provide services to external organisations as a means of income generation. Market segmentation was used to identify potential customers in the local area. It became evident that four large financial organisations had their headquarters within a 15-mile radius of the team’s base. The team decided that they could serve this type of organisation with existing resources and without any additional capital outlay. The team had experience of counselling and stress management intervention, which could potentially be valuable in the fast-changing world of finance. Case Study B Market segmentation was used by an occupational health nurse working independently. Segmentation allowed her to identify a number of small electronics companies within a 30-mile radius, mainly sited in industrial parks on the outskirts of town. On average the companies had fewer than 100 employees and would not require a full-time service. The nurse had transport, portable equipment and experience of working in industrial environments and felt able to meet the expected health surveillance needs of the companies. The marketing plan was therefore tailored to offer a peripatetic service on the customers’ own premises, with the emphasis on easy access to professional advice and support. In-house occupational health teams can also use segmentation to identify specific departments within an organisation and to ensure that services are being marketed according to the department’s anticipated needs.
Targeting Once the decision has been made to market to a certain segment it is essential to gather as much information as possible about potential customers, and indeed about competing service providers in the marketplace. The type of information that can be collated on the customer includes work processes and activities, the structure of the company and the economic climate of the market sector. This information can be
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obtained from the customer’s promotional material, annual report and accounts, company web sites and from local business networks. Such background information helps to ensure that marketing can be tailored to meet the expected needs and culture of the potential customer. Research into the market allows the service provider to consider the likely needs of the customer and predict some of the occupational health hazards and risks the customer may have. This professional perspective on the market sector will allow you to consider the services the customer is likely to need.
Case Study A (Continued) The NHS Trust occupational health team obtained the annual reports for the four financial companies and visited the web sites. This provided valuable information on the structure of the companies and their current business performance. The number of employees was also obtained by this method. It was noted that two of the companies regularly advertised for staff in local newspapers, suggesting that either business was booming or staff turnover was high. Professional journals and the media provided research data that suggested the fast pace of change in such organisations might be causing a higher-than-average level of sickness absence due to stress and anxiety, with two recent claims of work-related stress being settled in court. The research suggested that the organisations had the need (and financial means) to consider a comprehensive occupational health service. Case Study B (Continued) The independent occupational health nurse used a literature review to obtain background information on the hazards and risks of the electronics industry. Recruitment roadshows for the companies were held locally and these provided further information on the culture of the organisations and revealed the fact that employees were often on short-term contracts. This suggested that marketing should be tailored to promote health surveillance and pre-employment health assessments.
Positioning The information gained through targeting can be used to position your service to attract potential customers. The seven ‘Ps’ provide the key elements of the marketing mix:
r r r r r r r
people physical evidence process product place price promotion.
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The final four Ps – product, place, price and promotion – are usually used to describe the marketing mix required for goods. People, physical evidence and process cover the specific nature of services, including the ‘intangibility’ factor. The marketing mix allows one or more of the key elements to be adjusted according to the potential customer’s needs. It is naive to presume that the customer is interested only in price. For example, the targeting research may suggest that the customer is prepared to pay a premium price in order to obtain the services of highly experienced staff. The marketing mix should therefore be adjusted to place the emphasis on people. Alternatively, the customer may have staff working on a number of sites across the country; therefore access to services and consistency of service delivery is important. This would make the place and process elements of the marketing mix the most important. Understanding and adjusting the seven key elements of the marketing mix to meet customers’ needs can create a ‘unique selling proposition’ – the feature or features that distinguish one company’s services over another (Clarke 2000). The seven Ps are described in more detail below, as they are the core elements of the marketing mix that all services need to address. ‘People’ is first on the list as it is the foundation on which occupational health services depend.
People A service can only be as good as the people who deliver it. The skills, experience, competences and qualifications of professional staff are key components in the people element of the marketing mix. To deliver a quality service, competent, experienced occupational health professionals are essential. This should be the main emphasis in marketing a service and can be achieved in a number of ways:
r Using staff profiles and professional qualifications (within ethical guidelines – see below).
r Providing examples of professional staff’s experience, background r
and specific interest and expertise, e.g. 10 years’ experience in counselling or an interest in stress management. Providing references from other satisfied customers.
Physical Evidence Physical evidence is the tangible aspect of service delivery, including equipment and facilities. Customers are interested in the types of facilities used for service delivery and may request a visit to premises. They may want to see a mobile screening unit, inspect equipment in use, view examples of report styles and so on. Other things that can be used as tangible physical evidence of a quality service include new, modern equipment and disabled access to premises. Copies of standard letters, reports and consent forms can be
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useful in demonstrating style and format, but care is essential to ensure medical and commercial confidentiality. Also helpful is evidence of software used for recording health screening activities, appointment recall systems and production of reports. Statistical reports and outcome of services, such as statistics showing a reduction in sickness absence for a customer or cost savings made by decreased litigation and savings in employer’s liability premiums can be very useful.
Process The process of service delivery needs to be clear and this includes nature of referrals, turnaround time for reports, format of reporting, policies, procedures and agreed outcomes. The service provider may have a quality system in place, which can be used to demonstrate a consistent method of service delivery with audited processes (see Chapter 4). Other examples of the process of service delivery are: use of computerised appointment, recall and reporting systems; written policies and procedures for tasks, confidentiality and storage of records; compliance with ethical and professional guidelines; evidence of calibration and maintenance of equipment; system for handling customer feedback and complaints. Product What exactly is the service ‘marketing’? r A ‘one stop shop’ offering a comprehensive range of skill mix, including occupational health nurses and physicians plus health and safety advisers, ergonomists, physiotherapists, etc.? r A nurse-based service with an appropriate skill mix and particular expertise in health promotion, health screening, stress management and sickness absence intervention? r Particular expertise in one key area such as stress management, counselling, travel health? r A task-based service for customers with a specific need, e.g. audiometry, risk assessment? By identifying the expertise within the team and the aims and objectives of the service, the nature of the product and type of service on offer can be identified and an appropriate marketing plan created. Any service is doomed to fail if it markets a product or service it cannot adequately deliver. This inevitably leads to disappointed or dissatisfied customers who will not make use of the service again.
Place It is essential to consider where the service will be carried out. The service provider may have premises in a central location, easily accessible to all customers. But what about the customer with locations beyond the central area or staff working in remote areas? How
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will they access the service? Will employees be expected to travel to the service provider or is a mobile peripatetic service to be made available? Many SMEs do not have appropriate facilities within the work environment to carry out an on-site occupational health service, e.g. those based in small garages and workshops. They may also be reluctant to allow staff time away from work to access an occupational health service. This can present a challenge in service delivery. Some occupational health services meet this need by using fully equipped mobile units. In practice, staff can be mobile, and some equipment, such as vitalographs, is easily portable; however, a soundproof audiometry booth does not pack down easily!
Price Remember, pricing is only one of the seven Ps within the marketing mix. As stated earlier, it is a falsehood that customers are interested only in price; they may well have other areas of priority. Organisations will not always opt for the cheapest provider; many will be prepared to pay a premium price for perceived quality of staff, prompt turnaround times for reports, accessibility of services or other components of service delivery. In any commercial operation, a fundamental objective is to make a financial profit in order to survive. As discussed below, occupational health service provision can be carried out on a commercial basis without compromising professional and ethical standards. Prudent financial planning will achieve the business objective of making a profit in order to survive but can also provide funds for training, investment in facilities and resources, and the ongoing development and education of staff. Pricing for profit, therefore, is important. However, if the customer can remember only the price of the service, it suggests that perhaps the quality was lacking in some way. In occupational health we would hope that the competence and professional approach of the staff would be more readily recalled. Prices can be calculated by: 1. Fee for service: each item of service has a price and the customer pays per number of items used. This is often used as a means of pricing task-based services involving equipment, such as lung function tests or audiometry tests. 2. Cost of professional time: this allows the customer to be charged in units of time, usually on an hourly, half-day or full-day rate. This can allow the customer to make the best use of the professional’s skills, contracting for an agreed period of time during which a variety of services can be carried out.
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When costing work, the occupational health nurse has to consider covering the direct and indirect costs of offering the service. These will include:
r Staff salaries and benefits (including employer’s contribution to penr r r r r r r r
sion scheme, National Insurance, etc.). Cost of premises and running costs of facilities. Maintenance of equipment. Consumables. Professional indemnity and insurance. Training and development of staff. Transport (peripatetic or multi-site location). Depreciation of resources. Profit element.
Pricing is an important area in which expert advice may be required. Pricing is also influenced by other factors, including:
r Price charged by competitors: while customers may be prepared to
r r
pay a premium for a quality service, they are likely to be aware of the ‘going rate’ offered by other providers. This will have to be taken into account when pricing services. Constraints made by government or outside agencies: e.g. some NHS Trusts and local authorities are bound by government policies on pricing, outsourcing and income generation. What customers are prepared to pay: the concept of ‘value for money’ is ultimately decided by the customer and is intrinsically connected to the quality of the service. Employers are normally looking for financial benefits from occupational health, such as a reduction in sickness absence and improved productivity from a fit workforce. Perception of ‘value for money’ can influence the price employers are prepared to pay in achieving their own financial objectives.
Promotion There are a large number of methods, direct and indirect, that can be used to communicate with existing and potential customers. The aim of promotion is to get the service known to all and to portray a particular image of the service. The style and content of promotional material are important. Promotional material has to appeal to a wide range of customers. It must be visually attractive in order to encourage them to pick it up and read the content. Logos and brand names can be useful in attracting attention and encouraging people to find out more about the services on offer. Examples of ‘straplines’ include: r Occupational Health – Making your Workplace Better (WellWork Ltd, promotional material). r Occupational Health Solutions (Business Healthcare, promotional material).
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Once the reader has been attracted to the promotional material, the style and content of the information must be presented in a manner that will encourage them to read on. It is vital to avoid technical jargon and use language that will appeal to a range of readers. The emphasis should be on the benefits occupational health can bring to the customer and the unique selling points that the provider has to offer. Promotional materials for services need to highlight the benefits of the service to the customer, rather than just present lengthy lists of the services on offer. Customers need to know how these can make a difference to their organisation. For example:
r r r r
Cost savings due to a reduction in sickness absence. Reduced threat of litigation. Reduction in workplace accidents and inherent costs. Potential for reduction in employer’s liability insurance.
A professional image can be portrayed by consistency in letterheads, business cards and promotional leaflets. Good quality paper should be used for stationery, with printing in a clear typeface. This helps create an image of attention to detail, quality and reliability. The use of printed business cards, including staff qualifications, promotes the professional expertise available and provides customers with readily available contact details. Most organisations will have a web site to promote their business. The layout and design of the web site must also portray the professional image you wish to promote. If the graphics, text and functions are clear and stimulating this will enhance the image of a forward thinking, proactive organisation. Web pages can be used to outline services, introduce staff and promote events you may be planning. Video images can graphically display facilities. Offering direct e-mail contact encourages immediate access and interaction should the potential customer wish to contact you. Web pages can provide links to other sites of mutual interest, such as professional bodies, to provide a comprehensive occupational health network. It is essential that web sites and promotional literature be updated on a regular basis, to ensure only current information is conveyed. Networking is regularly carried out by nurses at seminars, conferences and in day-to-day interactions with colleagues and other contacts. Occupational health nurses working in single-handed posts often rely on networking to avoid professional isolation. Networking is not only used to maintain contact with peers and for personal development; it is also an essential marketing tool. Networking affords an opportunity to explore an overview of current trends, discover contracts coming up for renewal and learn of colleagues who may be looking for a change of post or direction. This can be useful information in establishing new contacts, potential work and an awareness of colleagues’ movements. Some or all of these may be useful in
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marketing. Networking is a two-way process of communication, providing an opportunity to let others know of your organisation and the services and professional opportunities you have available. Membership of professional groups and business networks affords excellent opportunities for networking. The local Chamber of Commerce, Business Link groups, the Federation of Small Businesses and other business contacts create opportunities to meet and establish working relationships with a broad base of potential customers. As outlined above, a service is often defined by the quality of the people delivering it. By participating in seminars, workshops and conferences, professionals enhance not only their own personal image but that of their organisation. Some occupational health service providers also use free seminars as a marketing tool to meet existing and new customers. Such events allow the professional image of the organisation to be presented in an interactive forum, encouraging customers to get to know the staff and culture of the provider.
Contracts Successful marketing should lead to a contract or service level agreement between the provider and the purchaser of the service. The contract or service level agreement should be agreed by both parties, to clarify:
r r r r r
The nature and volume of services. Agreed prices. Priorities and targets for service delivery. Procedures for monitoring quality standards. Procedures for raising complaints/grievances.
Tenders Organisations seeking to purchase a service may use the tender process to invite providers to submit bids for contracts. Many local authority and government departments are required to follow this procedure to ensure that best value is achieved in the purchasing process. Invitations to tender for specific services are to be found in professional and business journals. The organisation seeking a service will usually issue a tender specification, which outlines the nature of the service it is seeking and the expected volume of work, location, etc. The provider can then use this information to prepare a proposal for the tender, using the seven Ps of the marketing mix to describe the proposed service. Costings are also included in the tender submission. Tenders are usually submitted to organisations as sealed bids. The purchaser will draw up a shortlist of
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preferred bidders, who may be invited to present their proposals to the purchasing organisation prior to a final decision being made.
Professional and Business Ethics Both occupational health nurses and physicians need to ensure that, where a fee is charged for services, professional ethics are not compromised. Professional integrity must underpin any service in order for it to function ethically and to ensure safe outcomes for both employer and employee. Marketing occupational health services should not compromise these objectives. The Nursing and Midwifery Council Code of Performance, Conduct and Ethics (2004) states that this does not mean that nurses cannot participate in commercial organisations but that the fundamental principles of nursing must be maintained. This includes the necessity to ‘ensure that your registration status is not used in the promotion of commercial products or services, declare any financial or other interests in relevant organisations providing such goods or services and ensure that your professional judgement is not influenced by any commercial considerations.’ The Private Practice Forum of the Academy of Medical Royal Colleges (2000) offers guidelines for physicians to ensure compatibility between professional and business ethics. The guidelines are equally applicable to occupational health nurses, and aim to minimise conflict between professional and business ethics. They include the following advice:
r Limit advertising to the provision of factual information about services and avoid making excessive claims.
r Do not damage the professional, personal or business reputation of other occupational health providers and professionals.
r Ensure suitable procedures exist for the transfer of records on change of contract.
r Do not accept or perform work either on an individual basis or on behalf of an organisation that you are not competent to perform.
r Declare any potential conflict of interest to the client, e.g. contractual or other financial interest in respect of competitor companies. It is important that GMC and NMC guidelines, which limit advertising to the provision of factual information about qualifications and services, are adhered to.
Conclusion Marketing skills are important to all occupational health nurses in developing a client-focused approach and delivering a recognised quality
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service. Marketing can also be used as a tool in the continuous improvement of occupational health practice and the effectiveness of services. Marketing activities need not compromise professional integrity and ethics. The occupational health provider has a professional duty to ensure that an employer is meeting statutory obligations in health surveillance and risk assessment before any additional occupational health services are implemented. However, dialogue with the employer and a full needs assessment can be carried out only when contact with the customer has been achieved by the marketing process. It is essential to remember the role of informing and educating within marketing. There is always an objective to the activity: what are we trying to achieve? Your audience needs to be engaged and interested – the facts must be relevant to them and spur them to action. Marketing skills can take time to develop and the marketing process often takes many months before it is successful in attracting new customers to occupational health. However, if the challenges set out in the strategy Securing Health Together (HSC 2000a) are to be met, all occupational health nurses will need to continue developing and implementing marketing skills to reach the majority of the working population.
References Artus K., Atwell C., Bannister C., Cholerton C., Dymott S., Johnson G. et al. (1996) How to Market Your Professional Services: a Strategic Approach, Management Decision 30(7), 45–53. Clarke G. (2000) Marketing a Service for Profit, London: Kogan Page. Department for Business Enterprise & Regulatory Reform (2007) National Statistics URN 07/92.August. HSC (2000a) Securing Health Together: a Long-Term Occupational Health Strategy for England, Scotland and Wales, Sudbury: HSE. HSC (2000b) Report and Recommendations on Improving Access to Occupational Health Support, London: HSE. HSE (2005) Control of Noise at Work Regulations, London: HSE. Jowett S. (1996) Every Nurse’s Business: the Role of Marketing in Service Delivery, London: King’s Fund. Kotler P. and Armstrong G. (1991) Principles of Marketing, 5th edn, Englewood Cliffs, NJ: Prentice Hall. Macdonald E.B. (1992) Audit and Quality in Occupational Health, Occupational Medicine 42, 7–11. Maw J. and Miller C. (1996) Occupational Health Nursing: A Professional Perspective, London: Society of Occupational Health Nursing & Association of Occupational Health Nurse Practitioners (UK). NMC (2004) The NMC Code of Conduct: Standards for Conduct, Performance and Ethics July 2004, www.nmc-uk.org/aFramedisplay.aspx?documentID= 201.
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Occupational Health Advisory Committee (2000) Reports and Recommendations on Improving Access to OH Support, London: HSC. Private Practice Forum of the Academy of Medical Royal Colleges (2000) A Guide to Standards in Private Practice: Occupational Medicine, London: AINIRC. RCN (1998) Marketing Community and Specialist Nursing Services, London: RCN. RCN (1999) Working Well Initiative: Occupational Health Audit, London: RCN. UKCC (1996) Guidelines for Professional Practice, London: UKCC. Whitaker S. (1994) Self-Auditing the Occupational Health Physician’s Ethical Performance, Occupational Health 45(12), 412–13. Widtfeldt A.K. (1992) Quality and Quality Improvement, Occupational Health Nursing 40(7), 326–32.
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International Issues
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7
International Issues Panayota Sourtzi
Introduction The theoretical background of occupational health is generally assumed to be common across countries as well as amongst occupational health practitioners. According to this assumption, the content of occupational health programmes, both specialist and postgraduate, has a common basis. Occupational health practice, however, is based not only on theory, but also in the special working conditions that exist in each country, which are influenced by the country’s political situation and the resulting legislative requirements, as well as by its cultural background. Globalisation is the process of market uniformity throughout the world. As a result of globalisation, financial influences are the most important – not necessarily positive – factor influencing changes in occupational health service provision today.1 Although some of the wellestablished occupational health systems still keep their ideology and function, others have started altering their organisations to comply with this new situation. Meanwhile, international organisations with a direct or indirect interest in occupational health have tried to make certain policies of global importance and to influence countries to adopt them as national legislation. 1 It would be challenging to try to analyse in depth the provision of appropriate occupational health services in such an environment, e.g. to tackle the lack of occupational health service provision in developing countries, especially those where Western industry has moved as a result of cheaper labour, or to respond to the occupational health needs of migrant workers ready to accept employment at any cost to their health and against any existing standards in the host country. In the end I thought that this could not be covered appropriately in the frame of this chapter and therefore it was left out.
Occupational Health Nursing Edited by K. Oakley. C 2008 John Wiley & Sons, Ltd
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Occupational health nursing (OHN) practice varies not only between, but also within countries because of these influences; this can be seen in the published international literature. However, OHN is considered by most OH provision systems as a core professional activity that contributes to both the health of the working population and the success of the organisation to which the OH department belongs. This chapter describes both how international organisations influence occupational health nursing theory and practice and how globalisation alters occupational health practice, which in turn promotes changes in occupational health nursing. I will therefore give a comprehensive picture of occupational health nursing worldwide, and then focus on European Union (EU) countries, where considerable changes are happening continuously not only as a result of globalisation but also because of changes in EU legislation. In both sections, I refer to the relationship between education and practice.
Occupational Health Nursing in the Worldwide Context It is necessary to begin by introducing the main international organisations related to occupational health nursing. Figure 7.1 shows the web sites of international and European organisations related to occupational health and occupational health nursing that are discussed in this chapter. The International Labour Organisation (ILO) was established in 1919 and in 1946 became the first specialised organisation within the United Nations framework following World War II. The ILO is directly related to occupational health, as it brings together the three main partners in the world of work: that is, the state, the employers and the workers. Its main aim is to promote better working conditions throughout its member states. Today there are 178 member states in the ILO, representatives of which participate in the annual International Labour Conference. Its main objective is to study working conditions, prioritise emerging problems and propose ‘conventions’ and ‘recommendations’ to its member states, which sign them and assume responsibility for adopting them into their legislation systems. Currently, the ILO aims to eliminate child labour, improve gender equality and establish decent employment and income (ILO 2007). The organisation and function of occupational health services is part of the remit of the ILO and throughout its history it has proposed numerous conventions and recommendations on the subject (Forastieri 2007). The World Health Organisation (WHO) was also established within the UN framework in 1946 and its aim today is to ‘direct and coordinate health issues worldwide. It is responsible for providing leadership on global health matters, shaping the health research agenda,
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International
European
World Health Organisation www.who.int
European Commission europa.eu
International Labour Organisation www.ilo.int
European Agency for Safety and Health at Work osha.europa.eu
International Commission on Occupational Health www.icohweb.org
European Foundation for the Improvement of Living and Working Conditions www.eurofound.europa.eu
International Council of Nurses www.icn.ch American Association of Occupational Health Nurses www.aaohn.org
European Federation of Nurses Associations www.efnweb.org European Specialists Nurses Organisation www.esno.org
Occupational Health Nurses Association of Nova Scotia, Canada www.ohnans.com
Federation of Occupational Health Nurses within the European Union www.fohneu.org
Australian College of Occupational Health Nurses www.acohn.com.au
European Federation of Regulatory Bodies www.fepi.org
University of Occupational and Environmental Health, Japan www.uoeh-u.ac.jp/dept/hokengakubu e.html
Finish Institute of Occupational Health www.ttl.fi
National Institute of Occupational Safety and Health www.cdc.gov/niosh Occupational Safety and Health Administration – USA www.osha.gov
Figure 7.1 International and European Occupational Health and Occupational Health Nursing Organisations
setting norms and standards, articulating evidence-based policy options, providing technical support to countries and monitoring and assessing health trends’ (www.who.int). Occupational health is therefore one of the topics included in its agenda. One of the most recent documents accepted by the WHO was the Declaration on Workers Health, which refers to the global right of working people to work without the risk of becoming ill or injured because of their work (WHO 2006). The International Council of Nurses (ICN) is a federation of national nurses’ associations (NNAs), representing nurses in more than 128 countries. Founded in 1899, the ICN is the world’s first and largest international organisation of health professionals. The ICN works to ensure quality nursing care for all, influence health policies worldwide
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and advance nursing knowledge and recognition and respect for nursing. The ICN Code for Nurses is the foundation for ethical nursing practice throughout the world, while its standards, guidelines and policies for nursing practice, education, management, research and socio-economic welfare are used as the basis for international nursing policy. The ICN also actively promotes occupational health and safety for the nursing workforce. It is worth mentioning that the theme for International Nurses’ Day 2007 was ‘Positive Practice Environments: Quality Workplaces = Quality Patient Care’ (www.icn.ch). The International Commission on Occupational Health (ICOH) is an international independent professional society, founded in 1906 in Milan as the Permanent Commission on Occupational Health. Today the ICOH has individual members from 93 countries and collaborates with all organisations that have common interests. The ICOH triennial World Congresses on Occupational Health are a stage for scientific information exchange. The International Code of Ethics for Occupational Health Professionals (ICOH 2002) is a very important document guiding practice today, and has been translated into several languages. The ICOH has 33 Scientific Committees, one of which is the Scientific Committee on Occupational Health Nursing (SCOHN). A study by Burgel et al. (2000), supported by SCOHN, presented information on OHN practice for countries from all continents. This useful document gives an insight into the changes in OHN over recent decades in relation to education, range of activities undertaken, role descriptions and working titles. Although OHN exists in countries throughout the world, it would not be possible to refer to each one individually in this chapter; rather we will focus on the countries with the greatest influence on the specialisation today.
United States of America Occupational health nursing has a long tradition in the USA and this is reflected in the numerous postgraduate programmes in its various higher education institutions. The National Institute of Occupational Safety and Health (NIOSH) and the Occupational Safety and Health Administration (OSHA) regulate occupational health in the USA, and they are an invaluable resource for occupational health professionals worldwide. OHNs are considered one of the core professions providing occupational health services, and they participate in decision making in both organisations. The American Association of Occupational Health Nurses (AAOHN) works to advance, guide, promote and protect the profession though various activities, such as continuous education and publication
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(www.aaohn.org). Its journal has a wide readership and is very often the primary resource for OHNs worldwide, both those wishing to obtain information and those wanting to publish their articles. Education of OHNs is organised at both specialisation and postgraduate level, including master’s and doctorate, while literature is extensive in terms of textbooks and articles in professional and scientific journals. A recent document (AAOHN 2003) has defined the competencies of OHNs. The AAOHN’s definitions are presented in Figure 7.2, in comparison with the competencies published by other organisations. Research is well established and there are opportunities for OHNs to obtain funding for research projects in various occupational health topics. A study on research priorities for occupational health nursing revealed that they were similar to general OH research priorities (Rogers et al. 2000) and did not differ substantially from those revealed in a study a decade earlier (Rogers 1989).
Canada Canada is a much smaller country in terms of population and therefore working population than the USA, but has equally well-established occupational health and occupational health nursing. In Canada, OHNs are registered nurses holding a diploma or degree in nursing and a certificate, diploma or degree in occupational health and safety from a community college or university. The Canadian Nurses Association grants nurses who have this expertise the right to use the title of certified OHN. The role of OHNs in Canada includes improving the health and safety of workers, and thereby the health of the community. The association aims at advancing the profession, encouraging the development of national standards for OHN and continuing education (www.cohna-aciist.ca).
Australia The Australian College of Occupational Health Nurses is the professional body for occupational health nurses in Australia. It was formed in 1976 as the Australian Occupational Health Nurses Association to meet the needs of the increasing number of nurses employed in private and public workplaces. It currently ‘promotes the professional standing of Occupational Health Nurses and provides members with support, educational and professional development’ (www.acohn.com.au). In a recent study it was found that Australian occupational health nurses engage both in traditional curative tasks and in health promotion, management and research activities, but it was concluded that traditional activities still dominate their work. Participants believed that in the future activities related to wellness, management and research
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competent proficient expert.
Figure 7.2
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Comparison of OHN’s Competencies as Defined by the USA, UK and WHO/Europe
competent experienced expert.
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Clinician (primary prevention, emergency, treatment services, nursing diagnosis, individual and group care plan, general health advice and health assessment, research and the use of evidence-based practice). Specialist (occupational health policy and practice development, implementation, occupational health assessment, health surveillance, sickness absence management, rehabilitation, maintenance of work ability, health and safety, hazard identification, risk assessment, advice on control strategies, research and the use of evidence-based practice, ethics). Manager (management and administration, budget planning, marketing, service level agreements, quality assurance, professional audit and continuing professional development). Co-ordinator (occupational health team, worker education and training, environmental health management). Adviser (to management and staff on issues related to workplace health management, as a conduit to other external health or social agencies). Health educator (workplace health promotion). Counsellor (counselling and reflective listening skills, problem solving skills). Researcher (health needs assessment, research skills, evidence-based practice).
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communication personal and people development health, safety and security service improvement quality equality and diversity.
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WHO Europe competencies (Whitaker and Baranski 2001)
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clinical and primary care case management work force, workplace and environmental issues regulatory/legislative issues management health promotion and disease prevention occupational and environmental health and safety education and training research professionalism.
Core competencies
RCN/UK competencies (Bannister and Maw 2005)
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would be more important to their practice and that they would need to devote more time to them, but they sensed that their education needed to be updated before they could fulfil these new roles (Mellor & St John 2007).
Japan Nursing in Japan is well established and nurses have worked in occupational health services for a long time, although their roles and competencies are not clearly described in national legislation (Muto 2007). Ishihara et al. (2004) reported that OHNs’ roles include direct care to employees, education/advice and management. They compared these roles to those reported from other countries and found both similarities and differences between OHNs in Japan and the USA. These findings indicate that the needs of the working population are similar regardless of the country or the part of the world where they are employed. Japan, however, has a unique organisation of occupational health education, with a specialised University of Occupational and Environmental Health. Within this university is the Department of Public Health and Occupational Health Nursing, in the School of Health Sciences, where nurses are educated for this specific role. OHNs study for four years and, along with other OH specialists, are seen as the supporting staff for OH physicians. Japanese OHNs also have a leading role in the wider East Asian environment, collaborating with OHNs in other countries in the region and organising scientific and educational events.
Occupational Health Nursing within the European Union McK Graham (2002) in the previous editions of this book gave a comprehensive description of the EU and occupational health nursing practice in its member countries. The changes that have happened since the last edition was printed are such that much of his information is no longer valid today. These changes, particularly since entering the new millennium, have affected the working conditions of employees throughout EU countries, the financial situation across Europe (since the adoption of the common currency), and education in general and that of nurses in particular. Occupational health practice has also changed – in some countries very much. In others the changes are happening more slowly, but they happen everywhere. The new picture is not complete yet but the country examples that follow later in this chapter may help describe the future state of occupational health in EU countries.
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The always-expanding EU increases in terms of workforce size, but also in the range of working conditions. In 2007 there are 27 full-member countries and more are applying. The situation in the more developed old member states is so different to that in the new ones that not only the politicians but the EU citizens themselves feel that there is a danger that all the benefits that they formerly expected to be granted will be waived. Proposals for increases in retirement age – a result not only of the longer life expectancy in almost all EU countries, as well as the everdecreasing birth rate, but also of the challenging state of the social security sector – will affect the provision of occupational health services in the future. Working stability and security, wage agreements and unions will make way for an increased retirement age, work flexibility or ‘flexicurity’,2 individual contracts and competition. This new environment will create new challenges not only for the working population but also for occupational health service providers.
European Union Legislation Each EU country has its own legal system, history and practices, which are unique to it. Much has been done, however, to harmonise the legal obligations of employers in relation to working conditions and occupational health and safety. The Single European Act (1986) is one of the most important pieces of legislation to have come into force, in terms of health and safety. Article 118A of the Single European Act states: ‘Member states shall pay particular attention to encouraging improvements, especially in the working environment, as regards the health and safety of workers, and shall set as their objective the harmonisation of conditions in this area, while maintaining the improvements made.’ The Single European Act establishes that European Commission proposals for new health and safety directives must be accepted or not by ‘qualified majority voting’. Therefore there is a need for dialogue between all countries before proposals are adopted through the Council of Ministers. Then all member states can harmonise their legislation according to the adopted directive, although interpretation, application and enforcement still vary between the different countries. In terms of occupational health services in general, the EU organisations that have a decision-making position are the European Commission, the European Parliament, the Council of Ministers, the European Agency for Safety and Health at Work and the European Foundation for the Improvement of Living and Working Conditions. 2
A term recently introduced by the Danish prime minister, while presiding the EU, to reflect ‘flexibility’ and ‘security’ as the right combination for the employability of the workforce – a policy that has been in place in Denmark since the 1990s and has reduced unemployment considerably – which however, in practice will endanger worker stability and development as they are known to member states today.
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The European Commission, based in Luxembourg, is reorganised from time to time to reflect the current policies of the member states. Its main role is to manage the Community, and it ensures that member states fulfil their obligations under the Treaty. The directorates general that are of most interest to health and safety practitioners are the Employment, Social Affairs and Equal Opportunities and the Health and Consumer Protection, but there are others that have an impact on occupational health (europa.eu.int). The Commission makes proposals on Community policy, including policies on health and safety; these then are proposed to the EU Parliament, which considers and comments on them and can reject them or suggest amendments. Members of the European Parliament are elected by their individual member states; each country has a number of seats according to the size of its population. The Council of Ministers is the most important decision-making body, composed of national government ministers. The council examines and agrees, or refers back, directives that have been proposed by the Commission or the country that has the presidency (undertaken in six-month turns). In addition to the council, the heads of each member state meet twice a year to discuss broad areas of EU policy. The European Agency for Safety and Health at Work seeks to improve standards of safety and combat problems of work-related ill health in Europe by collecting and disseminating information to assist governments, employers, trade unions, workers and other stakeholders. The agency was established in 1994 and is based in Bilbao. It is governed by representatives from each member state and its work is in collaboration with health and safety work carried out by the European Commission and the European Foundation for the Improvement of Living and Working Conditions. According to the European Agency for Safety and Health at Work, the main research priorities for occupational health and safety today are the psychosocial work environment, ergonomic risk factors/ musculoskeletal disorders, dangerous substances and occupational health and safety management (European Agency for Safety and Health at Work 2005a, 2005b). The 2007 campaign focuses on musculoskeletal disorders and aims to inform employers, employees and OH practitioners at EU and country level. In addition, it publishes a newsletter, available electronically to anyone interested, and has various publications of interest to both the working world and the OH practitioner. The European Foundation for the Improvement of Living and Working Conditions is a European Union body that was established to work in specialised areas of EU policy by the European Council in 1975 (Council Regulation (EEC) No. 1365/75). Its role is to provide information, advice and expertise on living and working conditions by using comparative information and research.
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It is clear from the above that great importance is placed on health and safety by the EU governing bodies and it is certain that all member states try to place an equal importance in workers’ health and safety in their respective countries. It is not only EU institutions that influence OHN however, but also the EU-wide nursing organisations, which are presented below. The European Federation of Nurses Associations (EFN), formerly the Standing Committee of Nurses of the EU (PCN), was established in 1971 to represent the nursing profession and its interests to the European Institutions, and is the independent voice of the nursing profession, representing more than one million nurses within the EU. The changes that were proposed and adopted by the EU on nursing education and the free-movement directives were the result of this professional representation. Members of the EFN are the National Nurses Associations – which are members of the International Council of Nurses (ICN) and the Council of Europe – of the 27 EU member states as well as Croatia, Norway, Iceland and Switzerland. Associated members are three mandated representatives of the European Nursing Specialists Organisations. The International Council of Nurses (ICN), the World Health Organisation (WHO) and the European Nursing Students Association (ENSA) also hold observer status within the EFN General Assembly. EFN members meet twice a year, when important issues are discussed and decisions taken. The EFN Executive Committee also meets twice a year. Furthermore, some working groups are regularly constituted to allow more detailed work on issues discussed by the General Assembly, the Executive Committee and/or linked to EU-level discussions. The EFN plays an important role in safeguarding the health and safety of all nurses. FEPI is a new Federation of Nursing Regulating Bodies, formed as more and more countries succeed in giving the nursing profession more autonomy and self-regulation. It was established in 2004. FEPI’s primary aim is to protect European citizens by securing excellence in nursing competences and practice, professional standards, continuous education and training, as well as codes of conduct. The goal of the European Specialist Nurses Organisations (ESNO) is to facilitate and provide an effective framework for communication, cooperation and coordination between the European specialist nurses organisations and the European specialist nurses’ interest groups, in order to represent the mutual interests and benefits of these organisations in relation to and within the European Federation of Nurses (EFN). The Federation of Occupational Health Nurses within the EU (FOHNEU) is one of the specialist nurses organisations. It was established in 1993 in Windsor in the UK when the Royal College of Nursing’s European Working Group obtained a grant from the European Commission to help fund a symposium for EU OHNs. Representatives from
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Belgium, Denmark, France, Germany, Greece, Italy, the Republic of Ireland, Luxembourg, the Netherlands, Portugal, Spain, Finland, Norway and the UK met and decided that they wanted to understand and learn from each other (McK Graham 2002). Members of FOHNEU are national occupational health nursing associations or groups within each national nurses’ association. Observer status is granted to the national OHN associations of countries that are not members of the EU. FOHNEU represents 45 000 occupational health nurses working within the EU, is recognised by the European Commission and is represented in the EFN through ESNO. FOHNEU has been active in all European institutions that relate both to nursing and OH, trying to present the unique role of OHNs within the OH team. In relation to education, FOHNEU has developed a core curriculum, which has been proposed as a model for developing specialist OHN education and includes the following five modules (FOHNEU 1997):
r The Work of an OHN and Interaction (see www.fohneu.org/ r r r r
CoreCurrFinalforWebsite.doc) Planning an OH Service Administration and Organisation Health Promotion Evaluation and Development of OH Services.
OHN Education and Practice Although the EU regulates occupational health and safety legislation, organisation of occupational health practice varies greatly among EU countries, especially those that have recently joined. In agreement with the 89/391/EEC directive on OH services provided by competent practitioners, which has been adopted by all EU countries, OHNs are best placed within an occupational health service (OHS) to provide appropriate services to all employees. Implementation, however, differs from country to country, as does the role that OH professionals are expected to perform. Information on current education and practice of OHNs throughout EU countries is based mainly on three studies, which found large discrepancies between as well as within countries (Rossi 1987, Sourtzi 1993, Sourtzi et al. 2006). None of these studies included all 27 EU counties as they were performed at different times and well before the EU reached its current size. All three studies investigated the existence or otherwise of specialised education for OHNs, its duration and content, as well as the extent of OHN practice. Specialisation in occupational health is a requirement for employment in relevant positions in countries that have well-established occupational health services and a recognised role for OHNs (NaumanenTuomela 2001, Whitaker and Baranski 2001). Although there is no
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accepted international standard of education of OHNs, recommendations do exist on the content and the level and duration of such specialised education (WHO 1988, FOHNEU 1997). Sourtzi (1993) found that 5 countries out of 11 had specialisation programmes, although these courses differed both in content and duration. Higher degree level (MSc) study was only found in the UK, and that was multi-disciplinary. In the most recent study (Sourtzi et al. 2006), 10 countries were found to have specialisation programmes, of variable duration but generally at postgraduate level. Of the existing programmes, most were established in the second half of the 1990s, but Finland, Germany, Sweden and the UK established theirs before 1980. Out of the 10 countries, 2 offered courses at certificate level, 5 at diploma, 2 at degree, and the UK offered both diploma and degree programmes. In the French community of Belgium, and in Cyprus, Greece and Portugal, occupational health is included in postgraduate courses in community or public health nursing, either as a specialisation or in master’s programmes of at least one year’s duration. In this study it was reported that only registered nurses could apply for specialisation in OHN, but in some countries there were additional requirements, such as relevant experience. The content of the programmes had both similarities and differences. Subjects that were included in all or most of the specialisation programmes were:
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health promotion and health education prevention policies at the workplace occupational epidemiology environmental surveillance and health protection health assessment and surveillance organisation and administration of OH services.
OHNs were found to work in all countries for which data were available in all three studies. The only country that was found to have discontinued OHN as a nursing specialisation was Italy, where this role today is studied and practised as a separate profession (Sourtzi et al. 2006). The role of OHNs today seems more uniform regardless of education and this was reported in all three studies, although there was an evolution in the range of activities performed by OHNs from that reported by Rossi (1987) to the most recent study (Sourtzi et al. 2006), in which the most common activities that were reported were:
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health education/promotion disease and injury prevention first aid services administrative duties in the service health assessment and surveillance risk assessment and safety/environmental surveys/controls.
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In conclusion, OHN practice is widespread in the EU, but education in some countries is not yet developed to meet the contemporary demands of OHN practice. The development of postgraduate specialisation programmes based on well-developed educational models such as the Core Curriculum developed by FOHNEU (1997) could help advance the level of education and also practice of OHNs. Further to the above comparative data I shall refer to a few EU countries with well-established OHN. There have unfortunately been changes for the worse in two of them, suggesting that the future may not be as bright as hoped unless efforts are made to safeguard the vested interests of the OH profession and thereby the health of the working population.
United Kingdom The UK has the best-developed education for occupational health nurses in Europe, offering courses at diploma or degree level, as well as postgraduate studies. As a result of NMC registration changes in the UK in 2004, newly qualified OHNs must hold a minimum of a first degree in OH to be registered as specialists. This makes UK OHNs the best prepared to provide competent OH services, and although there are no legal requirements for the employment of OHNs, there are around 5000 working in the field, either within company-run OH services, external OH services or as freelance OH consultants (Education Group of FOHNEU 2005). The OHN competencies published by the Royal College of Nurses (Bannister & Maw 2005) are a good practice guide, not only for UK nurses but for OHNs throughout the EU. OHNs are organised in specialised groups, either within the Royal College of Nursing or in independent bodies, and there are many events and professional/scientific journals that provide the opportunity for OHNs to get information or publish their work.
The Netherlands McK Graham (2002) reported OHS changes in the Netherlands and the very positive impact these had for OHNs. Both company and private OHS in the Netherlands expanded during the 1990s, and this was one of the very few countries in the EU where the vast majority of the working population was covered. However, the focus that was placed on sickness-absence management, as well as on cost-effectiveness, resulted after some time in the extreme specialisation of private-owned OHS and in cuts in company-run services. Although there are still changes going on, it seems that most of the traditional OH professionals will either have to adapt to the new situation or cease to exist (Weel et al. 2007).
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Specialist occupational health nursing education was and still is available for Dutch nurses, although some programmes have ceased to exist because there are fewer nurses looking for such an education. Although company OH services have kept their nurses, external OH services have reduced the number of OHNs by hundreds because they were unable to provide services such as risk assessments and health checks. OHNs are still organised as a profession, although separate from the national nurses’ association, but their position has been weakened to such a degree that if they do not find a way to respond to the changing environment of OH in their country they may lose the game (www.arboverpleegkunde.nl).
Finland Finland has well-established OHN education and although the choice is not as wide as that in the UK, it is comparable. The Finnish Association of Occupational Health Nurses has 2500 members and OHNs are considered one of the two professions – alongside OH physicians – that are the core of OH services, both company run and external. According to the previous and current Finnish Occupational Health Care Acts, all employers are obliged to organise primary preventive occupational health services which aim at minimising harmful work environment risk factors to employees’ health, and preventing occupational diseases and accidents (Lamberg et al. 2007). The Finnish Occupational Health Care legislation and Good Occupational Health Practice guidebook also describe the role of OHNs, who make up the largest group of health care professionals involved in delivering health care at the workplace. Finnish OHNs have responded to future challenges, raised the standards of their professional education and training, modernised and expanded their role at the workplace, and for the most part work as members of larger multi-professional teams. They are often at the frontline in helping to protect and promote the health of working populations (Naumanen-Tuomela 2001).
Sweden Sweden has much in common with its neighbour Finland as OH services are well established and OHNs are members of the wider OH team (Bohlin et al. 2007). There is strong co-operation between OHNs from all the Nordic countries through the NORDSAM network. Although specialist education for OHNs still exists and the number of OHNs is considerable, changes that are taking place just now could influence the future of OHNs in either a positive or a negative way. The Swedish Institute of Working Life, the organisation that was responsible for providing specialist OHN education, among other things, ceased to exist on 1 July 2007 (www.arbetslivsinstitutet.se/en). The OHNs Association is trying
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to safeguard the position of OHNs and to advance specialist education by including it in the university-based programme, but OHNs will have to wait to know the results of the national dialogue and therefore how their future will look.
Conclusion The primary aim of the OHN is always to protect and promote the health of the worker. In this attempt they need to work with many different stakeholders and in many different ways. Therefore, they may contribute to the health of the workforce, as well as the public health agenda within the broader community. OHNs can also make a significant contribution to the economic success of the organisation that employs them. I tried to show in the introduction that OHNs are working to the highest professional standards; they bring to their occupational health service a unique professional view and a range of knowledge and skills that are based on the principles and practice of nursing science, as well as the special knowledge resulting from their specialist education in occupational health. Occupational health care systems and services vary a lot throughout the world and there is also wide variation in services within countries. However, the contents of all occupational health services should be based on primary prevention through the reduction of risks and control of hazards in the work environment, and the protection of workers’ health (Rossi et al. 2000). The development of a healthy work environment and the strengthening of occupational health services are seen as central objectives for all countries and workplaces (WHO 1995). Each country throughout the world – however challenging this may be – should guarantee occupational health services at least at the basic level defined by international organisations (Forastieri 2007).
References and Further Reading AAOHN (2003) Competencies in Occupational and Environmental Health Nursing, AAOHN Journal 51, 290–302. Bannister C. and Maw J. (2005) Competencies: an Integrated Career and Competency Framework for Occupational Health Nursing, London: RCN. Bohlin L., Hjalmarson L. and Westerholm P. (2007). Occupational Health Services in Sweden. In: Westerholm P. and Walters D. (eds) Supporting Health at Work: International Perspectives on Occupational Health Services, IOSH, 111. Burgel B., Camp J. and Lepping G. (2005) The Nurse’s Contribution to the Health of the Worker: Occupational Health Nursing in 2000 – An International Perspective, Working Party Report 10, SCOHN.
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Education Group of FOHNEU (2005) Occupational Health Nursing: Education and Practice in the EU Countries, www.fohneu.org/OHNinEUfinalreport1 .pdf (accessed 15 June 2007). EEC Council Directive 89/391/EEC of 12 June 1989 on the introduction of measures to encourage improvements in the safety and health of workers at work. European Agency for Safety and Health at Work (2005a) Priorities for Occupational Safety and Health Research in the EU-25, osha.eu.int/publications/ reports/6805648 (accessed 15 June 2007). European Agency for Safety and Health at Work (2005b) Future Occupational Safety and Health Research Needs and Priorities in the Member States of the European Union, agency.osha.eu.int/publications/reports/202/en/ index.htm (accessed 15 June 2007). FOHNEU (1997; revised 2002) Core Curriculum for Occupational Health Nurses, www.fohneu.org/CoreCurrFinalforWebsite.doc. Forastieri V. (2007) Occupational Health Services at the Workplace, ILO, www. ilo.org/public/english/protection/safework/health/hlthserv.pdf, (accessed 15 June 2007). ICOH (2002) International Code of Ethics for Occupational Health Practitioners, www.icohweb.org/core docs/code ethics eng.pdf (accessed 15 June 2007). ILO (2007) Information Leaflet, www.ilo.org/global/About the ILO/ lang- -en/docName- -WCMS 082361/PDF (accessed 15 June 2007). Ishihara I., Yoshimine T., Horikawa J., Majima Y., Kawamoto R. and Salazar M.K. (2004) Defining the Roles and Functions of Occupational Health Nurses in Japan: Results of Job Analysis, AAOHN Journal 52(6), 230–41. Lamberg M., Leino T. and Husman K. (2007) The Finnish Occupational Health System – Challenges and Approaches. In: Westerholm P. and Walters D. (eds) Supporting Health at Work: International Perspectives on Occupational Health Services, IOSH, 39. McK Graham C. (2002) European Perspectives in Occupational Health Nursing. In: Oakley K. (ed) Occupational Health Nursing, Chichester: John Wiley & Sons, Ltd. Mellor G. and St John W. (2007) Occupational Health Nurses’ Perceptions of their Current and Future Roles, Journal of Advanced Nursing 58(6), 585–93. Muto T. (2007) Status and Future of Japanese Occupational Health Services. In: Westerholm P. and Walters D. (eds) Supporting Health at Work: International Perspectives on Occupational Health Services, IOSH, p. 169. Naumanen-Tuomela P. (2001) Occupational Health Nurses’ Work and Expertise in Finland: OHNs’ Perspective, Public Health Nursing 18, 108–15. Rogers B., Agnew J. and Pompeii L. (2000) Occupational Health Nursing Research Priorities: a Changing Focus, AAOHN Journal 48(1), 9–16. Rogers B. (1989) Establishing Research Priorities in Occupational Health Nursing, AAOHN Journal 37, 493–500. Rossi K. (1987) Occupational Health Nursing World-Wide, AAOHN Journal 35, 505–9.
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Rossi K., Heinonen K. and Heikkinen M.-R. (2000) Factors Affecting the Work of an Occupational Health Nurse, Occupational Medicine 50, 369–72. Sourtzi P. (1993) Occupational Health Nursing in the European Community Countries: Education, Training and Practice, Occupational Health 45, 373–6. Sourtzi P., Atwell C., Claesson A., Rasteiro M. and Aguirre G. (2006) Eurohvision: Education and Practice of Occupational Health Nurses (OHNs) in Europe, Occupational Health 58(11), 11–12. Whitaker S. and Baranski B. (eds) (2001) The Role of the Occupational Health Nurse in Workplace Health Management, Copenhagen: WHO Regional Office for Europe. WHO (1988) Training and Education in Occupational Health, Geneva, WHO Technical Series, No 762, 24–26, 33. WHO (1995) Global Strategy on Occupational Health for All: the Way to Health at Work: Recommendation of the Second Meeting of the WHO Collaborating Centres in Occupational Health, 11–14 October 1994, Beijing, China. WHO (2006) Declaration on Workers Health: Approved at the Seventh Meeting of the WHO Collaborating Centres for Occupational Health, Stresa, Italy. Weel A.N.H. and Plomp H.N. (2007) Developments in Occupational Health Services in the Netherlands. In: Westerholm P. and Walters D. (eds) Supporting Health at Work: International Perspectives on Occupational Health Services, IOSH, 87.
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Occupational Health and Safety Katie Oakley
Introduction Occupational health nurses need to have sound knowledge of the health and safety regulations relating to the businesses for which they work. They must also be familiar with the requirements of the Health and Safety at Work Act 1974. ‘Health’ and ‘safety’ are interrelated and, in order to make workplaces safer, occupational health nurses should play an active role as part of the health and safety team. Understanding the hazards and risks to which their clients may be exposed means that more appropriate advice can be given; for example, to an employer on managing an employee’s return to work with reasonable adjustments following sickness absence; or to a health and safety committee on the requirements of a new piece of health-related legislation. This chapter attempts to demystify this complex subject, setting the context with an overview of the development of health and safety legislation in the UK and giving pointers to sources of further information. Two key themes which run through the legislation are discussed in detail, namely ‘risk assessment’ and ‘the competent person’. There is a particular emphasis in this chapter on the Health and Safety at Work Act 1974 and the 1992 set of regulations (especially the Management of Health and Safety at Work Regulations) issued in response to European Community directives. Two million people in the UK are thought to suffer ill health caused or made worse by work (Jones et al. 2006). Thousands of workplace accidents occur annually (HSC 2007). Millions of working days a year are lost (30 million in 2005/06) due to accidents and ill health, placing Occupational Health Nursing Edited by K. Oakley. C 2008 John Wiley & Sons, Ltd
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a huge cost on individuals, employers and society (HSE 2004a). The Health and Safety Executive (HSE) reports that in 2004/05 the most common types of work-related illness were musculoskeletal disorders and stress (HSE 2007). Health and safety are logically connected and interdependent. If a working environment is unsafe this can create health problems, and some health problems can create an unsafe working environment. In every workplace there are examples of the interaction between health and safety. In a garage body shop, for example, if people spray cars with isocyanates without following safe systems of work they are likely to develop respiratory problems. If a hospital cleaner pricks themself with a used needle which has been carelessly discarded in a rubbish bag (instead of a ‘sharps’ bin) this could cause them to contract a bloodborne disease such as hepatitis C. This chapter emphasises the importance of teamwork for problemsolving in occupational health and safety, with examples of how occupational health nurses can play an active role. They can work together, for example, on policy development, taking into consideration the organisational culture and relevant legislation. Occupational health and health and safety professionals should work collaboratively and are increasingly, in large organisations, working within the same department. Occupational health nurses have practical experience of problem solving from years of nursing training and practice. In addition, any good nurse will have excellent communication skills and the ability to explain complex issues, conditions and treatments in plain language. These skills and abilities can be put to good use in the workplace by transfering knowledge of legislation on occupational health and safety into practical advice for its implementation.
Health and Safety Law: Historical Background The origins of health and safety law date back to the industrial revolution and the associated concern and anxieties over working conditions. Outrage was felt by various campaigners over some of the conditions to which working people, including children, were exposed. Calls were made for action and social reform. The result was the introduction of various pieces of health and safety law in relation to specific areas of work. In 1802, the Health and Morals of Apprentices Act was passed. This related to working hours and conditions in the textile industry and was enforced by magistrates. In 1833, the Factory Act appointed inspectors to visit the textile factories and enforce the law. Other workplaces covered by legislation later in that century included potteries, matchmanufacturing factories and workshops. There were Factory and Workshop Acts in 1878 and 1901. The 1901 Act in particular was the basis
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of further 20th-century legislation and enabled the Secretary of State to make regulations covering a wider spectrum of industries. During the 20th century, much health and safety law was introduced to deal with specific areas of work, for example the Factories Acts in 1937 and 1961 and the Offices Shops and Railway Premises Act in 1963, as well as legislation related to other specific areas such as mines and quarries. The result was that some workplaces were covered by specific legislation, under which the employers had all sorts of duties and responsibilities towards their employees, while employers at other workplaces had legal duties and responsibilities regarding health and safety only under common law. The Health and Safety at Work etc. Act 1974 drew together existing law and extended it to all types of work, setting out broad duties for both employer and employee. It was the most important piece of health and safety legislation in the latter part of the 20th century.
The Health and Safety at Work etc. Act 1974 The government established a committee under Lord Robens to examine health and safety legislation and make recommendations. The Robens Report was published in 1972, proposing major changes in occupational health and safety, which led to the Health and Safety at Work Act 1974 and equivalent legislation in Northern Ireland. The Act sets out duties for employer and employee in all types of work. It refers to general principles only and intentionally gave no details; it is left to employers to work out how they are going to comply with the law in their particular work environment and organisation. The Act allows for the issue of Regulations and also Codes of Practice and Guidance Notes – practical and helpful publications – which support the regulations by describing in more detail what is necessary to meet the legal requirements. There are many regulations under the Health and Safety at Work Act, which is known as the enabling Act. If, for example, there is a breach of the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations, court action may be taken under the Health and Safety at Work Act. Under the Act, the employer must ensure, ‘so far as is reasonably practicable’, the health, safety and welfare of employees at work. The phrase ‘so far as is reasonably practicable’ is a cost/benefit equation measuring the risk against the sacrifice involved. Not being able to afford something necessary, however, is not an acceptable excuse. In 2007 the European Court of Justice ‘upheld one of the key elements of British health and safety law – the use of the key phrase “so far as is reasonably practicable”’ (HSE 2007a). The employer is required to provide a safe place of work. This covers equipment and methods of work. The employer must provide
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information, instruction, training and supervision. A written statement of the health and safety policy is required for organisations employing five or more people, and this must be made known to all employees. The employer is also responsible for ensuring that members of the public and other persons on sites under their control are not affected by their work activity. As previously stated, it is not all down to the employer – employees also have responsibilities under the Act, to themselves, to their colleagues and to members of the public. Employees are bound to take reasonable care for their own health and safety and that of others who may be affected by what they do or fail to do. They must not interfere with or misuse anything provided for their health, safety and welfare. Employees must also work and use work items in accordance with the health and safety training and instructions given by the employer. If, for example, employees have been provided with respiratory protective equipment and have received relevant training and management support and then ignore this, they may have to accept some responsibility for any health problems that result. There is a contractual agreement between the two parties, namely the employer and the employee. They are thus not free agents when they are at work, but have contractual obligations. Employees are expected, for example, to turn up for work on time, and equally to comply with any health and safety policies and training. If, however, the employer has not provided any health and safety induction or training and guidance to employees, then they are at fault for not fulfilling their part of the contract and are in breach of the law.
Improvement and Prohibition Notices The Health and Safety at Work Act 1974 gave Health and Safety Executive inspectors the power to issue Improvement and Prohibition Notices and thus enforce the Act. Following the introduction of Health and Safety (Enforcing Authority) Regulations (HSE 1998a), local authority inspectors also have enforcement powers in certain areas, for example, environmental health officers can inspect restaurants and school kitchens. Health and Safety Executive and local authority inspectors have broadly the same duties. They visit sites under their jurisdiction, with or without notice, for general inspections or following incidents; they can take photographs and remove specimens such as equipment and documents, and are entitled to speak to anyone in the workplace. Inspectors often have themes for a particular year, for example focusing on problem areas such as respiratory sensitisers or targeting particular sectors such as the construction industry. These themes will often be in line with national awareness campaigns, strategies and programmes (HSC 2000a, 2004; HM Government 2005).
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Generally, inspectors should encourage and help employers to meet the legislation by taking a partnership and collaborative rather than a threatening or aggressive approach. This requires good communication between both parties and a genuine desire on the part of the employer to share the aim of preventing ill health and accidents in the workplace. If the inspector finds a problem on visiting a workplace, he or she can issue oral and written warnings and, when necessary, issue two types of notice: the Improvement Notice and the Prohibition Notice. The Improvement Notice is issued when, in the inspector’s opinion, it can be shown that there is a breach of health and safety legislation. The notice gives a description of the breach, the relevant piece of legislation and the date by which the action should be completed, and may include a schedule which gives clear guidance on what remedial action is required to be taken. Generally, inspectors are willing to engage in dialogue to agree the date of compliance with the company, provided the proposed date is not too far away. The level of intervention taken by the inspector, whether giving the employer verbal advice, written advice or more formal enforcement action including prosecution, will depend on the extent of the breach and the risks to health and safety involved. An employer has 21 days to appeal against the notice if they think it is not appropriate, using the employment tribunal system. The Prohibition Notice is issued when the inspector considers there is a risk of serious personal injury. This requires an immediate cessation of the work activity concerned. Breaches of the law are dealt with by the courts under criminal law. Employers who obstruct inspectors in their work will pay the penalty. If an individual or company ignores or refuses to comply with a notice, prosecution can result. Breaches of regulations or cases of obstructing inspectors are tried summarily (in a magistrates’ court in England and Wales) and the maximum penalty is a fine of £ 5000. Other offences under the Health and Safety at Work Act 1974 are prosecuted either in the lower courts, where there is a maximum fine of £ 20 000 or six months’ imprisonment or both, or by jury in the crown court, where an unlimited fine and/or a prison sentence of two years can be given.
The Employment Medical Advisory Service (EMAS) The Employment Medical Advisory Service Act 1972 details the roles and responsibilities of EMAS within the HSE; these are to provide occupational health advice and information, investigate occupational health issues in the workplace, and safeguard and improve the health of those at work. The currently-named medical inspectors and occupational health inspectors (OH doctors and nurses), who were established as a result of this Act, work as specialists within sections of the HSE and now have the same enforcement powers as inspectors in the HSE. One of their
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activities given under the Act – provision of information – is now undertaken by several entities, such as ‘Workplace Health Connect’ and ‘HSE infoline’. Infoline does refer more complicated queries for advice to a local occupational health inspector when required. It can be helpful for occupational health nurses to establish communication links with their nearest OH inspector, as they are a useful professional resource.
More Health and Safety-Related Law and National Health and Safety Programmes and Strategies As well as knowing the requirements of the Health and Safety at Work Act, occupational health nurses should be aware of the existence of other Acts in relation to health and safety. There are numerous health and safety regulations under the Health and Safety at Work Act and, as mentioned in the introduction, occupational health nurses need to know which are of particular relevance to the workplaces they cover. Some regulations are likely to be relevant for all occupational health nurses – examples being the Safety Representatives and Safety Committees Regulations (HSE 1977), the Health and Safety (First Aid) Regulations (HSE 1981), the Noise at Work Regulations (HSE 2005a), the 1992 set of regulations, in particular the Management of Health and Safety at Work Regulations, the Control of Substances Hazardous to Health Regulations (COSHH) (HSE 2004b) and the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) (HSE 1995a). Keeping up to date involves reading the legislation, in conjunction with the Health and Safety Executive’s supporting literature. The Health and Safety Executive web site is the key source for occupational health and safety statistics and information on new and existing legislation and HSE publications (www.hse.gov.uk). It also contains information on the latest national strategies, campaigns and programmes, such as the Health, Work and Well-Being Programme (HM Government 2005). There are thus several HSE sources of good, practical advice available (Figure 8.1). Source
Web Site/Helpline
Comment
The Health and Safety Executive The Health and Safety Executive Workplace Health Connect (in partnership with HSE)
www.hse.gov.uk
The key web site for health and safety information. Information about HSE publications. Advice for employers and employees in small and medium enterprises.
HSE infoline: 0845 3450055 0845 609 6006 www.workplacehealthconnect. co.uk
Figure 8.1 Key Web Sites and Helplines for Information and Advice on Health and Safety at Work
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The early 21st century sees a clear emphasis on occupational health and safety as an important national issue. The government and Health and Safety Commission’s (HSC) strategic plan ‘Revitalising Health and Safety’ (HSC 2000a) has raised the profile of health and safety and encouraged partnership working. This plan has been built on by the HSC’s occupational health strategy ‘Securing Health Together’ (HSC 2000b), plus ‘A Strategy for Workplace Health and Safety in Great Britain to 2010 and Beyond’ (HSC 2004). In addition, the Health, Work and WellBeing Programme (HM Government 2005), led by the National Director for Work and Health, aims to improve the health and well-being of the working population and is a partnership between the Department for Work and Pensions, the Department of Health and the Health and Safety Executive. Other useful publications are produced by bodies such as the Institute of Occupational Health and Safety (IOSH), trade unions, the Royal Society for the Prevention of Accidents and the British Safety Council. Reading occupational health and safety journals, attending conferences and workshops, and networking with experts and colleagues are all ways for the practitioner to keep informed.
The 1992 Set of Regulations These regulations were introduced to implement EC framework directives, and comprise the Management of Health and Safety at Work Regulations, the Manual Handling Operations Regulations, the Health and Safety (Display Screen Equipment) Regulations, the Provision and Use of Work Equipment Regulations, the Workplace (Health, Safety and Welfare) Regulations and the Personal Protective Equipment Regulations. They gave the occupational health nurse an excellent opportunity to consolidate or expand on work that was being done prior to their introduction (RCN 1993). Prior to 1992, it was a case of advising that it was good practice to avoid manual handling or overcrowded offices, for example. The regulations provided specific legal requirement, as well as backing and support for implementing the more general requirements of the Health and Safety at Work Act 1974. Employers often need advice on associated policy, assessment and training requirements, as well as specific advice on temperature, humidity, noise, lighting, good housekeeping and so on. The Management of Health and Safety at Work Regulations are discussed in more detail later in the chapter, in the section on risk assessment.
COSHH The Control of Substances Hazardous to Health Regulations (HSE 2004b) require ongoing assessments of risks to the health of employees and others to be made and documented, and measures to be taken
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to prevent or control these risks. A hierarchy of controls is included. Health surveillance is an important part of occupational health nursing. It is a means of monitoring the effectiveness of preventative measures and safe systems of work set up after due assessment of the risks; it is not required for most workers (health surveillance is discussed in detail in Chapter 9). Training and information for employees is an absolute requirement of COSHH regulations. It is crucial that people understand the risks to which they are exposed and how to protect themselves.
Smoking In the latter part of the 20th century, areas of hazard such as smoking were not fully covered by the law. They were tested by the courts and there were some out-of-court settlements in respect of claims for damages due to the harmful effects of passive smoking. Smoking is now covered by the law across the UK and is generally outlawed in workplaces.
Civil Law In addition to the criminal law, duties exist in civil law. These arise either from statutory provisions or from the common law. The nature of duties under common law is determined by precedents, i.e. the judgements of court cases in the past. Not all court cases establish precedent but, for example, if an employee is suing their employer for negligence, previous judgements will be taken into consideration to establish whether the employer has breached common law duties. The amounts of awards of damages for personal injury are determined according to rules, tables and precedents. An award for pain and suffering caused by work-related upper-limb disorder, for example, would take into consideration the precedent set by the six turkey workers who won a total of £ 21 000 (Mountenay and Others v Bernard Matthews plc 1993). They had complained of pain and suffering caused by upper-limb disorder due to the repetitive nature of their work. There had been no job rotation, inadequate training and inadequate preventive measures. A precedent was set regarding workplace stress when a social worker was awarded over £ 175 000 damages for loss of earnings against his employers after alleging negligence and breach of duty of care (Walker v Northumberland County Council 1995). He had suffered two mental breakdowns, the second of which occurred after he had returned to work without measures being put in place to ensure continuing extra support following the first.
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Key Themes: Risk Assessment and the Competent Person
Risk Assessment The concept of ‘risk assessment’ runs throughout the legislation and can be related to health and safety in general. It is a common-sense approach that simplifies problem solving. Getting the process started can be time consuming and there is a certain amount of paperwork involved, but it does not have to be complex. Occupational health experts can assist employers in fulfilling their risk management responsibilities. There are many helpful Health and Safety Executive publications aimed at employers, which emphasise that risk assessment is a simple and practical exercise. It is a vital part of making workplaces healthier and safer, using a systematic approach and involving people within the organisation to identify hazards and control risks (HSE 2006a). The major information on risk assessment (including reference to pregnancy and work) is contained in the Management of Health and Safety at Work Regulations, which state that: The purpose of the risk assessment is to help the employer or self-employed person to determine what measures should be taken to comply with the employer’s or self-employed person’s duties under the relevant statutory provisions (HSE 1992b). This covers both the general duties in the Health and Safety at Work Act 1974 and the more specific duties in various regulations. These state that, having assessed the risks, arrangements for health and safety must be made by effective planning, organisation, control, monitoring and review. The regulations also refer to health surveillance requirements. The concept of risk assessment is familiar in that this approach is required by the Control of Substances Hazardous to Health Regulations (HSE 2004b) and is central to health and safety legislation. All employers are required to undertake a risk assessment of significant risks and to record the findings if they employ five or more people. They are required to make risk assessments and to undertake any planning, remedial works or changes in practice and information provision that should prove necessary (Figure 8.2). The idea is that by taking a preventative approach, accidents are avoided. This is preferable to being reactive and only taking action after something has gone wrong. Managers are responsible for carrying out assessments, with the help of staff – they should know the job, what is entailed and how it is done in practice rather than in theory. A system needs to be set up for every workplace that is suitable and manageable, so that those involved understand what is required and why it is
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What is a hazard? A hazard is something with the potential to cause harm. What is a risk? A risk is the likelihood that harm from a particular hazard is realised. Risk assessment involves employers asking themselves the following questions:
r r r r
What hazards exist in the workplace? Do they pose a risk to anyone? How big a risk do they pose – is the risk significant? How can we reduce and control the risk and thereby make the workplace safer?
Figure 8.2
Risk Assessment: Some Basic Questions
important. The occupational health nurse can help with setting up such systems and working out the best way to approach risk assessment for a particular organisation. Managers will need adequate training in how to perform a risk assessment and the system to be used, and suggestions on how to involve their staff in the process. Complex numerical formulae for risk assessment should not be necessary and may be unhelpful. Those doing the risk assessment need to look at literally everything that happens in the workplace: all activities, procedures and equipment, and the people involved. The most time-consuming work is initiating the risk assessment in the workplace; thereafter, assessments must be updated, but this becomes a process with which people are familiar. Once initial risk assessments have been performed and documented, with clear allocation of responsibilities, and remedial action has been taken, the process becomes an integral part of ongoing work. Checklists should be as simple as possible. Usually a simple system involving options of low, medium or high risk and indicating the control measures required and by what date is perfectly adequate. The HSE publication ‘Five Steps to Risk Assessment’ (HSE 2006a) includes a template recording form for basic risk assessments. Some organisations with multiple sites carrying out similar tasks make generic risk assessments to assist managers and avoid duplication. The idea is not to detract from managers’ responsibilities but to help them. Managers must check that the generic assessment is not invalidated by local differences, in which case a separate local risk assessment will be required. Staff need access to and information about the assessment and any working precautions necessary. Everybody at the workplace needs to be involved and on the lookout for hazards, and must ensure that these are reported. This is all part of engendering a health and safety culture within an organisation. Risk assessment in relation to health and safety is part of an organisation’s overall risk management strategy. Good risk management can help reduce insurance premiums, as well as assisting marketing and public relations – all important factors in the protection and growth of a business.
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The Competent Person The regulations stress the importance of developing safety cultures in which management of health and safety is integrated within the organisation. The emphasis is on managers taking responsibility for health and safety in their departments, with the support of competent advice. Kloss (2005), referring to the Management of Health and Safety at Work Regulations, says, ‘The employer must appoint one or more competent persons to assist him (Regulation 7). This provision puts more pressure than before on employers to appoint safety advisers and occupational health personnel with recognised specialist qualifications (though there is still no statutory requirement).’ Health and safety experts within organisations are generally known as health and safety ‘advisers’ rather than ‘officers’. Their role is to advise people and help them to take responsibility for health and safety within their own areas as an integral part of their jobs as managers and employees. Traditionally, the health and safety officer was from an engineering or operations background, with the emphasis on technical knowledge of machinery and engineering issues and on enforcing legal requirements. These are, of course, crucial for safe working, but the technical aspects are part of engineering management. Organisation of safe and regular maintenance systems of work should be occurring in any case. The engineering services manager will, and should, know more about the safety requirements in the boiler room than health and safety advisers, who may come from a variety of backgrounds. The Management of Health and Safety at Work Regulations require that the person advising on risk assessment is ‘competent’. The Health and Safety Executive recommends that this person be a manager who has been properly trained to do risk assessment, unless the risks are complicated, in which case outside advice may be needed. The ‘competent person’ referred to in the regulations is not therefore necessarily an outside expert, but is the best person for the job depending upon the circumstances. It is for management at the local level to decide who is competent to do the job. Under the sub-heading ‘Competent Advice’, the Health and Safety Executive states: Although you can probably find out most of what you need to know for yourself, you might find that you are dealing with issues that need technical knowledge you have not got. In that case, you need to have a source of competent advice. If not already available in-house, there are many people you can turn to for help – employers’ organisations, trade associations, chambers of commerce, local training organisations, local health and safety groups,
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trade unions, insurance companies, suppliers of plant, equipment and chemicals, and consultants. You can get information on specific issues by ringing HSE’s infoline (tel: 0845 345 0055) (HSE 2006b p. 4). A number of safety training courses are available, the basic level being the National Examination Board for Occupational Safety and Health (NEBOSH) certificate, with more specialist training available at NEBOSH diploma level. Health and safety belongs to us all – total responsibility cannot be delegated to a health and safety consultant or a safety adviser who comes around at intervals with a checklist. Specialists can be invaluable for technical advice, support and policy development, updating and strategic advice. They may also help with more difficult issues and with problem-solving and technical aspects, such as air sampling measurements and so on. The people doing the job need to be aware and informed of the hazards to which they are exposed, and involved in protecting themselves and others from coming to any harm. The audit process needs to be locally driven. As discussed, nowadays the emphasis in health and safety law is on managers recognising responsibilities for their areas, and being involved with and aware of hazards and risks and health and safety management. The onus is on the employer to demonstrate how they decided that the person they appointed as ‘competent person’ was worthy of that title. The Basingstoke and Deane Borough Council v J. Sainsbury plc (1998) case, relating to a fatal accident, emphasises this point. Davies (1999) states: ‘The depot safety adviser at the time of the accident was a nurse who had been placed in the role of “occupational health and safety adviser”. She was expected to perform work which should have been undertaken by someone with considerably more training and experience in safety.’ Davies goes on: ‘the case cannot illustrate enough the need for all employers to engage a competent health and safety adviser relative to the type of business they operate.’ The occupational health nurse should be able to help to advise management, in conjunction with the health and safety adviser, on who would be competent for which piece of legislation. It may be that the health and safety adviser is competent for some of the legislation, the occupational health nurse for other parts, and that some outside advice is also needed for certain aspects. This all needs to be planned at a local level within an organisation. The occupational health nurse may be competent, for example, to advise in the office setting but not in the construction industry. Advising on health-related legislation is part of the job, so keeping up to date by whatever method is appropriate and effective, including extra training where necessary, is essential.
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It is up to all professionals to be clear and assured about their competencies, and aware of the limitations of their knowledge. As well as knowing where to obtain information, it is also crucial to know what, and to whom, to refer when you do not have the relevant competency.
Engendering a Safety Culture: Health and Safety Committees and Problem-Solving Teamwork
Health and Safety Committees The most effective committees are those chaired by someone at director level. This demonstrates commitment from the top of the organisation and means that health and safety is taken more seriously by lower management levels. The chairman must be someone with authority and power. If this is not the case then it is difficult, and sometimes impossible, to obtain commitment and funding to implement the initiatives and recommendations of the committee. With top-level management commitment a health and safety culture is engendered, and health and safety is taken seriously by everyone in the organisation. People then appreciate the importance of reporting incidents (including near-misses) and accidents. Accident prevention is one of the main functions of health and safety committees. They also have an advisory and monitoring function, because, as already discussed, the prime responsibility for health and safety lies with the people working in the organisation. The committee should keep under review the measures taken to ensure the health and safety at work of employees. The committee’s objective is the promotion of cooperation between employees and employers in instigating, developing and carrying out measures to ensure health and safety at work. It is good to have broad representation, including occupational health, on the committee. The committee considers incident and accident statistics, examines the results of safety checklists/audits, reviews health and safety regulations, considers submitted safety reports, continues the development of safety rules and safe systems of work, reviews the effectiveness of the health and safety training for employees and ensures good and up-to-date communication on health and safety. The role of the occupational health expert on the committee is specified in Figure 8.3. Strategic issues rather than individual department-level details should be considered, and meetings are usually held quarterly. Terms of reference and membership must be communicated to all staff, e.g. by notice-board display, on the intranet, by e-mail and on induction. The method for bringing matters to the attention of the committee should also be made clear to all staff. This is usually via safety representatives or managers where problems cannot be resolved at local level.
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The role of the occupational health expert is to assist the employer in meeting legal obligations under Section 2 of the Health and Safety at Work etc. Act (1974). This involves:
r r
Keeping the employer aware of their role and responsibilities regarding provision of appropriate standards of pre-employment screening, necessary periodic health surveillance and sickness-absence control. Keeping the employer informed of the implications of new legislation and its relevance to health surveillance programmes.
Figure 8.3 Committee
The Role of the Occupational Health Expert on the Health and Safety
Where there is a unionised workforce, there is a requirement to establish a health and safety committee when two people have asked for one. This requirement does not apply to non-unionised workforces, but the Health and Safety Commission recommends the establishment of committees in all except smaller establishments. Since 1996, regulations have required all employers to consult employees on health and safety matters (HSE 1996).
Teamwork Occupational health and safety problems often need input from a variety of people, such as physicians, hygienists, safety experts and nurses, as well as employers, employees and safety representatives. Finding solutions ideally involves a team approach to problem solving, which often involves the following stages:
r Assessing the risk. r Deciding what needs to be done to reduce the risk. r Deciding who are the best people to do the job, depending upon the particular circumstances, legislative requirements and their expertise. The general approach to a consideration of safety matters requires an understanding of the people, policies and structure of an organisation. A useful start to considering relevant factors about an organisation’s safety culture is to ask questions such as those listed in Figure 8.4. If there are safety personnel (either in-house or external consultants) then good communication with them is crucial for a team approach. The occupational health nurse’s training and background knowledge of physiology should be complementary to the safety officer’s training and expertise. In some smaller companies the occupational health nurse may have been appointed in the joint role of occupational health and safety adviser; this will require additional training in safety matters (Davies 1999).
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r r r r r r r r r r r r r r r r
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What are the hazards? How many employees are there and what is the breakdown in terms of age, sex, jobs, skills? What are the legislative requirements? Is there a health and safety policy statement (required if there are five or more employees) and supporting policies? Are they satisfactory and regularly updated? Is there commitment to health and safety from top management? Are management and staff aware of their responsibilities regarding health and safety? Is there a health and safety committee? What is the accident reporting and follow-up system? Have risk assessments been undertaken and documented? Does audit occur and are staff involved? What systems have been established, and how well are they are they working? Is there induction training and a rolling programme of training on health and safety, and how effective is it? Is there a safety department or adviser? Are there departmental representatives? Is there an occupational health nurse? What are the skills and responsibilities of the occupational health nurse?
Figure 8.4 Some Questions to Ask when Assessing the Safety Culture of an Organisation
In some local authorities there are large health and safety departments, with several health and safety officers working as a team and specialising in different areas such as manual handling, fire safety and health promotion. Some large companies have a separate occupational health department staffed by physicians and nurses. Most occupational health nurses have a safety adviser colleague but usually only parttime medical advice. Only a few large companies and hospitals have a team of physicians, nurses and health and safety specialists providing a fully comprehensive occupational health and safety service. As previously discussed, whoever is providing health and safety advice must be ‘competent’ under the legislation. The following case study demonstrates how an occupational health nurse can make a difference to workplace health and safety by working in a flexible and imaginative way as a team member.
Manual Handling Case Study The charity Backcare estimates that the cost of back pain to the NHS, the economy and society is £ 5 billion per year (HSE 2006c). In the health care sector back pain is one of the main occupational risks. Loss of nursing staff through sickness absence and retirement due to back injury is a drain on resources, in addition to the human cost to those injured in terms of pain and suffering, loss of income and possible change of career. Nurses have been awarded damages for back injuries sustained
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at work (£ 803 000 in the case of Douglas v Bexley and Greenwich Health Authority 2000). So how should a hospital try to reduce the risk to staff from back pain and comply with the Manual Handling Regulations, while providing the best possible care for patients? How can occupational health nurses help? The 1992 Manual Handling Operations Regulations state that manual handling must be avoided so far as is reasonably practicable. If this is not possible then an assessment must be made of the operation involved. There is a requirement to reduce the risk of injury. Assessment is to involve employer and employee, and includes looking at the task, load, environment and individual capability. Records must be kept, and training given. The regulations state that following assessments ‘it is not sufficient to make changes and then hope that the problem has been dealt with . . . monitoring must continue.’ This hospital approached the issue by establishing a manual handling working party, which included representatives from all involved parties (including the occupational health nurse manager). It considered best practice and studied the requirements of all relevant law (including the Manual Handling Operations Regulations), as well as the latest good practice guidance, such as HSE and Royal College of Nursing publications. The working party then produced a policy covering all aspects of the hospital’s strategy for meeting the regulations. The policy was clear, concise and well-communicated, and systems were put in place for updating and periodic audit of the policy. It is crucial that hospitals receive competent advice, and the working party reviewed how other hospitals had dealt with this. It found that several hospitals were using their own physiotherapists, working with occupational health nurses, trainers and ward nurse facilitators whom they had trained. Other large hospitals had appointed full-time manual handling trainers with physiotherapy or nursing backgrounds. One local hospital had decided to use an independent manual handling trainer who was an occupational health nurse by training. By matching this independent trainer’s course to its local needs and taking up references, this employer demonstrated that it had taken precautions in establishing the trainer’s competence and was pleased with the results. It was able to demonstrate that it had studied what was required and felt confident that it had appointed competent, trained and experienced members of its own staff to work with the independent trainer in implementing the most suitable policy for the hospital. The working group decided to appoint the same independent trainer to help it set up its training for managers and staff involved in manual handling and to advise on assessments. There are thus several acceptable ways of achieving the same end of complying with the requirements of the Manual Handling Regulations for individual organisations. The onus is on the employer to
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demonstrate that they have done what could reasonably be expected in establishing the suitability of whoever is nominated as the competent person.
Conclusion Occupational health and safety are everyone’s responsibility and are inextricably linked. Clearly, the requirements and opportunities for the occupational health nurse to work in health and safety vary greatly depending on the setting. Whatever the situation, however, occupational health nurses need an understanding of the health and safety legislation relating to the workplace they are advising. It is up to all professionals, including occupational health nurses, to be clear and assured about their competencies, to keep up to date and to be aware of the limitations of their knowledge. As well as knowing where to obtain information, it is also crucial that they know to whom they can refer when they do not have the relevant competency. This chapter has provided an historical overview of health and safety in the UK, with particular reference to the links between occupational health and health and safety. Two key themes that run through health and safety legislation and guidance, namely risk assessment and the competent person, were outlined. The aim was to illustrate some of the ways in which the occupational health nurse can make a difference to workplace health by keeping abreast of health and safety issues and getting actively involved in collaborative working with employers, employees and health and safety colleagues.
Acknowledgements I am extremely grateful to Mary Guinness and Julie Wood for generously giving their time to comment on the draft chapter for this third edition of the book. Thanks are also due to Neil Cooper for his views on my original draft for the first edition, and to Dr Ivan Johnson for his comments on the first edition.
References and Further Reading Basingstoke and Deane Borough Council v J. Sainsbury plc (1998). British Safety Council web site, www.britishsafetycouncil.co.uk. Davies C. (1999) The Need for Competent Advice, Safety and Health Practitioner. Employment Medical Advisory Service Act 1972. Factories Act 1961. Health Act 2006.
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Health and Safety at Work Act 1974. HSC (2000a) Revitalising Health and Safety: Strategy Statement, June, Wetherby: DETR, www.hse.gov.uk/revitalising/index.htm. HSC (2000b) Securing Health Together: a Long-Term Occupational Health Strategy for England, Scotland and Wales, Sudbury: HSE. HSC (2000c) Occupational Health Advisory Committee Report and Recommendations on Improving Access to Occupational Health Support, Sudbury: HSE. HSC (2004) A Strategy for Workplace Health and Safety in Great Britain to 2010 and Beyond, Sudbury: HSE, www.hse.gov.uk/aboutus/hsc/strategy 2010.pdf (accessed 15 July 2007). HSC (2007) Health and Safety Statistics (2006/07), Sudbury: HSE, www.hse.gov. uk/statistics/overall/hssh0506.pdf (accessed 15 July 2007). Health and Safety Executive (HSE) web site, www.hse.gov.uk. HSE (1977) Safety Representatives and Safety Committees Regulations. HSE (1981) First Aid at Work Health and Safety (First Aid) Regulations. HSE (1992a) Health and Safety (Display Screen Equipment) Regulations (as amended). HSE (1992b) Management of Health and Safety at Work Regulations (as amended). HSE (1992c) Manual Handling Operations Regulations (as amended). HSE (1992d) Personal Protective Equipment at Work Regulations (as amended). HSE (1992e) Workplace (Health, Safety and Welfare) Regulations. HSE (1995a) Reporting of Injuries, Diseases and Dangerous Occurrences Regulations. RIDDOR web site: www.riddor.gov.uk. HSE (1995b) Health Risk Management: a Practical Guide for Managers in Small and Medium-Sized Enterprises, Sudbury: HSE. HSE (1996) Health and Safety Consultation with Employees Regulations. HSE (1997) HS(G) 65 Successful Health and Safety Management, 2nd edn, Sudbury: HSE. HSE (1998a) Health and Safety (Enforcing Authority) Regulations. HSE (1998b) Provision and Use of Work Equipment Regulations (PUWER). HSE (2000) An Introduction to the Employment Medical Advisory Service, HSE5, Sudbury: HSE. HSE (2004a) Interim Update of the ‘Costs to Britain of Workplace Accidents and Work-Related Ill Health’, Sudbury: HSE. HSE (2004b) Control of Substances Hazardous to Health Regulations: Approved Codes of Practice. HSE (2005a) Noise at Work Regulations. HSE (2005b) Guidance for Employers on the Control of Noise at Work Regulations, www.hse.gov.uk/pubns/indg362.pdf (accessed 15 July 2007). HSE (2005c) Control of Vibration at Work Regulations. HSE (2006a) Five Steps to Risk Assessment, Sudbury: HSE, www.hse.gov.uk/ pubns/indg163.pdf (accessed 15 July 2007). HSE (2006b) Essentials of Health and Safety at Work, 4th edn, Sudbury: HSE. HSE (2006c) Backs! 2005 Initiative: Final Report, Sudbury: HSE.
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HSE (2007a) Case 127-05 European Commission v United Kingdom, press release. HSE (2007b) Occupational Health Statistics Bulletin, www.hse.gov.uk/ statistics/overall/ohsb0506.htm (accessed 23 July 2007). HM Government (2005) Health, Work and Well-Being: Caring for our Future: a Strategy for the Health and Well-Being of Working Age People, Department for Work and Pensions, Department of Health and HSE, www.dwp.gov.uk/ publications/dwp/2005/health and wellbeing.pdf (accessed 15 July 2007). Offices, Shops and Railway Premises Act 1963.s The Robens Report (1972) Safety and Health at Work, London: TSO. HMSO (1996) Safety Representatives and Safety Committees, 3rd edn, London: TSO. Institution of Occupational Safety and Health (IOSH) web site, www.iosh.co.uk. Jones J.R., Huxtable C.S. and Hodgson J.T. (2006) Self-Reported Work Related Illness in 2004/05: Results from the Labour Force Survey, Sudbury: HSE, www.hse.gov.uk/statistics/swi/swi0405.pdf (accessed 15 July 2007). Kloss D. (2005) Occupational Health Law, 4th edn, Oxford: Blackwell Publishing. Mountenay and Others v Bernard Matthews plc (1993) unreported case. NMC (2004) The NMC Code of Conduct: Standards for Conduct, Performance and Ethics, www.nmc-uk.org. RCN (1993) The Occupational Health Nurse: Opportunities for Developing Professional Practice in Relation to Current Health and Safety at Work Regulations, London: Royal College of Nursing. Royal Society for the Prevention of Accidents (ROSPA) web site, www.rospa.co. uk. Scottish Parliament (2005) Smoking, Health and Social Care (Scotland) Act, TSO. The Smoke-Free (Premises and Enforcement) Regulations 2006. Smokefree England web site, www.smokefreeengland.co.uk. Walker v Northumberland County Council (1995) Industrial Cases Reports (September 1995) Part 8: 702–22.
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Health Surveillance, Health Assessment and Health Screening Cynthia Atwell
Introduction This chapter looks at the role of the occupational health nurse in health assessment, health surveillance and health screening within the workplace. It will discuss legal standards, risk assessment, biological monitoring, setting professional standards for care and the occupational health nurse’s responsibilities. The main focus of the chapter is on the health and safety implications in assessing health, taking account of the requirements of the Disability Discrimination Act 1995. The purpose of any health care initiative within the workplace must be to safeguard the health of the workforce, the business and the wider community. To safeguard everyone, including the occupational health nurse, there must be clearly written instructions that set out how health assessments and surveillance will be carried out. This chapter provides some examples of the content of such instructions, to protect against accusations of discrimination and provide a uniform approach to these procedures. Some occupational health practitioners may consider that this undermines their professionalism but it is vital for the practitioner to demonstrate their competence, and to provide evidence of professional and clinical audit as well as the quality of the health initiatives being carried out. The RCN has set out guidance for occupational health audit (RCN 1999). Clearly documented standards for practice that are regularly audited will ensure that occupational health uses best practice, Occupational Health Nursing Edited by K. Oakley. C 2008 John Wiley & Sons, Ltd
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based on current evidence, providing clients with the highest standard of care in the workplace.
Health Surveillance Health surveillance is defined by the Health and Safety Executive (HSE) as ‘putting in place systematic, regular and appropriate procedures to detect early signs of work-related ill health among employees exposed to certain health risks; and acting on the results’ (HSE 1999a p. 5). Health surveillance is a statutory requirement under several regulations, including but not limited to:
r The Management of Health and Safety at Work (Amendment) Regulations 2006, Regulation 6 (HSE 2006a).
r The Control of Substances Hazardous to Health (Amendment) Regulations 2004, Regulation 11 (HSE 2004).
r The Control of Lead at Work Regulations 2002, Regulation 10 (HSE 2002). Health surveillance is often confused with general health screening. It is important that the OH nurse understands the difference and can identify the need for health surveillance through the risk assessment process. Health surveillance is a legal requirement under certain circumstances. Health screening is ‘good practice’ as a means of promoting a healthy lifestyle and identifying early signs of non-occupational disease. In February 2004 the Health and Safety Commission (HSC) launched a strategy for workplace health and safety (HSC 2004). In this, the HSC presents a vision for the future of health and safety and for the first time health at work has been recognised as a major factor in the health of the nation. This document highlights the need to work in partnership with others and states that one of the aims is ‘to contribute to the nation’s health and well-being, and [deal] with health inequalities’. In order to know if and what type of health surveillance is necessary to comply with legal requirements, a full assessment of risks to health must be carried out. Once the risks have been identified, a decision must be made on the type of surveillance that is appropriate. It may well be the occupational health nurse, either alone or with a health and safety manager, who carries out the assessment of health risks as part of the overall risk assessment process. This requires a methodical approach, examining exactly what is being handled in the work process. Figure 9.1 is a suggested checklist for assessing risks to health. If the occupational health nurse is to be responsible for health surveillance activities within the organisation then it is vital to have a written procedure that documents how this will be carried out and when
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What work is being carried out? Examine all the jobs and functions workers are carrying out, e.g. office, sales production, maintenance, stores, loading, delivery, cleaning, packing, driving. What are they doing? What are the hazards to health? r Physical, e.g. noise, excesses of heat/cold, vibrating tools, sources of radiation. r Chemical, e.g. dust, fumes, gases, liquids. r Biological, e.g. infections from human or animal sources such as blood, infestation. r Psychosocial, e.g. piecework, shifts, night work, dealing with public, risk of violence, repetitive work, high/low responsibility. r Ergonomic, e.g. manual handling, computer work (DSEs), machine displays, rapid/repetitive handwork, using hand tools, standing/sitting. How will the hazard affect the worker? r Can it be inhaled? e.g. dust from production process, packaging, cleaning; fumes from welding, soldering, solvent tanks/cleaners; any other source of dust, gases, fumes, vapours that could be inhaled. r Can it be ingested? e.g. potential hand-to-mouth contamination. r Can it be absorbed through the skin or eyes? e.g. chemical absorption through broken or unbroken skin; splashes to the eyes or on to skin. r Can it cause deafness? e.g. noise from machinery, other sources – is it continuous or intermittent and for how long are people exposed? r Who is exposed to the hazard? Male/female; young/old; pregnant or nursing mothers. How many people are exposed and for how long; is it continuous or intermittent? r What are the likely health effects? Short and/or long-term on e.g. lungs, skin, other systems; also consider effects on mental health. How well is the hazard controlled (hierarchy of measures)? r Eliminate, substitute or change, i.e. don’t do it, use something less harmful or change the process. r Enclose and isolate, e.g. handle in enclosed unit. r Segregate to reduce numbers of people exposed to the hazard. r Reduce by improving ventilation, e.g. local extraction ventilation; general ventilation (open windows). r Control by implementing a safe system of work, e.g. can the work be done in a different way that makes it safer? r Suppress (noise/dust), e.g. damp dusting; use of acoustic material on noisy machinery/tools. r Control by improved housekeeping and/or disposal of waste, e.g. keeping work areas tidy, with no clutter; putting items away and storing them properly; getting rid of waste materials regularly. r Use of personal protective equipment (PPE) or clothing, e.g. gloves, aprons, respiratory protection, eye protection. Is it adequate; does it provide sufficient protection in the circumstances in which it is being used?
Figure 9.1
Assessing Risks to Health
employees will be referred to an occupational physician. An example of a health surveillance procedure is shown in Figure 9.2. Health surveillance aims to detect early signs of work-related ill health so that appropriate actions such as referral to medical specialists can be taken.
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r
r r r r
r r r
A definition of what is meant by health surveillance, such as: ‘Health surveillance is a statutory requirement specified in the health and safety regulations for workers potentially exposed to hazards to health that have been identified through the risk assessment process. This surveillance may include clinical tests such as lung function testing and audiometry, as well as other examinations such as skin examination.’ Health surveillance will be carried out as agreed with the employer, identified through the risk assessment process. Testing procedures such as lung function testing, audiometry and vision screening will be undertaken in accordance with the procedures set out in the occupational health instruction manual and/or the equipment manufacturer’s instructions. Any employee who has an abnormal test result and/or for whom the OH nurse identifies a potential or actual health effect will be referred for a further assessment, preferably to an occupational physician, for advice and/or examination. Details of the health surveillance findings, including test results, will be recorded in the employee’s health records, appropriately signed and dated. These records will be maintained and kept in accordance with the requirements of health and safety regulations, the Data Protection Act 1998, the Nursing and Midwifery Council (NMC) and the General Medical Council (GMC). The employee will be informed of the outcome of the health surveillance and appropriate occupational health advice and information will be given. Management will be informed of the overall results of the health surveillance of groups of employees, ensuring confidentiality is maintained. The OH nurse will advise the company on the implementation of a recall system to comply with health and safety regulations and/or the needs of the employee.
Figure 9.2
Example of a Health Surveillance Procedure
National Surveillance Schemes At a national level, statistics on occupational disease are produced from a variety of sources, including physician-reporting and self-reporting schemes. There is no one UK centre responsible for national surveillance of all occupational disease but composite figures are produced by the HSE in their occupational health statistics bulletin (HSE 2006b). Examples of information included in this bulletin are: data on selfreported ill health from the Labour Force Survey, data from specialist doctors in THOR (The Health and Occupation Reporting Network) and data on fatal occupational diseases. Manchester University runs the UK voluntary occupational health surveillance scheme, THOR (www.medicine.manchester.ac.uk/coeh/ thor/). THOR incorporates SWORD (Surveillance of Work-related and Occupational Respiratory Disease) and several other surveillance schemes. The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (HSE 1995a) require employers, the self-employed and those in control of premises to report workplace incidents to the Health and Safety Executive (or local authority where appropriate) within specified times. There are more deaths from workplace-related diseases than from
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accidents in the workplace, and the onset of these diseases is often insidious. Ross et al. (1995) stated that national surveillance schemes showed an under-reporting of workplace related diseases under RIDDOR.
Legal Requirements The law is very specific (e.g. Control of Substances Hazardous to Health Regulations, Management of Health and Safety at Work Regulations) about what is appropriate and when health surveillance should be carried out (based on assessment of risks to health) and has set out the following basic four criteria:
r Where it is known that work can affect the health in some way. r Where there are valid ways to detect the disease or health condition. r Where it is likely that damage to health will occur under the particular working conditions.
r Where health surveillance is likely to be of benefit to employees. The purpose of health surveillance is to protect the health of employees, by early detection of adverse health effects that could be caused by exposure to hazardous substances or other workplace hazards (Figure 9.3 provides examples). It will assist with the evaluation of control measures, through the collection of measurements and data, with the aim of bringing about improvements in the working environment through the reduction of employee exposure to hazards.
Who Can Carry Out Health Surveillance? Health surveillance can be carried out by a number of different people, depending on the type of surveillance and level of competence required.
Occupation
Exposure To
Baker
Flour dust
Paint sprayer Farm worker Painter Hairdresser Forestry worker
Isocyanates Mouldy hay Solvents Shampoo, dyes Vibration
Noise
Figure 9.3
Valid Test/ Assessment Lung function respiratory questionnaire (RQ) Lung function RQ Lung function RQ Skin exam Skin exam Questionnaire on symptoms Audiometry
Health Effect Asthma
Asthma Farmer’s lung Dermatitis Dermatitis Hand/arm vibration (HAVS) Deafness
Examples of Workplace Hazards and Appropriate Tests
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The main issue is that the person carrying out the health surveillance is trained and competent to do it. In ‘Health Surveillance at Work’ (HSE 1999a) the HSE advises a hierarchy for health surveillance as follows: A Responsible Person: this will be a non-medical person, e.g. manager, supervisor, health and safety representative or first-aider, who has been trained to carry out simple observation procedures, such as checking for skin damage on hands, making enquiries about symptoms or using a simple questionnaire. The responsible person will be expected to document the observations and report any adverse problems to the manager or, where available, the occupational health nurse or doctor, so that further action can be taken. A Qualified Person: this will normally be an occupational health nurse, who will carry out health examinations, enquiring about health effects, and perhaps include tests such as lung function and audiometry. Records of the examinations must be maintained and a system for referral for further investigation by an occupational health physician must be implemented. A Medical Practitioner: this will normally be a qualified occupational health physician; however, general practitioners (GPs) fulfil this role in many organisations. This level of medical surveillance will include a clinical examination looking for any signs of adverse health effects. The doctor carrying out this level of surveillance must have knowledge of the hazards in the workplace and their effects on health. According to Aw (1999 p. 300), ‘Confusion over terminology has led to biological monitoring occasionally being included as an activity under health surveillance. By definition, biological monitoring is not a clinical or physiological procedure to detect early health effects. It refers to the analysis of biological samples for the determination of the extent of exposure.’ Blood, urine and breath can be tested. It is important that the occupational health nurse understands the purpose of biological monitoring, and that it is used as intended and not confused with a preventive procedure (it is discussed in this chapter in order to provide information and for completeness). Biological monitoring measures the effects of exposure to chemical substances, such as lead, mercury or cadmium, by regularly testing the blood or urine of anyone exposed and looking for the specific substance. With other chemicals, such as toluene, styrene and xylene, the test will be to identify the metabolites in the biological sample. An occupational health nurse should be competent to manage the process but will need support from an occupational health physician in the interpretation of results and for advice on managing those with significant uptake. Ultimate responsibility to provide health surveillance under health and safety law rests with the employer; however, day-to-day management will probably be delegated to a responsible manager. In the majority of large organisations the occupational health nurse is the health
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professional most likely to be involved in setting up and managing the health surveillance programme, working with an occupational health physician and other members of the team, such as the occupational hygienist, toxicologist and chemical engineers. In small and medium-sized enterprises (SMEs) the responsibility for this may fall within the remit of the manager responsible for general health and safety, who will require outside professional support and advice. Workplace Health Connect was set up in 2006 in partnership with HSE to provide free, practical advice to employers and employees on workplace health and safety in SMEs (HSE 2006a). An advice line (0845 609 6006) and supporting web site, www.workplacehealthconnect.co.uk, give tailored practical advice on workplace health and safety and return to work issues. Alternatively, you can get access to occupational health advice through a local GP practice, NHS Trust occupational health service, private occupational health provider or consultant. The main factor in deciding on what support is needed is identification of the risks, to assess what level of health surveillance is needed and the level of competence required from an outside source: someone who has knowledge of the workplace hazards and their effects on health and, more importantly, how to manage and control these hazards to ensure the workforce is adequately protected.
Drugs and Alcohol When drug and alcohol policies are introduced in the workplace they need to be agreed in consultation with the employees to be effective. Regarding drug and alcohol policies, the Health and Safety Executive (HSE 2006a) advises the employer, ‘if you decide strict standards are needed because of safety critical jobs then agree procedures with workers in advance. Disciplinary action may be needed where safety is critical.’
Health Assessment and Pre-Employment Assessment This is a process that requires the collection of detailed information on the health status of an individual and will include details of their occupational history, and clinical measurement tests to identify abnormalities. This will provide a baseline for assessment of an individual’s fitness for a particular job. Fitness is assessed against the hazards and demands associated with the job and their likely effects on the individual’s health. This type of assessment is a ‘health risk assessment’, which requires a professional medical/nursing opinion on ‘fitness for work’, the outcome of which can have implications under the Health and Safety at Work Act 1974, the Disability Discrimination Act 1995 and the Human Rights Act (1998).
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The occupational health nurse must understand the potential and actual health risks associated with the occupation for which the individual has applied. The outcome of the assessment is reported back to the company in terms of the level of ‘fitness for task’. Pre-employment health assessment is a major part of any occupational health service’s role, with the main responsibility for this falling initially on the occupational health nurse. In some cases a health risk assessment is a specific legal requirement with specific fitness standards and requires input from an HSE-appointed doctor. Examples include:
r r r r
Ionising Radiation Regulations (HSE 1999b) Diving at Work Regulations (HSE 1997) Railway Safety Critical Work Regulations (HSE 1994) Control of Lead at Work Regulations (HSE 2002).
Other, more general regulations are relevant to health risk assessment in all workplaces, such as:
r Management of Health and Safety at Work Regulations (HSE 2006a) r Control of Substances Hazardous to Health Regulations (HSE 2004) r Health and Safety (Consultation with Employees) Regulations (HSE 1996)
r Access to Medical Reports Act. In addition to the law, national guidance is to be followed relating to specific workplaces, such as guidance produced by the Department of Health for health care settings (e.g. ‘Health Clearance for Tuberculosis, Hepatitis B, Hepatitis C and HIV: New Healthcare Workers’ (DoH 2007)). Most pre-employment health assessments are carried out by nurses, the level of assessment being based on the type of risk to health. However, there is a great deal of unnecessary ‘hands on’ medical assessment carried out which has little or no value. Such assessments are timeconsuming and costly, as well as providing little benefit to either the employer or employee. The Faculty of Occupational Medicine (2006) has identified areas of concern and recommends that undertaking tests and examinations on healthy people is treated different to dealing with the sick, though the same strict ethical principles must be applied. A study of pre-employment screening carried out by Whitaker and Aw (1995) demonstrated little difference in rejection rates of those screened by multi-staged approach compared to those who were medically examined. Pre-employment assessment is an area that requires careful planning, using agreed fitness criteria (where these are required), particularly in relation to the Disability Discrimination Act 1995. Pre-employment assessments must be carried out to an agreed standard to ensure a unified approach to the process. Referral for advice will be necessary in cases
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where there is doubt about fitness for work. Occupational health nurses should not reject candidates without consulting their GP or, preferably, an occupational physician for further advice. In low-risk jobs, formal pre-employment assessment may not be necessary and it will be satisfactory for the potential employee to provide simple information regarding any disability and their ability to carry out the job. The recruitment officer could administer a questionnaire, with any positive results being referred for more formal assessment by an occupational health nurse. The example questionnaire presented in Figure 9.4 would provide non-confidential information to the employer, which would allow appropriate adjustments to be made to accommodate the disabled worker. This would support the requirements of the Disability Discrimination Act. A sample occupational health nursing standard for health assessment is outlined below.
r r r r r r r r r
Do you have any difficulty in carrying out normal day-to-day activities or gaining access to buildings, climbing stairs, etc.? Do you have any medical condition or disability that you believe your employer should be made aware of? Do you have any medical condition that could affect your ability to do the job for which you have applied, or could affect your safety or the safety of others with whom you work? Have you had any medical condition that you think has been caused by or is made worse by your work? Have you ever been ill-health retired? Do you have any difficulty in reading normal print, using display screen equipment or using a computer? Do you have any difficulty hearing and in particular using the telephone? Do you have any medical condition of which, in your own interest, first aid personnel should be aware? Are you undergoing any current medical treatment or have you any treatment or investigation planned?
Declaration
Approximately how many days sickness absence have you taken in the past 2 years?
I would answer YES to one or more of the above questions
YES
None of the above applies to me
NO
I confirm that the declaration provided above is correct to the best of my knowledge, and I understand that making a false declaration could jeopardise my employment with (Company Name) Name: .............................................................................................. (block letters) Signature: ................................................ Date: ...................................................
Figure 9.4 Example of a Pre-Employment Health Questionnaire for People in Low to Medium-Risk Occupations
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Pre-Employment Health Assessment
r Definition: ‘Health Assessment’ is a ‘one-to-one health interview’
r r
r r
r
r
r
r r r r
carried out by an OH nurse, which may include clinical testing, with the purpose of assessing an individual’s ‘fitness for work’. The outcome of the assessment is reported back to the company in terms of the level of ‘fitness for task’; it is a health risk assessment, and has legal implications under the Health and Safety at Work Act 1974 and the Disability Discrimination Act 1995. Individuals will be informed of the purpose of the assessment and what to expect, including clinical test procedures and the outcome. If health questionnaires are used these will be checked for completion and the OH nurse will go through the answers for clarification and/or more information, as necessary, which will be recorded on the health record. Assessment of fitness for work will be based on the requirements of the job, with reference to the job specification and/or the company’s fitness standards and/or workplace risk assessment. Clinical testing procedures, e.g. lung function tests, audiometry, vision screening, etc., will be carried out in accordance with the procedures set out in the instruction manual and the equipment manufacturer’s instructions. The OH nurse will make decisions on fitness for work based on the above, using professional and clinical judgement. All decisions on fitness for work will be recorded in the health record, signed and dated. Further information will be sought from the GP if necessary, to obtain details of past medical history to assist the OH nurse in making the assessment, and/or the employee will be referred to an occupational physician. All cases where there is doubt about fitness for work, or where employees require medical assessment for statutory or mandatory reasons, will be referred to an occupational physician for advice and/or examination. No employee will be rejected by the OH nurse alone; any employee raising concerns must be referred to an occupational physician for advice and/or examination. The health assessment records will be kept confidential and securely locked, with access limited to OH doctors and nurses. OH nurses will comply with the requirements of the NMC Code of Professional Conduct, with specific reference to confidentiality and record keeping. OH nurses will comply with the requirements of the Access to Medical Reports Act 1988 when seeking reports from GPs, consultants or other health professionals, using the approved forms.
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r OH nurses will advise on the possible implications of the Disabil-
r
r
ity Discrimination Act 1995 and will provide guidance appropriate to the case, including advice on workplace modifications and the implementation of ‘safe systems of work’. OH nurses will be fully conversant and comply with any specific requirements of health and safety legislation, HSE guidance notes and standards applicable to the workplace and type of health assessment being carried out. Employees will be informed of the outcome of the assessment and of any recommendations that are made to management.
In jobs classed as higher risk, fitness criteria should be developed based on the findings of the risk assessment. The potential employee’s suitability will be assessed against those criteria. The assessment will be objective and will not allow for bias on the part of the employer, or more importantly the occupational health nurse or doctor. Any advice regarding employment must be based on sound scientific evidence, therefore pre-employment assessments require in-depth knowledge of the job the applicant has applied for and a thorough assessment of the applicant’s ‘abilities’ in relation to that job, where there are specific risks to health identified through the risk assessment. People with known health problems should never be rejected without having undergone a full health assessment. This will include obtaining information from the employee’s GP and/or consultant, with the informed signed consent of the employee concerned, as required under the Access to Medical Reports Act 1988. Any information obtained from the employee’s GP should not be passed on to the employer without the explicit consent of the individual (RCN 2003). What is required is for the nurse to interpret the contents of the report to help make an informed decision regarding fitness for work. If this procedure is implemented, it will not only be nondiscriminatory but will be a more cost-effective way of dealing with pre-employment assessments. It will conserve resources, allowing more occupational health service time and resources to be spent on prevention and control of workplace hazards, concentrating on the ‘healthy workplace’ and not just the ‘healthy worker’, although of course they are both important aspects of occupational health practice.
General Health and Lifestyle Screening This is a process that takes a detailed health and family history and records clinical measurement tests such as blood pressure, cholesterol, height/weight = body mass index (BMI), spirometry and ECG in order to identify abnormalities. Depending on the outcome of the tests, health
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advice is provided to the individual with the intention of improving their level of fitness. The individual can then make informed choices about lifestyle and understand the implications their decisions may have on their personal health. The appropriateness of general health screening in the workplace must be agreed with the employee and employer. The employee must understand that the purpose is to detect early signs of non-occupational ill health, to undertake lifestyle assessment and to offer health education. Programme 2 in Securing Health Together (HSC 2000) recommends that ‘the work environment should be used to tackle the non-work contributors to work-related ill health; doing all that is required to rehabilitate individuals after ill health; and to promote general health.’ Therefore, modern occupational health practice will require more involvement of the occupational health nurse in general health and lifestyle screening, as defined above. According to Lewis and Thornbory (2006), ‘General health screening must not be confused with “health surveillance”, which may be carried out as part of primary health care’, therefore strict protocols and procedures will be required to ensure everyone understands the purpose of such screening and how any adverse findings will be managed. As with any care provided in the workplace, general screening should be carried out with the full knowledge of the workforce, and with the individual’s informed consent. The occupational health nurse must ensure that the employee is fully aware of the differences between ‘health assessment’, ‘health surveillance’ and ‘health screening’, and that they understand the purpose of each and how the information will be used (Data Protection Act 1998). General health and lifestyle screening is normally voluntary and is not a legal requirement for employment. However, screening may show up health problems that could have implications for employment in safety-sensitive work, such as a large goods vehicle (LGV) driver who has raised blood pressure. Before embarking on such a screening programme the OH nurse must agree with the employer how such problems will be managed, in order to safeguard the employee and the employer. Once a problem has been identified, it cannot be ignored (‘If you don’t know what to do with the answer, don’t ask the question’).
The 10-Year Strategy for Occupational Health The government strategy for occupational health, Securing Health Together (HSC 2000), set out a long-term plan for meeting the health needs of the working population in England, Scotland and Wales. The aim of the strategy is to:
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r Reduce ill health in workers and the public caused, or made worse, by work.
r Help people who have been ill, whether caused by work or not, to return to work.
r Improve work opportunities for people currently not in employment due to ill health or disability.
r Use the work environment to help people maintain or improve their health. The HSC ‘Strategy for Workplace Health and Safety in Great Britain to 2010 and Beyond’ (HSC 2004) clearly sets out the expectation that occupational health and other stakeholders should be actively involved in preventing ill health and promoting rehabilitation. The whole concept of the strategy is centred around partnerships, with people and organisations interested in health working together to meet the strategy’s aims and provide access to occupational health care for everyone. The Confederation of British Industry (CBI) produced a report of a survey it carried out in 1999 of occupational health provision in the UK (CBI 2000). This report highlighted the need for more access to occupational health advice and provision, especially for SMEs. This has partly been addressed with the implementation of Workplace Health Connect.
Record Keeping Record keeping is an essential part of occupational health practice. It provides baseline information on the individual’s state of health, and will help to identify trends in ill health as well as to confirm the adequacies of the conclusions of the risk assessment process and the effectiveness of the control measures implemented. Where health surveillance is carried out there is a legal requirement to keep records. Regulation 11 of the COSHH Regulations 2004 (HSE 2004) requires health records to be kept for 40 years, i.e. 40 years from the date of the last entry. Health records should be kept confidential and comply with the standards for professional nursing practice (NMC 2004), and must be kept within the ethical and professional guidelines for medical records (Medical Defence Union 1996; Faculty of Occupational Medicine 2006). According to the NMC (2004), the main principles for record keeping are:
r Records are an integral part of nursing care (this applies equally to occupational health practice).
r Good record keeping is a mark of a skilled and safe practitioner (even r
more important when working in occupational health practice, out of the mainstream of health care). Records must not contain abbreviations and/or jargon.
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r Records should be written so that everyone can understand (never write anything in the record that you would not wish the employee (patient) to see). Entries must be identifiable with a name and signature, and dated. There must be a secure system for keeping records that excludes unauthorised access and maintains confidentiality.
r r
Confidentiality can be a problem within the occupational health setting, as managers consider they have the right of access to records. This can sometimes be a cause of conflict between the occupational health practitioner and manager. However, as Lewis and Thornbory (2006 p. 39) point out, ‘For occupational health nurses, one of the basic requirements for practice is that they should be competent to manage inappropriate requests to disclose personal health information without the informed consent of individuals.’ The occupational health nurse will require a standard for practice that provides guidance for the manager on the health professional’s role regarding record keeping and confidentiality. Figure 9.5 shows suggested contents for a standard for record keeping.
1. The OH nurse will establish and maintain personal health records of employees under the following circumstances: (detail what these are, e.g. assessments, surveillance, screening). 2. Personal health records will be maintained in secure, confidential storage. This will normally be at (location). Records will be kept in accordance with the requirements of the NMC ‘Code of Professional Conduct: Standards for Conduct, Performance and Ethics’ and ‘Standards for Records and Record Keeping’. 3. No information will be written on the health record that is likely to be detrimental to the individual to whom the record refers. The OH nurse will, as far as possible, inform the individual of the contents of the record. 4. OH nurses will comply with all legislation pertaining to the collection, maintenance and distribution of personal health records, such as:
r r
the Data Protection Act 1998 the Access to Medical Reports Act 1988.
5. Records required under health and safety regulations (e.g. COSHH (amendment) Regulations 2004, Management of Health and Safety at Work (amendment) Regulations 2006) for the purpose of managing health surveillance programmes will be kept as in (2) above and for a minimum of 40 years after the last entry is made. 6. Records will be archived (outline company procedure for this). 7. If the company goes out of business the personal health records of employees will be . . . (outline company procedure for this and how it will be managed). 8. OH nurses will ensure employees are aware that a personal health record is being kept, and that they have right of access to the record under the Data Protection Act 1998. 9. OH nurses will not give confidential health information to managers without the written, signed, informed consent of the employee to whom the information relates.
Figure 9.5
Example of Standards for Record Keeping
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Health Records and the Data Protection Act 1998 The Data Protection Act 1998 supersedes the 1984 Act and includes manually-held data, of which occupational health records held by companies will be a part. The new act replaces the 1990 Access to Health Records Act, which did not include all occupational health records. The act defines a ‘health record’ as ‘consisting of information relating to the physical or mental health or condition of an individual, and which has been made by, or on behalf of, health professionals.’ Health records, whether held on computer or manually, will be subject to data protection.
The Main Principles of the Act Personal data shall be: 1. 2. 3. 4. 5. 6. 7.
processed fairly and lawfully obtained for specified and lawful purposes accurate and kept up to date adequate, relevant and not excessive kept no longer than is necessary for their given purpose processed in accordance with the person’s rights subject to appropriate safeguards against unauthorised use, loss or damage 8. transferred outside the European Economic Area only if the recipient country has adequate data protection. It must be remembered that a number of health and safety regulations stipulate the requirements for the collection and retention of personal health data, e.g. COSHH, Lead at Work Regulations, Asbestos Regulations. This act does not change these requirements but all such records will be covered by data protection. The main emphasis of the Data Protection Act is on consent and it is the responsibility of the occupational health nurse to ensure that employees give informed, written consent to, and are made aware of, all personal health data that are kept on them. This will include records of health assessments, surveillance, medical examinations and sickness absence that are held by the company. This act does not alter the requirements for the confidentiality of health records.
Conclusion Health surveillance is a major role for the occupational health nurse. It is important that they understand the difference between health assessment, health surveillance and health screening and, more importantly,
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that the employee and employer understand their purpose and function within the workplace. Occupational health nurses must: have a thorough understanding of the legal requirements for health surveillance and health risk assessment; be competent to carry it out; know their limitations and when to refer to a medical practitioner for further advice. An essential requirement for effective health surveillance, health assessment and health screening is good record keeping. It can provide the occupational health nurse with information on the health of the business and should be used to improve the health of the workforce. Records will provide information on health trends and will help to identify any inadequacies in risk assessment and the subsequent control systems put in place. Systems to provide feedback to the employer and employee should be implemented, ensuring that confidentiality is preserved.
References and Further Reading Access to Medical Reports Act 1988. AOHNP(UK) (2000) A Quality Pathway for Occupational Health, Leicester: AOHNP(UK) Publications & W. Mercer. Aw T.C. (1999) Health Surveillance. In: Sadhra S.S. and Rampal K.G. (eds) Occupational Health: Risk Assessment and Management, Oxford: Blackwell Science. Aw T.C., Gardiner K. and Harrington J.M. (2006) Occupational Health: Pocket Consultant, 5th edn, Oxford: Blackwell Science. Confederation of British Industry (2000) Their Health in Your Hands (Focus on Occupational Health Partnerships), London: Waterside Press. Data Protection Act 1998. Disability Discrimination Act 1995. DoH (2007) Health Clearance for Tuberculosis, Hepatitis B, Hepatitis C and HIV: New Healthcare Workers. Faculty of Occupational Medicine (1995) Quality and Audit in Occupational Health, London: FOM, Royal College of Physicians. Faculty of Occupational Medicine (2006) Guidelines on Ethics for Occupational Physicians, 6th edn, London: FOM, Royal College of Physicians. Health and Safety at Work Act 1974. HSC (2000) Securing Health Together: a Long-Term Occupational Health Strategy for England, Scotland and Wales, Sudbury: HSE. HSC (2004) A Strategy for Workplace Health and Safety in Great Britain to 2010 and Beyond, Sudbury: HSE, www.hse.gov.uk/aboutus/hsc/strategy2010. pdf. HSE (1994) Railway Safety Critical Work Regulations, London: HSE. HSE (1995) The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations, Sudbury: HSE.
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HSE (1996) Health and Safety (Consultation with Employees) Regulations, Sudbury: HSE. HSE (1997) Diving at Work Regulations, London: HSE. HSE (1999a) Health Surveillance at Work, London: HSE. HSE (1999b) Ionising Radiation Regulations, London: HSE. HSE (2002) Control of Lead at Work Regulations, London: HSE. HSE (2004) Control of Substances Hazardous to Health (Amendment) Regulations, London: HSE. HSE (2005) Control of Vibration at Work Regulations, Suffolk: HSE. HSE (2005) Essentials of Health and Safety at Work, 4th edn, Sudbury: HSE. HSE (2006a) Management of Health and Safety at Work (Amendment) Regulations, London: HSE. HSE (2006b) Occupational Health Statistics Bulletin 2005/06, www.hse.gov.uk/ statistics/overall/ohsb0506.htm (accessed 18 July 2007). HSE web site, www.hse.gov.uk. Human Rights Act 1998. Lewis J. and Thornbory G. (2006) Employment Law and Occupational Health: a Practical Handbook, Oxford: Blackwell Publishing. Manchester University Centre for Occupational and Environmental Health web site, www.medicine.manchester.ac.uk/coeh. Medical Defence Union (1996) ‘Can I See the Records?’ Clinical Notes Disclosure and Patient Access, London: MDU. NMC (2004) The NMC Code of Conduct: Standards for Conduct, Performance and Ethics, www.nmc-uk.org. Packham C.L. (1998) Essentials of Occupational Skin Management, Southport: Limited Edition Press. RCN (1998) Guidance for Nurses on Clinical Governance, London: RCN. RCN (1999) Working Well Initiative: Occupational Health Audit, London: RCN. RCN (2003; revised 2005) Confidentiality RCN Guidance for Occupational Health Nurses, London: RCN. RIDDOR web site, www.riddor.gov.uk. Ross D.J., Sallie B.A. and McDonald, J.C. (1995) SWORD 94 Surveillance of Work-Related and Occupational Respiratory Disease in the UK, Occupational Medicine 45(4), 175–8. Whitaker S. and Aw T.C. (1995) Audit of Pre-Employment Screening by Occupational Health Departments in the NHS, Journal of Occupational Medicine 48(2), 75–80. Workplace Health Connect web site, www.workplacehealthconnect.co.uk.
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Mental Health and Stress Angela Franklin
Introduction The relationship between health and work was recognised by Ramazzini as long ago as the sixteenth century. His early observations were mainly concerned with the physical effects of work on health. In the early part of the twentieth century the social and psychological effects of work became more apparent. Factors such as self-esteem, drive and influence over one’s environment were highlighted by the work of Elton Mayo, Trist and Bamforth, Freud and others. By the end of the last century, the Labour Force Survey (LFS) of workrelated health problems (OHR 1998) estimated that more than two million people in Great Britain believed that illness was caused or exacerbated by work. The incidence of stress and mental health problems was second only to musculoskeletal problems. This pattern persisted with the 2004–05 Labour Force Survey (Figure 10.1) (HSE 2005). In 2005–06 an estimated 24.3 million working days were lost due to work-related ill health; 10.5 million of these were due to stress, depression or anxiety (HSE 2006). Over the last 10 years claims for long-term incapacity benefit for musculoskeletal problems have dropped by 42 % and claims for mental and behavioural disorders now account for more incapacity benefit claims than do musculoskeletal problems. A third of new claimants cite mental health conditions as the primary cause of their incapacity – compared with one-fifth in the mid-1990s (Department of Work and Pensions 2007). Work-related mental health problems are much publicised. While it is important to be aware of the potential negative effects of work on health, Occupational Health Nursing Edited by K. Oakley. C 2008 John Wiley & Sons, Ltd
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Illness Stress and mental health Back injury Upper limb, neck
Figure 10.1
Number of People Affected 1998 2004–05 515 000 509 000 508 000 452 000 375 000 347 000
Labour Force Survey of Illness Caused or Exacerbated by Work
the positive effects on individual health, the economy, community and society should not be underestimated. One only has to observe the negative mental, physical and social effects of unemployment to recognise that lack of work is also a cause of ‘stress’. This chapter is not just about preventing work-related mental health problems, but also about promoting a sense of well-being. It will start by defining some of the words commonly used when talking about work and mental health, then look at organisational and individual influences on health at work, the management of mental health risks and, finally, psychiatric disorders.
Definitions ‘Stress’ is a word commonly associated with the negative effects of work on health. The word is used to describe both the cause (e.g. ‘stressful’, ‘stressor’) and effect (e.g. ‘feeling stressed’). The Oxford English Dictionary (1996) defines ‘stress’ as ‘pressure or tension, physical or mental strain’. As positive mental health is the objective of occupational and organisational interventions, it is useful to define what we are aiming to achieve. The OED provides the following definitions: Mental – ‘of, in or done by the mind’. Health – ‘a state of being well in body or mind’. There are a number of helpful definitions of health with which the reader is probably familiar. The World Health Organisation and Simnett (1995) provide more expansive definitions than the one given above. However, another commonly used term is ‘well-being’. Ryff (1989) defines ‘Happiness or well-being’ as a balance between positive and negative affects (mood). The characteristics of well-being are given in Figure 10.2.
Organisational Theories When considering mental health issues in the workplace it is important to have an understanding of organisations and of how they work. Organisations develop as a result of a person or persons with an idea for a
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Self acceptance
r r r
the most recurrent criterion of well-being characteristic of self-actualisation optimal functioning and maturity.
Positive relations with others
r r r
warm, trusting relationships ability to love empathy and affection.
Autonomy
r
internal locus of evaluation.
Environmental mastery
r
active participation in and mastery of the environment.
Purpose in life
r r
sense of direction and intention goals, purpose, meaning.
Personal growth
r r
development of one’s potential to grow and expand as a person openness to experience.
Figure 10.2 Characteristics of Happiness or Well-Being Source: Adapted from Ryff (1989)
service or product. In the early life-cycle of an organisation, this person is likely to be the leader. Although the organisation may have a building and physical structures, in essence it is a collection of people with some degree of shared feelings, interactions, aims and experiences. As an organisation grows, formal rules, procedures, structures and culture develop. There is a great deal written about organisational development, culture and structures. This chapter does not explore this subject in any depth but a number of suggestions for further reading are included.
Organisational Culture Knowledge and understanding of organisational culture helps to explain the behaviour of people in the workplace. There are a variety of definitions of culture. The common themes that appear in the various definitions suggest that it is a group phenomenon, based on commonly held views, beliefs and values resulting in certain behaviour patterns. According to Schein (1999), ‘culture matters because it is a powerful, latent and often unconscious set of forces.’ He proposes that organisational culture is the pattern of basic assumptions that a given group has invented, discovered or developed in learning to cope with the problems of external adaptation and internal integration. These patterns have worked well enough to be considered valid and are therefore taught to
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new members as the correct way to perceive, think and feel in relation to those problems.
Organisational Models There are a number of organisational models or theories of organisational structure. In general, theories reflect two models:
r The organismic model, which views the organisation as an organism, i.e. a system made up of inter-dependent parts.
r The mechanistic model, based on the scientific management system, which views the organisation as a machine. There has been a move away from the mechanistic model. Morgan (1998) states that the move towards a biological model of organisation is a result of the recognition ‘that employees are people with complex needs that must be satisfied if they are to lead full and healthy lives and to perform effectively in the workplace.’ The biological metaphor for organisations concentrates on the ability of organisations and human organisms to adapt to changes in the environment.
The Changing Workplace Change and the ability of organisations and people to adapt is a recurring theme in organisational theory. As technology advances, industry has moved from manufacturing to service provision and social structures have altered. Information technology has allowed faster access to information and raised expectations for faster response. In some instances it has led to automation and standardisation of tasks, reducing the opportunity for creativity and initiative. Individuals have been forced to adapt to new working patterns. These may involve 24-hour service provision and increased part-time working. There are more women in the workforce and a greater need for childcare facilities. There is greater uncertainty and a short-term outlook. Unlike previous generations, employees now do not expect to join one company for life. However, in some sectors high employment means that organisations are competing for skilled people. Where job security is no longer guaranteed, individual expectations are changing. Employees are interested in what an organisation can do for them in terms of development and growth.
Managing Health Risk in the Workplace Compensation awards have been made against organisations that place unreasonable strain on employees. Case law – Walker v Northumberland County Council – has determined that employers have a duty of
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care to protect the mental health of employees where the risk is reasonably foreseeable (Kloss 1998). In 1999, the Health and Safety Commission produced a discussion document to encourage debate on the extent to which stress at work should be regulated under health and safety legislation. A general obligation already exists under the Health and Safety at Work Act 1974 and the Management of Health and Safety at Work Regulations 1992 for employers to assess the risks of all hazards to health in the workplace and introduce measures to reduce those risks. It is generally accepted that this obligation also applies to mental health risks. Employers have a duty to:
r r r r
identify causes of stress measure the risk implement preventative measures monitor the effectiveness of preventative measures.
To assist organisations in making this assessment, the Health and Safety Executive (HSE) has produced the Management Standards for WorkRelated Stress. According to the HSE (Health & Safety Executive 2007), ‘The Management Standards represent a set of conditions that reflect high levels of health, well being and organisational performance.’ An overview of the standards is given in Figure 10.3. The issue of stress at work and its effects on individuals is widely publicised. The personal cost to the individual includes ill health, reduced
Demands Includes issues like workload, work patterns and the work environment. Control How much say the person has in the way they do their work. Support Includes the encouragement, sponsorship and resources provided by the organisation, line management and colleagues. Relationship Includes promoting positive working to avoid conflict and dealing with unacceptable behaviour. Role Whether the person understands their role within the organisation and whether the organisation ensures that the person does not have conflicting roles. Change How organisational change (large or small) is managed and communicated in the organisation.
Figure 10.3 Health and Safety Executive Management Standards for Work-Related Stress: a Summary
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self-esteem and financial, social and relationship problems. The cost to the organisation includes the loss of skilled, knowledgeable employees and loss of productivity through increased turnover, sickness absence, poor morale and lack of commitment. In attempting to address these problems, some organisations have introduced workplace programmes to combat the negative effects of stress. These have focused on lifestyle issues and are aimed at changing risk behaviours such as smoking, poor diet and lack of exercise, or improving coping skills through relaxation, time management and counselling programmes. The success of these interventions has been limited (Simnett 1995). In many cases, employees will learn new coping skills, only to find they are unable to put them into practice in an unchanging workplace. It has become increasingly apparent that these interventions need to be supported by organisational approaches, not only to combat the negative physical and psychological effects on health, but also to improve organisational effectiveness. This is particularly relevant when increased productivity has to be achieved with fewer people and within strict financial constraints. Another option might be to deal with mental health issues through private medical care, permanent health insurance and ill-health retirement schemes. These schemes are important for accessing prompt treatment or ensuring financial security for individuals who can no longer work. However, there is a potential for these facilities to be used as an alternative to risk assessment and prevention. Strategies should emphasise targeted intervention and evaluation. Data that can be used to help identify the causes and extent of pressure in an organisation may be readily available. Examples are given in Figure 10.4. In general the issues that influence well-being in the workplace can be split into three categories: individual factors, job-related factors and organisational factors (Figure 10.5). In May 2000 the Health and Safety Executive reported that the Bristol Stress and Health at Work study estimated that ‘five million workers suffered from high levels of stress at work.’ Both this study and the Whitehall II study cited poor work design as a major preventable cause of work-related health problems. Figure 10.6 expands on the notion of ‘job design’ and provides further examples of preventative measures that can be introduced to reduce the risk of work-related mental health problems and promote well-being.
Individuals in the Workplace Individual employees do not all experience events and influences in the same way, so although standards for good organisational and management practice can be set, individual differences also need to be considered.
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Gather data about the mental health of the workforce and the organisation
Sickness absence data Accident rates Customer complaints Error rates Staff turnover and information gathered from exit interviews Anonymous information collected by employee assistance programmes or occupational health services Commercially available ‘stress audit tools’ Attitude surveys Environmental surveys
Analyse
Identify main sources of pressure within the organisation
Determine priorities
Based on analyses and requirements under the Management of Health and Safety at Work Regulations Based on identified priorities
Set objectives Assess options for action
Development and implementation of mental health strategy r to reduce identified risks r to promote a culture that is protective of mental health Pro-active occupational health services Person/job fit Training to raise awareness Early referral systems Access to treatment
Develop and implement a programme
Based on above assessment
Continually evaluate success of programme
Measure effectiveness against agreed objectives and maintain a review of standards on which action is based
Figure 10.4
Managing Mental Health in the Workplace
Individual Factors r Relationships r Social environment r Finances r Coping skills r Support systems r Personality Job-Related Factors r Control over organisation and pace of work r Too much/insufficient work r Nature and variety of work r Clarity of role and expectations r Shift patterns and hours of work r Work environment r Responsibilities r Opportunity to use skills r Relationships
Figure 10.5
Influences on Well-Being
Organisational Factors r Job security r Management support r Relationships r Communication r Opportunity for personal growth r Organisational change r Control or influence
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Job Design Control over organisation and pace of work Clear job description Feedback on performance Opportunity for career development Training To perform tasks expected To develop coping strategies To develop support systems
Raising Awareness of Mental Health Issues Acceptance that problems arise Early recognition of problems Encouragement to seek help Communication Minimal uncertainty and misinformation Consistent Procedures Sickness absence Disciplinary Leave Rotas and shifts
Figure 10.6 Preventative Measures to Reduce the Risk of Work-Related Health Problems and Promote Well-Being
Stress Response The responses that once equipped humans with the mental and physical resources to survive physical threat now operate in an environment where the threat is more often psychological and prolonged. The main requirement for our ancestors was the ability to respond to threats from the physical environment, such as heat, cold and danger. The ‘fight or flight’ response is the basic physical and mental adaptation that equips humans with the energy to deal with acute environmental demands. This basic response involves the autonomic nervous system in the release of catecholamines (adrenaline and noradrenaline) into the blood stream, which help mobilise the body for fight or flight. According to Goleman (1998), increased levels of these hormones are circulating when energy levels are high, producing maximum effort and positive mood states. Goleman differentiates between the effects of catecholamines and the effects of cortisol. Cortisol is released in addition to catecholamines when an individual’s appraisal of the ‘threat’ leads to feelings of helplessness or despair. Cortisol also affects the immune system. It is worthwhile considering how the brain responds to stimuli and the effects it produces.
r Perception – notice changes in the environment through sensory stimulus.
r Apraisal – cognitve and emotional (distinguish cause and intensity of feeling).
r Action – behaviour in response to appraisal. The emotional centre of our brain reacts in the same way as that of the primitive human brain. In order for the species to survive, reactions to danger have to be quick; therefore information received through the
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senses is first processed through the area of the brain called the amygdala. This is the emotional centre, where the sensory stimuli provoke a response before the logical areas of the brain (pre-frontal lobe and neo-cortex) process and evaluate the information. The neurochemical alerting system described above signals to the amygdala and the other brain regions to strengthen the memory of important stimuli. Therefore emotional memory imprinted in the amygdala can trigger reactions to similar stimuli in later life. The pre-frontal lobe modifies all but the strongest emotions. So although a logical evaluation of threat occurs, there will also be a feeling or emotion attached to that evaluation. Past experience, self-esteem, habitual thought patterns may all contribute to the subjective evaluation. As a result, our emotions may influence responses before our brain has the opportunity to mount a logical response. Eight emotions have been identified; five are concerned with protection, survival and avoidance:
r r r r r
anger fear sadness disgust shame
and three with bonding:
r enjoyment r surprise r love. Some organisations have relied upon the promotion of protective emotional responses to manage and promote productivity through uncertainty, insecurity and internal competition. The physiological response to environmental demands acts as a protective safeguard against danger. The response is designed to be shortlived in order to quickly deal with the danger and then allow bodily responses to return to normal. In some work environments, threat can be perceived as ever-present, resulting in a state of hyper-vigilance. The physiological changes thus have little opportunity to return to normal. The psychological, physical and behavioural signs that may result are outlined in Figure 10.7. The response to threat will depend on an individual’s evaluation of the situation and their perception of their ability to deal with it.
Example 1 An employee highlighted the lack of childcare facilities at her company. Her manager asked her to explore the demand within the organisation, sources of local provision and local-authority regulations, and to
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Physical and Psychological Constant tiredness Frequent headaches Backache or other musculoskeletal aches and pains Inability to concentrate Loss of confidence Low self-esteem Irritability Tearfulness Poor sleep
Figure 10.7
Behavioural Increased use of alcohol, tobacco, caffeine Increase/decrease in eating Absence and/or poor timekeeping Poor work performance Lack of judgement Indecisiveness Conflict Withdrawal
Signs and Symptoms of Persistent Arousal and Feelings of Helplessness
provide an initial report on her findings. Although the employee had not previously undertaken a project of this nature, she had provided secretarial support to other projects. This project increased her already busy workload but she evaluated that she would have sufficient time if she made some adjustments to her work schedule. She felt that she had control over the design of the project and was able to identify sources of support to help on any areas of potential difficulty. When an individual experiences work demands that are sufficiently challenging and allow a high degree of control over how the work is undertaken, this is likely to result in a positive mood and enjoyment of the task. The physical response will be an increase in catecholamines. On the other hand, individuals might feel they have no control over the design and organisation of their work, with excessive workload and tight deadlines, or insufficient workload and no deadlines. They are likely to experience negative mood and an increase in the production of catecholamines and cortisol. An extreme example can occur in unemployment.
Example 2 An employee provides administrative support to the head of department. However, various other tasks are gradually introduced into the work from other parts of the organisation. These are laborious, bureaucratic and time consuming. There is no forum to influence the way in which these tasks are carried out. The employee is sure there is an easier way, given sufficient resources and time. In addition, the Department Head is completing an important project. He is blinkered to the other demands on the employee and makes increasing demands on his time. The employee becomes progressively more despondent and feels helpless. Working longer hours makes little impact on the workload. The employee begins to receive complaints about his work. He becomes anxious and is not sleeping properly. At work, tiredness makes concentration difficult and he begins to make mistakes. Further criticism leads to lower
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Effort and Positive Effect
Work Characteristics Demanding High degree of control Creative
Emotional Response Joyful Happy
Physical Response Increase catecholamine Low cortisol
No Effort and Positive Effect
Creative Personal control
Pleasantly relaxed
Low hormone output
Effort and Negative Effect
Demanding Repetitive Low degree of control
Helplessness Distress
Increase catecholamine Increase cortisol
No Effort and Negative Effect
No control Unemployment Imprisonment
Helplessness Giving up Passivity
High hormone output, particularly cortisol
Figure 10.8 The Effort and Effect Model Source: Adapted from Frankenhauser (1989)
self-esteem. Eventually, feeling unable to cope any longer, he visits his GP, who signs him off work for one month with ‘stress’. The differing responses in these two examples are demonstrated by Frankenhauser’s (1989) Effort and Effect model (Figure 10.8), developed out of the study of different work sites. The model outlines the characteristics of work processes and their effect on activity and mood. The active state is characterised by effort, commitment and determination. This is often accompanied by a positive mood. It is most often found in jobs where there is a high degree of personal control and autonomy, where creativity and initiative are required.
Psychiatric Disorders Pre-existing mental health problems may also present an issue in the workplace. According to Davies (1997), more than 20 % of adults experience mental illness at any one time. 40 % of GP consultations involve problems of this nature. However, many people with mental health problems effectively contribute to organisations and society. The Disability Discrimination Act 1995 requires reasonable1 adjustments to work tasks, design or environment to enable an employee with a disability to function in a particular role. Under the Act, a disability is defined as a ‘physical or mental impairment, which has substantial and long term2 adverse effect on a person’s ability to carry out normal day to day activities’ (DLO 40 1995). The Disability Discrimination Amendment Act 2005 removed the requirement for a ‘mental impairment’ to be ‘clinically well recognised’, present in the 1995 Act. Consultation is now being undertaken to decide whether the definition should be further 1 ‘Reasonable’ takes into consideration the cost of the adjustment in relation to the degree to which it would help. 2 ‘Long term’ means that the effect of the disability has lasted or is expected to last more than 12 months.
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amended to remove the requirement for a disability to have a ‘substantial and long term adverse effect on a person’s ability to carry out normal day to day activities’ (Disability Rights Commission 2006). A good psychiatry textbook will provide information on psychiatric disorders and their classification, including psychotic disorders such as schizophrenia. This chapter is confined to anxiety disorders, affective disorders, alcohol problems and personality disorders. Appendix 10.1 provides an overview of the process of mental health assessment. It should be remembered that the problems listed are, to a greater or lesser degree, accessible to pharmacological treatment and/or therapies such as cognitive behavioural therapy. Therefore, the presence of mental health problems will not preclude employment. Examples of particular problem areas are given to highlight potential adjustments that might be considered in the workplace.
Anxiety Disorders The physical effects of anxiety are those caused by the neurochemical responses described earlier in this chapter. As discussed, when the response to perceived threat is persistent and the body does not have the opportunity to return to a normal state of arousal, anxiety disorders might develop. Stress Reaction describes an immediate response to a threat that is normally self-limiting. However, where the threat is extreme a severe stress reaction can develop. Post-Traumatic Stress Disorder is characterised by avoidance of the threat or similar threats, flashbacks and nightmares. This reaction is normally associated with events that are life-threatening or outside normal human experience. In the workplace this may include such things as bank raids, or soldiers exposed to or witnessing horrific or life-threatening events in war. Adjustment Reaction describes a slower response to threats such as significant life changes or organisational change. This reaction may resolve with support and reassurance. Generalised Anxiety Disorder is characterised by:
r r r r
persistent apprehension or anxiety disturbed sleep (early and middle insomnia) muscle tension, tremor or restlessness sweating, increased heart rate and gastric pain.
Panic Disorder is characterised by:
r r r r r r
rapid onset of the symptoms of anxiety fear of a catastrophic event anticipatory anxiety hyperventilation increased heart rate sweating.
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In panic disorder the problem can become self-perpetuating as the individual becomes increasingly afraid of the symptoms that occur during panic attacks, thereby provoking further anxiety. An important part of recovery is an understanding of the process provoking the attacks. Phobic Anxiety includes fear of a specific object or circumstance. Examples include:
r agoraphobia (fear of crowds or being away from home) r claustrophobia (fear of enclosed spaces) r social phobia (fear of negative evaluation). These three examples all have significance in the workplace. An individual with agoraphobia may have difficulty with business travel or even attending work. An individual with claustrophobia may have difficulty working in a building where the only access involves use of a lift. An individual with social phobia may have difficulty if work includes public speaking or a high profile. Obsessive-Compulsive Disorder (OCD) is characterised by intrusive thoughts and compulsive rituals. Although the individual may identify that the rituals are senseless they are compelled to carry them out. This disorder is distressing and likely to cause problems if the employee has difficulty working in an efficient manner. Rituals may be a cause of poor timekeeping or intrude in the working day. Examples are repeated hand washing and repeated checking. There are many people who have an obsessional trait. These do not manifest in the extreme way of OCD and in some occupations where accuracy is important, such a trait may be highly desirable.
Affective Disorders The core features of Depression are low mood, low self-esteem, lack of drive or energy and anhedonia (lack of capacity for enjoyment). The Beck Depression Inventory (Beck 1997) is a wellvalidated and reliable self-rating questionnaire. There are 21 items used to measure the depth of depression. Beck’s cognitive triangle can also be used to assess an individual’s evaluation of: r The self – in depression there is a sense of worthlessness. r The world – in depression there is a sense of helplessness. r The future – in depression there is a sense of hopelessness. According to Beck a sense of hopelessness is considered a predictor of suicidal intent. Bipolar Affective Disorder also includes episodes of depression, along with mania or hypomania. Symptoms include elevated mood, irritability, disinhibition, increased activity, increased appetite, increased libido and reduced sleep. In mania, psychotic symptoms such as hallucinations or grandiose delusions may also be present. Individuals experiencing an episode of hypomania may initially be highly productive and creative, but this is not sustainable. Once mood has stabilised with treatment,
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there may be problems with returning to work alongside colleagues who have witnessed extreme behaviours.
Alcohol Problems There are three types of alcohol use: r Problem Use – causing relationship, social, financial and employment problems. r Hazardous Use – causing physical illness such as liver disease, delirium tremens, accidents or suicide. r Dependency – characterised by cravings, early morning drinking, altered tolerance to alcohol, patterns of drinking, withdrawal symptoms and increased importance of alcohol above other aspects of life. Many organisations will have a policy on alcohol and how an employee with an alcohol problem can expect to be treated. Where occupational health services are available, the policy will generally include an initial referral to the service, rather than disciplinary action. The referral will usually seek an opinion on whether an alcohol problem exists, the individual’s likely response to treatment and options for referral for treatment. Where treatment is accepted, the occupational health service will normally monitor progress.
Personality Disorders Personality disorders are usually apparent by adolescence and persist into adulthood. According to Lipsedge (2000), ‘Personality disorder is a constellation of attitudes and patterns of behaviour, which reflect the individual’s characteristic way of relating to other people and which causes distress to the individual and/or others.’ According to the DSM IV classification, personality disorders include the Paranoid, Dissocial, Emotionally Unstable, Histrionic, Dependant and Obsessional. A number of workplace problems may result, depending on the type of personality disorder. These may include difficulties with inter-personal relationships, over-sensitivity to criticism, difficulty with authority or rules, need for close supervision and support, impulsiveness, lack of emotional control and difficulty coping with change.
Common Mental Health Problems In 2005 the British Occupational Health Research Foundation published the results of a systematic review of workplace interventions for people with common mental health problems3 (BOHRF 2005). The review identified that there were gaps in the evidence for successful workplace interventions, but made recommendations based on the evidence currently available. Amongst the recommendations to health professionals was that ‘The bio-psycho-social model of (ill) health is helpful in 3
Those mental health problems that occur most frequently, are most prevalent and are least disabling in terms of stigmatisation and discriminatory behaviour.
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understanding the complex interactions between the individual’s mental health, attitudes to work and their social environment and focuses attention on the barriers to normal recovery and return to work.’
Sickness Absence and Illness Behaviour According to Kloss (2005), ‘It is sometimes difficult to distinguish a case of ill-health from one of misconduct.’ In the case of absence from work, ‘sickness absence’ is not normally construed as misconduct; however, being absent from work without good reason is. A concept that is worth consideration in occupational health is that of illness behaviour. Occupational health professionals are frequently asked to determine whether there is an underlying health reason for potential breaches in discipline, most commonly excessive sickness absence from work. A medical model tends to be used, based upon the presence of a detectable disorder or ‘underlying medical condition’. Advice can then be given on the likely prognosis in terms of continuation or duration of the behaviour, and on whether reasonable adjustments to work tasks or the environment would be likely to result in improvement. The outcomes of the occupational health referral will fall broadly into five categories: 1. Identification of an impairment that may qualify under the Disability Discrimination Act 2005. 2. Identification of a health problem that has a predictable course and resolution. 3. Identification of a health problem for which the course, treatment and outcome is not predictable. 4. Ill-health retirement – this requires that an individual would be unable to work even with optimum treatment and reasonable workplace adjustment. 5. No underlying medical problem, which may be taken by managers to confer individual responsibility. The issue becomes a management rather than a health problem. Nurcombe and Gallagher (1986) differentiate between disease, disorder and illness:
r Disease is described as a classifiable set of symptoms, clinical findings and aetiology as a result of disturbed bodily function.
r Disorder is described as a syndrome of somatic or psychological dysfunction where the aetiology is not understood.
r Illness is described as the subjective perception of being unwell. r
Illness can be present with or without identifiable disease. It is also distinct from illness behaviour. Illness behaviour describes the process of ‘being ill’: 1. 2.
symptom experience assumption of the sick role
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3. 4. 5.
medical care contact dependent patient role recovery.
Abnormal Illness Behaviour In abnormal illness behaviour there may be persistence of the sick role despite recovery. It is argued that illness behaviour does not necessarily equate with the degree of illness and that daily hassles are a predictor of illness behaviour. This could be as a result of stress, which may amplify symptoms, resulting in the adoption of a sick role as a coping method. Pressures in the workplace may cause individuals to perceive themselves to be sick in order to reduce anxiety by relief from occupational responsibility. However, concern about ‘presenteeism’ has also arisen when employees attend work despite illness. This illness behaviour can be attributed to guilt about absence and the effects on colleagues; attitudes of colleagues and managers; fear of charges of malingering; and job insecurity. In these cases symptoms may be amplified to justify the need for absence and individuals may ‘seek permission’ from peers, managers, OH professionals or their GP in order to validate the illness.
Conclusion Work-related mental health problems are widely recognised as an issue, not only for affected individuals but for employing organisations and society. Both organisational and individual factors, identified as influencing well-being at work, need to be assessed and appropriately addressed in order to reduce risk and promote effectiveness. Work has an important role in providing opportunities for personal growth, achievement and a sense of identity. This may be of particular importance for those with pre-existing mental health problems, for whom suitable adjustments to work under the Disability Discrimination Act 2005 need to be considered.
Illness Affirming Behaviour Munchhausen Malingering Hypochondriasis Illness Denying Behaviour Non-compliance with diagnosis and treatment
Factitious Disorder Conscious feigning of symptoms but with little or no insight into motives Dissociative Disorder Unconscious simulation of symptoms Malingering Conscious feigning of symptoms with awareness of motives
Figure 10.9
Some Examples of Illness Behaviour
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Occupational health professionals are likely to be consulted when difficulties arise as a result of mental health problems at work. However, measures that reduce risk and promote early recognition of issues and appropriate referral will help to minimise the impact of problems on the individual and the organisation.
References and Further Reading Argyris C. (1992) On Organisational Learning, 2nd edn, Massachusetts: Blackwell Business. Beck A. (1997) Beck’s Depressive Inventory, Harcourt Publishers. BOHRF (2005) Workplace Interventions for People with Common Mental Health Problems, www.bohrf.org.uk (accessed 16 February 2007). Covey S. (1992) The Seven Habits of Highly Effective People, London: Simon & Schuster. Davies T. (1997) Mental Health Assessment in ABC of Mental Health, British Medical Journal 314, 1536. De Board R. (1978) The Psychoanalysis of Organizations: a Psychoanalytical Approach to Behaviour in Groups and Organisations, London: Routledge. Disability Discrimination Act 1995. Disability Discrimination Amendment Act 2005. Disability Rights Commission (2006) Consultation on Definition of Disability in Anti-Discrimination Law, www.drc.org.uk/about us/drc scotland/news/ consultation on definition of.aspx (accessed 21 February 2007). DLO 40 (1995) A Brief Guide to the Disability Discrimination Act Page 4, Bristol. DSM IV (1994) Diagnostic and Statistical Manual of Mental Disorders, 4th edn, DSM-IV, American Psychiatric Association. Department for Work and Pensions (2007) Welfare Reform, www.dwp.gov.uk/ welfarereform (accessed 21 February 2007). Fradette M. and Michaud S. (1998) The Power of Corporate Kinetics, New York: Simon & Schuster. Frankenhauser M. (1989) A Biopsychosocial Approach to Work Life Issues, International Journal of Health Services 1(4), 747–58. Goleman D. (1996) Emotional Intelligence, London: Bloomsbury. Goleman D. (1998) Working with Emotional Intelligence, London: Bloomsbury. Handy C. (1990) Inside Organizations, London: Penguin. Handy C. (1993) Understanding Organizations, 4th edn, London: Penguin. Handy C. (1994) The Empty Raincoat, London: Arrow Books. Handy C. (1995) Gods of Management, London: Random House. HSC (1999) Managing Stress at Work, discussion document. HSE (2000) HSE Publishes New Research on Occupational Stress, E080:00, 18 May 2000. HSE (2005) Self-Reported Work-Related Illness in 2004/05: Results from the Labour Force Survey, www.hse.gov.uk/statistics/swi/swi0405.pdf.
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HSE (2007) Management Standards for Occupational Stress, www.hse.gov.uk/ stress/standards (accessed 27 February 2007. HSE (2006) Comparisons of Work-Related Illness and Injuries Statistics, www.hse.gov.uk/statistics/overall/comparison.htm. Kets De Vries M. (1995) Organisational Paradoxes, Clinical Approaches to Management, 2nd edn, London: Routledge. Kloss D. (2005) Occupational Health Law, 4th edn, Oxford: Blackwell Publishing. Lawrence P.R. and Lorsch J.W. (1967) Organisation and Environment, Harvard: Harvard Business School Press. Lipsedge M. and Kearns J. (2000) Psychiatric Disorders. In: Cox R.A.F., Edwards F.C. and Palmer K. (eds) Fitness for Work, 3rd edn, Oxford: OUP. Morgan G. (1998) Images of Organisation, Executive Edition, London: Sage. Nurcombe B. and Gallagher R.M. (1986) Illness Behaviour. In: The Clinical Process in Psychiatry, Cambridge: Cambridge University Press, pp.11–37. OHR (1998) Two Million Blamed Work for Ill Health, Occupational Health Review 73, 4–5. Ryff C. (1989) Happiness is Everything, or Is It?, Journal of Personality and Social Psychology 57(6). Schein E. (1985), cited in: Matthews (1996) Strategy, Planning and Control, Kingston University Business School Course Text, pp. 7.4–7.10. Schein E. (1999) The Corporate Culture Survival Guide, San Fransisco: Josey-Bass. Simnett I. (1995) Managing Health Promotion, Chichester: John Wiley and Sons.
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Appendix 10.1: Mental Health Assessment Why are You Seeing the Employee? r Self referral r Management referral r Pre-employment assessment. Problem What is the nature of the problem for which the employee has been referred? r Problem as reported by the employee r Problem as reported by referring manager r Information from medical reports if available. History of the Problem r When did the problem start? r Has the employee consulted the GP? r Have there been any investigations? r Has there been a referral to a specialist? r Is the course of the problem stable or does it fluctuate with time? r What things make it better or worse? Effects of the Problem r How does the employee feel the condition affects work life? r Does the employee’s perception coincide with the manager’s perception? r How does the employee feel the condition affects home life? Past Medical History r Are there any other current or past health problems? r Is the employee taking any medication or is there a history of treatment? Family History r Is there a family history of health problems? r Is there a history of early stressors, such as loss of close family member or early separation? Personal History r What jobs has the employee had? r How long have they been in the current job? r What are the main responsibilities or tasks in the current job? r What is the employee’s home life like, e.g. relationships, children, finance, housing, social support?
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Personality How would the employee describe themself before they became unwell? r Interests r Moods r Social relationships r Reaction to stress and setbacks. Sign and Symptoms r Are there any problems with sleep, appetite, libido? r Is there diurnal mood variation? Appearance and Behaviour How does the employee appear? r Clothes r Self-care r Posture r Facial expression r Eye-contact r Mannerisms. Speech Are there any disorders of thinking recognised from speech? r Pressure of thought (rapid speech) r Interruption to thought process or thought insertion (lack of continuity of speech or disjointed ideas). Mood r How does the employee describe their mood? r Does this fit with their appearance? Thought Content r Are there any worries or preoccupations? r Are there any obsessional, suicidal or murderous thoughts? r Are there any abnormal beliefs, delusions, illusions or hallucinations? Cognitive State r Are there any problems with memory, attention, orientation in time and place? Insight r Does the employee think that there is a problem? r Is the employee complying with any prescribed treatment?
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Musculoskeletal Disorders and Ergonomics
Claire Raistrick
Introduction
What Do We Mean By Work-Related Musculoskeletal Disorders? Musculoskeletal harm is the result of pathological changes in the muscles or soft tissues. The harm may arise due to a range of risk factors. Action to prevent or minimise work-related musculoskeletal disorders (WRMSDs) needs to be multi-factorial, as it seeks to correct work situations. This chapter will focus on musculoskeletal risk factors that are associated with work activities and explore how an organisation may use ergonomics to control its work activities and minimise the development of WRMSDs, thus avoiding or minimising loss related to these disorders.
What is the Picture of WRMSDs in the Workplace? Because WRMSDs do not have the notoriety associated with fatal accidents or disease conditions, employers may treat them with an unwarranted complacency; it is vital to consider the wider picture of loss that is attributable to them. Nearly 3.5 % (DfWP 2006) of workers in the UK are affected by WRMSDs each year and the Health and Safety Executive puts the cost to society at £ 5.7 billion (based on 1995/96 figures) (HSE 2006). In 2004/05, Occupational Health Nursing Edited by K. Oakley. C 2008 John Wiley & Sons, Ltd
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WRMSDs affected an estimated 1 million workers a year: some 50 % of those suffering with work-related ill health (HSE 2005b). WRMSDs are designated a priority programme by the Health and Safety Executive (HSE). There are early indications that the incidence of WRMSDs may be falling (HSE 2005b). WRMSDs largely affect the back (45 %) and upper limb (37 %); it is less common to suffer a lower limb disorder (18 %) (HSE 2005b). Work situations across all industries are implicated, particularly those involving manual handling and use of the upper limbs, including computer work. WRMSDs may be categorised as back pain, particularly low back pain, or work-related upper limb disorders (WRULDs). Nevertheless the media has popularised the term ‘RSI’ (repetitive strain injury), a term that is widely and often incorrectly used to refer to upper limb disorders. The generic term WRULDs is preferable as it encompasses a variety of health conditions affecting the upper limb; such conditions are not necessarily associated with repetition, strain or injury. WRULDs may affect the joints, muscles, tendons and other soft tissues of the neck, shoulders, arms, wrists, hands and digits. Symptoms commonly include pain, aching or discomfort, sometimes accompanied by tenderness, swelling, abnormal sensations, impaired movement or weakness. The diagnosis may be a discrete disease (e.g. tenosynovitis, shoulder capsulitis) or non-specific pain syndromes. See Appendix 3 of ‘Upper Limb Disorders in the Workplace’ (HSE 2002) for further details.
Some 48 000 (40 %) of the non-fatal injuries (over-3-day) reported under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 (HSE 1999) in 2004/05, were caused by handling, lifting or carrying (HSE 2005b). This figure may be closer to 100 000 if the estimate of under-reporting highlighted by the Labour Force Survey is accurate (HSE 2005b).
What is the Incentive to Do Something About WRMSDs? Experiencing WRMSDs inevitably causes suffering. In 2003/04, each person suffering work-related back pain took an estimated 18.7 days off work in that 12 month period, and those suffering with WRULDs took an estimated 18.3 days off work (HSE 2005b). The cost to the individual of pain and discomfort may be difficult to assess, whereas reduced pay or costs associated with treatment are more tangible. The employer’s costs due to WRMSDs may include sickness absence payments, management of sickness absence and return to work, cover
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for absent workers, reduced business capacity, legal costs associated with personal injury claims or prosecution and/or management time spent investigating the ‘accident’. A recent HSE research report has shown that active case management, and particularly ‘best-practice rehabilitation approaches’, reduces losses associated with WRMSDs (Hanson et al. 2006). It would be prudent to actively manage existing cases of WRMSDs while concurrently using ergonomics to redesign work situations to reduce the extent of WRMSDs in the future.
What is Ergonomics? Ergonomics is an applied science that takes account of physical and psychological capabilities and human limitations. Using ergonomics to design work activities can avoid or minimise the development of WRMSDs. Good ergonomic design can also contribute to efficiency and effectiveness, both important components of productivity. Ergonomics is often described colloquially as ‘fitting the task to the person’. The rationale for using ergonomics to design work activities is a combination of complying with legislation, minimising loss, increasing productivity and improving safety and occupational health. A simple ergonomics model (Figure 11.1) places the person at the centre and looks outwards to the different facets of work design, thereby providing a wider perspective. By considering each issue, employers can gain greater control over the effects of work activities on workers. The model’s structure helps pinpoint issues that may cause concern; an example is shown in Figure 11.2. Many WRMSDs occur because the human body has such a vast range of apparent capability: humans can adopt awkward postures, apply
Figure 11.1
c Matrick Ergonomics Ltd (2006) Simple Ergonomics Model
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Pick Face Operator Perspective Individual Who is doing the work
Selects and picks products from racking and pallets, and packs into boxes on conveyor. Issues
r r r r r
Some tall workers Cut of trousers restricts bending Shoulder and back symptoms reported
r
Load size varies Load weight 0.25 kg to 11 kg (handling outside guidelines) Boxes can get stuck on racking
Workstation & Workplace The work area
r r r
Display screens above eye level Conveyor below knee level Racking beyond conveyor
Work Environment The conditions in the workplace
r r
Chilly when doors left open Access to one side of pallet only
Work Organisation How workers are organised
r r r
No control over workload Pick rate: 5 to 90 seconds Definite rest breaks, unless overtime
Task What is being done
Figure 11.2
Use of a Simple Ergonomics Model to Highlight Issues
extreme forces, make repetitive movements and lift excessive weights. The penalty is that injury occurs. Such harm commonly accumulates over a time period that may, in extreme cases, be only a few hours; or it could take days, weeks, months or even years before harm becomes apparent. It is important to remember that just because people can do something doesn’t mean that it is safe to do so.
Two components were assembled by screwing one into the other. This repetitive task required workers to use an excessive twisting force while in awkward postures. A miniscule increase in the dimension of the smaller item caused a tighter fit. Production continued, with reduced productivity. Within two weeks, workers reported symptoms, one suffering a permanent WRULD.
The term ‘ergonomic’ is also increasingly used to market products, e.g. ergonomic chair, ergonomic mouse, ergonomic scissor lift. Injudicious use of this term may be misleading.
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A chair may have been designed using ergonomics principles; this does not guarantee that it is appropriate for a specific application. It is necessary to evaluate the chair’s features in its intended work situation, e.g. does the seat depth adjust sufficiently, enabling users to obtain back support; does the height adjust to achieve the required working height for the hands?
Ergonomics Risk Assessment
Employers’ Reservations Sometimes employers fail to take action to manage the ergonomics risks within their workplace. This may be due to ignorance, or lack of confidence in how to approach a seemingly momentous task. HSE documents provide a wealth of advice that can be used to understand what is meant by the risk assessment process. These range from general documents such as ‘5 Steps to Risk Assessment’ (HSE 1998a) to more specific guidance on how to undertake manual handling (HSE 2004), display screen equipment (HSE 2003) and upper limb risk assessments (HSE 2002). The guidance and risk assessment checklists provided within these documents are relatively simple and straightforward to follow, and will help you to get started. Generally it is preferable to seek specific training to ensure that risk assessors achieve the competence to undertake this responsibility. An effective training programme will deliver knowledge, provide structured, guided practice in the use of the checklists and establish competence as a risk assessor. Ergonomics training providers are listed on the Ergonomics Society web site, www.ergonomics.org.uk.
HSE Regulations and Guidance The Management of Health and Safety at Work Regulations 1999 (MOHAS) (HSC 2000) require employers to undertake risk assessments of work activities, including those that may cause WRMSDs. Identifying how risks arise and their potential impact on the workforce will help to inform the employer on how best to manage such risks. A general or baseline risk assessment, done to comply with MOHAS, should be sufficient to inform you whether workers may be exposed to ergonomics risks. The Manual Handling Regulations 1992 (HSE 2004) and Health and Safety (Display Screen Equipment) Regulations 1992 (HSE 2003) respectively require that manual handling operations (MHOs) and use of display screen equipment (DSE) should be considered from an ergonomics perspective. Similarly, within the Workplace (Health, Safety and Welfare) Regulations 1992 (HSC 1996) there are specific requirements regarding workstation and seating, and layout and movement,
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which may also impact on musculoskeletal health. The guidance that accompanies these regulations, and additional guidance in ‘Upper Limb Disorders in the Workplace’ (HSE 2002), should be considered.
Approach In undertaking ergonomics risk assessments a proactive approach is preferable. However, in my experience most ergonomics interventions are reactive: an injury occurs or workers report symptoms and it is only then that the situation is taken seriously. Generally organisations with a proactive approach find that they are better able to manage WRMSDs and can either prevent harm arising or respond quickly to a developing situation. A thorough knowledge of work activities, an awareness of problems or symptoms affecting workers and an appreciation of the extent to which risk factors are present will all help ensure an effective response to ergonomics issues. Walking around the workplace to observe worker adaptations helps to identify possible ergonomics problems. Ask yourself:
r r r r r
Why is there a cushion on that chair? What is an upturned crate doing under this workstation? Why is there a piece of foam strapped to this tool? Why are there reams of paper under some computer screens? Why are workers standing on broken-down cardboard boxes?
Use of Checklists Using a checklist assists a systematic examination of the relevant risk factors, thereby guiding observation and discussion. It is essential to involve the workforce at all stages of the risk assessment process. Make sure they realise you are assessing the work activity rather than their performance. In each work situation an initial decision is necessary to determine whether a detailed risk assessment is required. The manual handling (HSE 2004) and upper limb risk assessment (HSE, 2002) guidelines provide risk filters that help to quickly establish whether an activity is likely to warrant a detailed risk assessment. This weeds out those activities that probably present a low risk of harm and allows time and effort to be spent on more significant risks. If you are in any doubt, always do a detailed risk assessment. In the case of DSE work, the definition of a DSE user and consideration of the examples in the guidance (HSE 2003) will help to establish whether a risk assessment is necessary. It is often
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most straightforward to class all workers who have access to DSE as users and to carry out a risk assessment. When seeking to achieve best practice it is desirable to reduce or eliminate all possible risk factors for all workers. Each checklist covers pertinent risk factors to prompt identification of hazards. It is helpful to make notes about the details you discover and to start to brainstorm possible solutions as you go along. Make sure that the assessment is based on normal working practices – what is done, not what should be done. Observe and involve several workers. Take fluctuating circumstances into account and get a realistic perspective on the worst case scenario, not just the best case.
Action Plan Common to all ergonomics risk assessments is the necessity to establish actions or remedial steps that will reduce or eliminate ergonomics risk factors. Actions may seem a higher priority in cases where the risk is perceived as high; this should not stop you from also taking those actions that are relatively easy and quick to implement and will produce a degree of improvement. Often there are a range of possible solutions that will have varying effects. Implementing solutions is generally an iterative process. All actions should be reviewed to ensure they have had the desired effect and, in particular, to check that they have not, inadvertently, made the situation worse. Ongoing evaluation and ultimately a re-assessment once the changes have bedded in are also necessary. There are many useful sources for ideas on remedial steps, e.g. HSE documents such as ‘Solutions You Can Handle’ (HSE,1994b), equipment catalogues, trade journals and industry groups. Case studies such as those on the HSE web site (www.hse.gov.uk/msd/experience.htm) or in ‘A Pain in Your Workplace?’ (HSE 1994a) can be especially informative. When care has been taken during the initial planning of a work activity, fewer problems are likely to be identified during a risk assessment, employees will be less likely to experience harm and employers will experience fewer costs.
Good Work Design Figure 11.3 shows a model that summarises the ergonomics risk factors pertinent to consideration of stress and WRMSDs. With reference to the potential for musculoskeletal harm, the model considers seven factors. These fall under the broad headings of ‘task’ and ‘environment’. Task includes consideration of working postures, force, repetition, duration and load/object/equipment. Environment encompasses the physical working environment and work organisation (or psychosocial) issues.
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c Matrick Figure 11.3 Ergonomics Risk Factors Related to Stress and WRMSDs Ergonomics Ltd (2004)
There are close links between work organisation (psychosocial issues) and the risk factors that are associated with stress; the topic of stress is covered in Chapter 10. This chapter will focus on the specific relevance of work organisation to the development of WRMSDs. In carrying out a musculoskeletal risk assessment, the assessor may be aided by various regulations, guidance, best practice and/or ergonomics principles. It is not necessary for all seven factors to be present for harm to result and in certain circumstances one factor alone may trigger symptoms. It is therefore necessary to address the range of causative factors in improving work design. Individual capability is an important consideration and, because the normal range of capability is so wide, it is vital to ensure that work activities are sufficiently well-designed to protect most workers. An ergonomics approach would consider the combined effect of these risk factors and identify ways to design the work so that it could be achieved comfortably and safely by most fit, healthy people. Those who are more vulnerable, due to injury, ill health or perhaps a temporary condition such as pregnancy, will require more detailed consideration. The employer will need to decide whether the Disability Discrimination Act 2005 applies: is the worker ‘disabled’ as defined by
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this legislation and if so, what might constitute ‘reasonable adjustments’ to the workplace to ensure that the worker is not disadvantaged, e.g. limiting loads, altering the task, providing handling aids. One of the problems with the design of work activities is that those making the decisions may be ill-informed about the capabilities and limitations of humans. Workers will strive to accomplish unsafe activities, and because they manage to do the work without any obvious or immediate effect it is deemed achievable. However, much of the impact of musculoskeletal injury is cumulative and harm builds up over a period of time. Often it is only when there is a significant degree of harm that an individual begins to suffer.
Musculoskeletal Disorders: Risk Factors Referring to Figure 11.3:
Work Organisation (Psychosocial) Psychosocial factors are strongly linked with the development of physical harm associated with WRMSDs, and also have a significant connection with mental health and stress. The interaction between the worker and the organisational environment, be it the management structure, culture, or the way that work is organised, can affect performance and well-being. The word ‘psychosocial’ is increasingly being used in preference to the more familiar term ‘work organisation’ to refer to workers’ psychological responses to work. Psychosocial factors have long been recognised as affecting general health and have been shown to influence the development of WRMSDs, in combination with the more commonly recognised physical risk factors. Undesirable psychosocial factors (HSE 2002, 2004) include: r Workers having poor control of work or working methods. r Workers receiving insufficient training or information. r Work demanding high levels of attention and concentration. r Ineffective use of workers’ skill base. r Workers being excluded from pertinent decision-making processes. r Workers being restricted to repetitive, monotonous tasks. r Workers’ activities being machine or system paced. r Workers perceiving work demands as excessive. r Working without breaks or unnecessarily quickly, encouraged by reward systems, e.g. payment, personal targets. r Restricted social interaction. r Significant effort not being matched by reward systems (e.g. selfesteem, resources and remuneration). Whether workers are under time pressure related to the speed at which a production line is set, because a report must be finished in a tight time
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scale, or because the response to calls in a call centre is not achieving the target, the consequences are similar. Workers may experience increased muscle tension and change their behaviour, e.g. not adopting a safe working posture by taking the time to adjust workstation furniture or work pieces, taking shortcuts, or missing breaks and changes of activity that would otherwise occur naturally within their work cycle.
Working Environment Harm may be associated with the following three factors: Vibration Exposure to whole body vibration (e.g. driving, heavyequipment operators) and hand–arm vibration (e.g. use of hand tools) can result in musculoskeletal harm. The effect of whole body vibration can be influenced by body posture (e.g. sitting or standing), the type of seating and the frequency of the vibration. It is difficult to separate the effect of vibration from sitting or manual handling activities that the worker may also undertake. Exposure to vibration causes muscles to be tensed in an attempt to dampen the vibration and this in itself contributes to musculoskeletal harm. Hand–arm vibration often arises due to use of motorised handheld/guided power tools. The vibration alters the sensation of the hand, which can lead to over-gripping to maintain control of the tool. Further information on vibration may be found in ‘Hand–Arm Vibration’ (HSE 2005a). Lighting Inappropriate lighting (e.g. dim light, shadow, glare or flickering light) may be indirectly associated with musculoskeletal effects if a worker has to adopt an unsuitable posture to get closer to their task or to view it from a different angle. Alternatively, it may result in the worker misjudging a distance or failing to see an obstacle while manual handling. Further information on lighting may be found in ‘Lighting at Work’ (HSE 1998b). Thermal Comfort Cold temperatures result in a number of physical adaptations, including decreased blood flow, sensation, dexterity and grip strength. Workers may experience muscle fatigue more quickly due to the decreased blood flow. Equally, workers may find handling loads and other items more awkward, and need to increase their grip to achieve the same strength they would have a warmer environment. Working Posture Awkward, fixed or constrained working postures are associated with musculoskeletal harm; they require greater muscular effort and may involve less efficient use of muscles. This subject is discussed more fully later.
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The impact of postural problems will be affected by other risk factors such as repetition, the extent of force and/or the duration for which postures are held.
Force Harm may occur related to excessive use of force when handling loads; use of fast movements to effect movement of a load, tool or work piece; or local forces affecting the body tissues, e.g. a tool digging into the skin, the edge of a work surface pressing onto the wrist. A worker’s efficiency in transmitting force may be influenced by their posture, their speed of movement or an object’s dimensions and weight. Similarly, a cold environment, a vibrating tool/machine or the wearing of gloves may require a greater grip force than otherwise. Repetition Repetition may involve repeated use of the same muscle groups and/or frequent movements for prolonged periods. In both cases muscular effort is taking place, and the more repetitive the task the longer will be required for recovery. Examples: r Production line work. r Packing, assembly and inspection tasks. r Use of computers, particularly data entry or other rapid keying tasks. r Highly repetitive use of pointing devices, e.g. mice. Duration Duration refers to the length of time a task lasts per day and the number of days the task is undertaken each week. Increased exposure to the risk will inevitably be associated with increased duration. Unless balanced with sufficient recovery time, WRMSDs become more likely, due to the cumulative nature of these injuries. Load/Object/Equipment Work activities require manipulation of a wide variety of items. This may involve: r Manual handling of a load (e.g. moving a patient; handling a drum, sack or box containing raw materials; loading or delivering items). r Using a tool or other item of equipment (e.g. electric screwdriver, input device). r Manoeuvring, working on, or otherwise manipulating a combination of work pieces (e.g. assembling parts, packing). The combination of forces required, postures used and the degree of repetition, as well as the other risk factors, will influence the risk of harm associated with using these items. The weight, bulk, rigidity, handholds/shape and any intrinsically harmful features (e.g. sharp, hot, corrosive) can affect the way that items are handled or used and how they are positioned in relation to the body.
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Anatomy and Physiology Individual capability varies widely in terms of the range of movement of joints and the forces that can be applied.
Metabolic Processes in Muscle Work During ordinary movement, when there is sufficient oxygen in the bloodstream, a chemical balance is maintained. With insufficient oxygen in the blood, perhaps because an activity is too intense (e.g. prolonged, repetitive, static), there are changes in muscle metabolism. Work design requires sufficient opportunities for lower levels of muscle activity or periods of rest so that the ‘oxygen debt’ associated with more intense work can be repaid. Static and Dynamic Work During dynamic effort the movement of muscles assists with muscle metabolism. However, during static effort muscles remain contracted as they hold a posture, causing lactic acid to accumulate and, if prolonged, producing acute pain and muscle fatigue. Work design should allow frequent changes in posture. Redesigning the work activity to enable a neutral, supported body posture is desirable; even if the posture remains static, the muscular effort required will be reduced, resulting in less muscle fatigue. Work activities requiring static muscular effort include: r Keeping the back bent, e.g. stooping over a work activity. r Holding items in the arms, e.g. carrying loads. r Reaching the arms forward, e.g. working across an obstruction. r Standing for prolonged periods, e.g. standing assembly tasks. r Raising the shoulders, e.g. to position hands at working height. Dynamic work may also lead to excess lactic acid production if the activity is intense or strenuous. The onset of muscle fatigue and the speed of recovery from it vary and are related to the duration and intensity of the activity and the physical fitness of the individual.
Anthropometrics Anthropometrics uses scientific knowledge about variation in workers’ size and strength capabilities to increase accuracy regarding design decisions. Data are available for hundreds of different dimensions, e.g. sitting eye height, reach and shoulder width. The application of anthropometrics helps ensure that the work design is suitable for the range of workers and matches the tasks they will carry out.
Percentiles Anthropometric data cover the whole range of human sizes, using a scale known as percentiles. The ideal design aims to match
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the requirements of smaller (5th percentile) and larger (95th percentile) workers, as well as those in between. The ‘average’ or mean value is equivalent to the 50th percentile; any design that just seeks to satisfy the needs of the average worker will be increasingly unsuitable for those who are smaller or larger than this measurement. A standing workstation with a working height to suit the 50th percentile worker may cause taller workers to stoop and shorter workers to raise their shoulders. In both instances workers are forced to adjust their body position, moving it away from the more satisfactory neutral position.
If the work situation can be adjusted to accommodate the widest possible group of workers, the likelihood of WRMSDs is significantly reduced. The use of anthropometric data is fraught with difficulties and even with training anthropometrics should be used cautiously.
Using Ergonomics Good work design requires consideration of clearance, reach and posture.
Clearance Clearance needs to be sufficient for the largest worker, and this would define the minimum acceptable dimension. Clearance is relevant in many situations, e.g. legroom under a workstation; space in which to adopt a good posture for manual handling; size of handles on loads. If the clearance is sufficient for the larger worker it will also be sufficient for the smaller worker.
Reach Zone of Convenient Reach All items need to be within reach of the worker. They should be positioned to avoid the need to lean the body forwards or sideways and ideally to avoid stretching. The maximum area within which items (e.g. work materials, tools, equipment and controls) should be located is called the zone of convenient reach (ZCR). The ZCR should be in front of the body but may be extended sideways if the worker can rotate safely to face a new direction (Figure 11.4).
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c Matrick Figure 11.4 Zone of Convenient Reach and Normal Working Area Ergonomics Ltd (2006)
Normal Working Area Manipulative work and storage of frequently used items should be closer to the body, in the normal working area (NWA). The NWA equates to the length of the lower arm (normally elbow to centre of handgrip) and defines the horizontal work area, usually on a work surface (Figure 11.4). The greater a reach is beyond these dimensions, the more likely it is that workers will develop WRMSDs. A repetitive task involving manipulation of small items was undertaken using a range of poor postures, including excessive reach. A mat, representing the NWA, was provided on each workstation. Workers were given training to ensure they understood that locating items within the area indicated by the mat would reduce their reach and improve their posture.
Posture Neutral Posture A neutral posture results in the least physical stress to the musculoskeletal system. As muscles are at their best mechanical advantage in the mid-point of their range, this allows more effective application of force, including grip strength. Figure 11.5 shows neutral seated and standing postures. Harmful Postures r Extension, flexion (beyond 15 degrees), lateral flexion or twisting of the neck. r Hunched or asymmetric shoulder position.
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Figure 11.5 (2006)
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c Matrick Ergonomics Ltd Neutral Posture: Seated and Standing
r Abducted or unduly flexed (more than 90 degrees) arms. r Working with the arms or hands behind the body. r Extension, flexion, ulnar or radial deviation of the hands, or rotation of the wrists.
r Extension, flexion, lateral flexion or twisting of the back. r Unsupported back, leg, foot or arm posture. r Crossed or otherwise constrained leg or foot posture. Back Manual handling and working above a work item are frequently associated with spinal flexion; such stooping or sideways bending causes an uneven application of force to the intervertebral discs and makes them more prone to injury. Using a working posture that maintains the natural curves of the spine reduces the force on the discs and is desirable. During seated work this may be further improved if the back is supported by a correctly adjusted seat backrest. Twisting the spine compounds the uneven forces affecting the discs, whether standing or sitting. Bending the trunk forward results in either extending the head back or increasing the effect of the weight of the head. Shoulder Reaching upwards is typically associated with extension of the spine, perhaps also causing raised or asymmetric shoulder postures. Harmful shoulder postures are also commonly associated with: a working height that is too high; reaching behind the body; working with the arms above heart level or certainly above shoulder level. Arm and Hand Non-neutral arm and hand postures are associated with the development of WRULDs. A working height that is too high may cause abduction, as the upper arm is lifted away from the body to
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raise the hands. An inappropriate tool design or poorly-oriented task may force workers to use non-neutral hand and wrist postures.
Resting the arms on the work surface during keyboard work results in flexion of the hands, which will be avoided if a neutral body posture can be achieved, often assisted by raising the seat.
Grip Tasks should be designed to use the grip that permits most effective use of the body. A power grip allows larger muscle masses to be used, enabling a much stronger gripping strength – an object is typically enclosed in the palm, e.g. a hammer. A precision grip requires items to be held between the thumb and fingers, e.g. holding a container by pinching its sides; using a precision tool. A precision grip allows greater accuracy but increases the physical stress on the tendons, especially if combined with non-neutral hand postures; the potential for harm increases when tasks are repetitive or of longer duration. Generally a power grip is preferred; however, this may still be harmful during repetitive movements or if using excessive force. Tasks, including the use of tools, should allow the wrist to be used in a neutral posture. Normal Line of Sight The normal line of sight is defined as 15 degrees below the horizontal eyeline when the worker is maintaining a neutral head and neck posture; ideally this should be maintained, with lateral twisting of no more than 15 degrees to either side of the body’s midline. There should never be any need to extend the head back.
A typical recommendation is that display screens be raised to the horizontal eye line. However, compromise may be necessary when a worker also has to look down at the keyboard; in this instance the screen should be placed lower to avoid the repetitive, more extreme up and down head movements that will otherwise result.
Working Height Working height is the height at which the worker’s hands are positioned to undertake tasks; it is not the height of the work surface. Knowledge of the task demands allows the optimum working height to be established and thereafter the work-surface or work-piece height determined, incorporating anthropometric data as necessary. Figure 11.6 shows the musculoskeletal effects that can occur if the working height is inappropriate.
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Working Height
Observed Posture
Physical Effect
Too high
Shoulder(s) raised
Too low
Stooped
Cramp, discomfort or pain affecting shoulders and neck Backache or pain
Figure 11.6
Effects of Inappropriate Working Height
Seated/Standing Work Standing upright and maintaining the shape of the natural curves in the spine prevents deformation of the intervertebral discs. However, maintaining this standing posture increases the static muscular workload and is associated with higher energy expenditure, making standing tiring; consequently, sitting is often preferred. The correct choice from the ergonomics perspective depends upon the tasks being undertaken. Some work activities present physical constraints that prevent a satisfactory sitting and/or standing posture, and in these instances a sit/stand seat may provide a suitable alternative. It is good practice to evaluate a seat in its intended work situation before making any purchasing decisions. Good suppliers will generally agree to a trial period.
Manual Handling Use of or movement of work items, whether in preparation for, during or upon completion of a work activity, will often involve manual handling. Much of the potential for hazardous manual handling can be avoided by careful consideration of each item’s location, avoiding a MHO that is outside the HSE risk assessment filter. This filter provides guidance on lifting and lowering, carrying, twisting, pushing and pulling, and handling whilst seated (HSE 2004). A detailed manual handling risk assessment will be necessary whenever a hazardous manual handling activity is identified, including all MHOs that are outside the HSE filter. Comfort It is common for workers to describe their posture as comfortable, even if to the trained eye their posture and body movements seem unsatisfactory. Workers may accept mild discomfort because they have not yet experienced significant symptoms. When assessing a work activity, it can be useful to evaluate workers’ experiences of discomfort as this can help to tease out issues. It is also good practice to set up a system to encourage and facilitate reporting of symptoms that may be related to work situations. This allows early intervention and can often preclude more serious harm.
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An ergonomic design solution should avoid discomfort, but sometimes individuals will interpret changes to their posture as ‘not comfortable’, when they actually mean the posture is unfamiliar. It is important to ensure they understand why changes are being recommended.
Seeking Further Advice
A Cautionary Tale Mistakes and oversights can occur when carrying out ergonomics risk assessments. However, perhaps the worst mistake is to not attempt them at all! Seemingly insurmountable problems can be tackled, but you must do it one step at a time. Consider involving an ergonomist and pull together a team of relevant people, including those who manage and work in the area. Define your goal, meet regularly and keep the project going between meetings. Remain wary of solutions until you have thought them through in their entirety, discussed them with the workforce and undertaken a trial.
A second-hand scissor-lift was purchased to reduce the risk associated with loading heavy boxes onto a pallet at floor level. The scissor-lift introduced further risks associated with excessive reach because of its bulky design and had to be removed shortly after installation.
Competent Practitioners Ergonomists come from a wide range of backgrounds (e.g. biological sciences, psychology, health and engineering). Registered members and fellows of the Ergonomics Society may be recognised by their entitlement to use the abbreviations MErgS and FErgS after their name. Others with an interest in ergonomics may be designated Associate members, without necessarily inferring competence. Additionally, an ergonomist may be registered as a European Ergonomist (Eur Erg). It can be tempting to try to investigate ergonomics issues in-house. However, in complex situations, perhaps when workers are reporting symptoms, or where a new work situation is being designed, particularly if it involves significant capital expenditure, you may feel more comfortable arranging an expert assessment. An ergonomist will use their expertise to tease out what can be an intricate web of issues and draw on a much broader experience of solutions. Whether you are looking for a fresh approach, an authoritative external voice, an extra pair of hands to supplement in-house expertise,
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or are being forced to seek ergonomics expertise by your insurer, it is important that you select your ergonomist carefully.
References and Further Reading Disability Discrimination Act 1995. Department for Work and Pensions (2006) Background to Labour Market Statistics: September 2006, www.dwp.gov.uk/mediacentre/pressreleases/ 2006/sep/empl060-stat130906-lms.asp (accessed 26 September 2006). Dul J. and Weerdmeester B. (1993) Ergonomics for Beginners: a Quick Reference Guide, London: Taylor & Francis. Ergonomics Society web site, www.ergonomics.org.uk. Hanson M.A., Burton K., Kendall N.A.S., Lancaster R.J. and Pilkington A. (2006) The Costs and Benefits of Active Case Management and Rehabilitation for Musculoskeletal Disorders, HSE Research Report 493, Sudbury: HSE. HSC (1996) Workplace Health, Safety and Welfare: Workplace (Health, Safety and Welfare) Regulations 1992 (as amended by the Quarries Miscellaneous Health and Safety Provisions Regulations 1995), L24, Sudbury: HSE. HSC (2000) Management of Health and Safety at Work Regulations 1999 Approved Code of Practice and Guidance, L21, Sudbury: HSE. HSE web site, www.hse.gov.uk. HSE musculoskeletal disorders web site, www.hse.gov.uk/msd/index.htm. HSE (1994a) A Pain in Your Workplace?, HS(G)121, Sudbury: HSE. HSE (1994b) Manual Handling: Solutions You Can Handle, HS(G)115, Sudbury: HSE. HSE (1998a) 5 Steps to Risk Assessment, HS(G)183, Sudbury: HSE. HSE (1998b) Lighting at Work, HS(G)38, Sudbury: HSE. HSE (1999) A Guide to the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995, L73, Sudbury: HSE. HSE (2002) Upper Limb Disorders in the Workplace, HSG60(rev), Sudbury: HSE. HSE (2003) Work with Display Screen Equipment: Health and Safety (Display Screen Equipment) Regulations 1992 (as amended by the Health and Safety (Miscellaneous Amendments) Regulations 2002), L26, Sudbury: HSE. HSE (2004) Manual Handling: Manual Handling Operations Regulations 1992 (as amended), L23, Sudbury: HSE. HSE (2005a) Hand–Arm Vibration, L140, Sudbury: HSE. HSE (2005b) Health and Safety Statistics 2004/05, www.hse.gov.uk/statistics/ overall/hssh0405.pdf (accessed 26 September 2006). HSE (2006) Musculoskeletal Disorders, www.hse.gov.uk/msd/index.htm (accessed 26 September 2006). McKeown C. and Twiss M. (2001) Workplace Ergonomics: a Practical Guide, Wigston: IOSH Services Limited. Pheasant S. (1996) Bodyspace: Anthropometry, Ergonomics and the Design of Work, 2nd edn, London: Taylor & Francis.
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Health Promotion
Tracy McFall; Updated by Katie Oakley
Introduction A plethora of health promotion books have been written in the past twenty years, so to do justice to the subject in just one chapter is a lofty aspiration for any writer. Nevertheless, with a somewhat overwhelming challenge, I have tried to present some of the debates ensuing in the larger world of health promotion and relate them to an occupational health setting. The reader must view this chapter as a ‘taster’ and should be encouraged to explore the topic further. No two occupational health settings are the same, and health promotion activity is often seen as a luxury in a very hard-pressed service. However, if occupational health is to engage in wider public health issues as outlined in recent government strategies (Acheson 1998; Scottish Office 1998; Scottish Executive 2000, 2001; DoH 2004; HM Government 2005), it is my opinion that we must move from the traditional medical model of occupational health and embrace the new public health agenda of not only reacting to workplace ill health but actively promoting the health of the workforce that we serve. In this chapter, I have highlighted the reasons why I think it is important for the occupational health nurse to understand how health can have a positive and/or negative impact on work. The world of work is changing and critics of occupational health practice have highlighted that the speciality has been slow to adapt to the changing health demands of the UK workforce. I believe the first step in promoting health at work is understanding not only the present but the future potential Occupational Health Nursing Edited by K. Oakley. C 2008 John Wiley & Sons, Ltd
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health care needs of the workforce. Health promotion means different things to different people. I shall try to outline a model for health promotion and how this relates to the occupational health nurse. Maslow (1954) suggests that individuals have a ‘hierarchy of needs’ and in order to make behaviour change they need to be able to make choices and have their basic ‘living’ needs met. If the occupational health nurse is to engage in effective health promoting work, they will need a strong grounding in what contributes and influences workers to make health changes. Further into the chapter I suggest that the occupational health nurse needs to see health promotion in a wider societal context. That is, in engaging in health-promoting activities, the nurse must be aware of the ‘external to work’ influences that can limit an individual’s ability to make lifestyle changes. The occupational health nurse is asked to see that an individual’s ability to make health choices can be as much influenced by economic and environmental factors as by personal motivation. Finally, I shall discuss the role of research and evaluation in occupational health and health promotion. There has never been a greater emphasis on evidence-based practice and occupational health nurses face some real challenges in ensuring that health promotion activities are evaluated and based on the best interventions available. The recommendations at the end of the chapter slip easily off the pen, but the steps required to accomplish them are quite tough. Education, increased resources and better access to occupational health for all must surely be our vision for the future.
Health at Work Sickness absence and ill-health retirement place a financial burden on business in an ever-increasingly competitive marketplace (as discussed in detail in Chapter 8). Every experienced occupational health nurse knows first-hand that these figures of working days lost and illness caused or made worse by work also bring great personal suffering and financial hardship to Britain’s labour force. According to the Health and Safety Executive (HSE), in 2004/05 (and for several years previously) the most common types of work-related illness were musculoskeletal disorders and stress (www.hse.gov.uk). The Health Education Authority (1997), however, states that the greatest cause of non-work-related disease affecting sickness absence for which statistics are available is coronary heart disease. Therefore, occupational health nurses must have a wide vision of how they can promote the population’s public health and, in the author’s opinion, should not concentrate exclusively on workplace hazards. A study by Williams et al. (1998) investigating occupational health in the NHS has shown that sickness absence costs the NHS £700 million
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per year. The report identifies a worrying and increasing trend of stressrelated illness in the NHS workforce, the main causes being attributed to ever-intensifying workloads without matching resources (Williams et al. 1998). Rogers et al. (1999), when addressing the health risks to nurses, question why NHS occupational health services have been slow to tackle ill health in health service employees. Indeed, one might wonder, if the NHS cannot get it right for its staff, what hope is there for private industry to take up the cause? Sadly, as many NHS occupational health nurses will testify, staff health is often a low priority in a system already struggling to cope with excessive demands and limited resources. Thompson (1998) asserts that the work environment represents only one part of the total environment of human beings, but a very important part of societal structure in Western countries has been built around paid work. Work is a necessity for most adults and the majority of people will spend a considerable amount of adult life in the workplace. It could be suggested that an individual’s health status has a huge impact on how they interact in the workplace and, thus, a huge impact on their (and their family’s) entire life. Indeed, concurring with Thompson (1998), it could be assumed that any type of ill health will have a direct impact on an individual’s work experience and on an employer’s experience of an employee’s productivity. For the majority, sickness absence is limited to a few minor ailments and diseases occurring intermittently throughout their working lives. For most of these individuals, it rarely has any significant impact; but for others, sickness absence may be prolonged and even result in job loss. A question for the profession is whether the occupational health nurse can have a positive impact on the health status of employees and reduce absence and ill health in its broadest sense, and not only illness related to work.
Changing Work Environment For the occupational health world to make an impact on the promotion of health in the workplace, the sector needs to understand the changing nature of work in the UK and how work interacts with everyday human existence. Thompson (1997) claims that the practice of occupational health has failed to respond to the contemporary health needs of the working population and is often perceived as being stuck in the traditional heavy industry setting. The Health and Safety Executive (HSE 1998) illustrates this point by concluding that industry in the UK is changing, and there has been a steady decline in heavy industries (e.g. manufacturing, mining, energy and farming), where traditionally there was a high risk of accidents and other work-related illnesses. Nevertheless, occupational health data continue to show increasing ill health in
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the workplace, and if the traditional occupational health dilemmas are disappearing (e.g. asbestosis, lead poisoning, etc.), these will be replaced by new workplace illnesses (e.g. call centre ergonomic health problems, stress). Occupational health nurses are forced to deal with these workplace issues now, with limited data and evidence-based interventions on offer. Perhaps one of the greatest dilemmas facing occupational health nurses in promoting workplace health is that nearly 99 % of firms in the UK are small, with those employing fewer than 50 people accounting for about 50 % of the working population (HSE 1998). The HSE (1998) claims that small firms and the self-employed have difficulty accessing health information and are unaware of the services available to offer advice. Promoting health at work seems a lofty aspiration when the bulk of UK employees and employers have little or no access to occupational health services. For health promotion at work to have any impact, it could be said that the first step must be to provide greater access to occupational health services for all UK employees.
Occupational Health and Health Promotion The government has acknowledged the importance of promoting health in the workplace (Golby 1996; Thompson 1997; Ballard 1998; Holyroyd 1998; Scottish Office 1998; DoH 2004; HM Government 2005). With the adult working population of around 22 million people spending 60 % of waking hours at work, it is claimed that the workplace is an appropriate, supportive and effective setting for health promotion (GGHB 1998; Holyroyd 1998; Mills 1998; Scottish Office 1998). Why should the government contend that occupational health services are an intrinsic part of the new public health agenda? Mills (1998) believes that workplace health promotion may represent a good investment for companies in lowering absenteeism and staff attrition, as well as increasing morale and productivity, although he does not substantiate this claim with hard data. Thompson (1997) writes that workplace health promotion should take a well-rounded approach, i.e. targeting interventions at both the workplace environment and the individual, and using a variety of strategies to achieve objectives. Some authors suggest that occupational health practice has already made the shift from being a mostly reactive, treatment-based service to being a more proactive, self-directed and health-promoting service (Smith 1996; Pickvance 1997; Mills 1998; DoH 1999a). Yet very few UK organisations commit significant resources to meaningful health promotion initiatives, and occupational health services have a long road to tread in order to prove that the workplace is a valid and worthwhile arena for health promotion.
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If positive changes in workers’ health have taken place in the last 30 years, Rogers et al. (1999) believe that workplace health promotion has been improved by the Health and Safety at Work Act 1974 and other legislation, and worker-initiated action (i.e. action by trade unionism and not primarily by occupational health practitioners). Rogers et al. (1999) go on to suggest, citing the NHS as an example, that occupational health practitioners are under great pressure not to rock the boat and to keep politics under wraps. One colleague highlighted this problem by discussing her dilemma: she felt a group of employees were under stress relating to their work, but owing to business culture and anxiety about addressing the problem, she could provide only a reactive counselling service for stress and felt unable to tackle the underlying organisational causes. Part of this dilemma may be explained by a lack of understanding among UK managers about the benefits of tackling health issues. Wilkinson (1999), in a qualitative study of 19 randomly-selected health education/promotion unit specialists, discussed their perception of how managers of different organisations saw the role of health promotion in the workplace. The findings suggested that the influence of the medical model, dealing with the illness or injury once it has occurred, is greater than that of health promotion programmes in the workplace. Many occupational health nurses report great difficulty in convincing employers of the ‘value-added’ aspects of health promotion activities.
Health Promotion The World Health Organisation (WHO 1946) defines health as a ‘state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’. Although criticised for being idealistic and utopian, it is an aim towards which health care and other social actions may be orientated (Baggott 1994). Health promotion has grown in prominence in the past 20 years, despite the fact that it can mean different things to different people (Naidoo & Wills 2000). For the field of occupational health, the Downie and Tannahill model appears well matched to the workplace arena. Downie et al. (1996) conclude that the Tannahill framework provides a model for defining, planning and, most importantly, ‘doing’ health promotion. Health promotion specialists Naidoo and Wills (2000) note that the Tannahill model of health promotion is widely accepted by health care workers and agree that it is primarily descriptive of what goes on in practice. Tannahill (1985) states that ‘health promotion comprises efforts to enhance positive health and reduce the risk of ill health, through the overlapping spheres of health education, prevention and health protection.’ Downie et al. (1996) suggest that with the model, there are seven domains that may be identified (Figure 12.1).
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Health Education
5
2
7 4
1
Prevention
Figure 12.1 the numbers.
3
6
Health Protection
Tannahill’s Model of Health Promotion. See text for an explanation of
The seven domains are as follows (these include examples to encapsulate the work of occupational health nursing): 1. Preventive measures, such as coronary heart disease screening and health surveillance, e.g. audiometry, lung function testing. 2. Educational efforts to influence lifestyle in the interest of preventing ill health, as well as efforts to encourage the uptake of preventive services, e.g. a well woman clinic with teaching on breast screening and examination, or a hearing conservation teaching programme with access to audiometry testing. 3. The overlap between preventive health protection and prevention, e.g. introduction of the Health and Safety at Work Act 1974 setting standards to reduce accidents in the workplace. 4. An overlap of all spheres of the model, described as encompassing policy commitment to preventive health education, e.g. an occupational health nurse presenting information on health and safety responsibilities at a new manager’s induction course. 5. Positive health education, which falls into two categories: (a) influencing behaviour on positive health grounds, e.g. healthy eating canteens with healthy eating plans (b) helping groups, individuals or whole communities to develop positive health attributes, e.g. encouraging employees to access specialist advice for work-related or personal stress as a means of taking control of their lives.
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6. Health protection, e.g. in a hospital setting, implementing a policy of evidence-based glove selection based on risk assessment. 7. Raising awareness of, and securing support for, positive protection measures among the public and policy makers. In addition, Maslow (1954) cautions that an individual has a hierarchy of needs, with well-being fully achieved only as the individual travels through this hierarchy (Figure 12.2). In this model, self-esteem and the ability to express one’s emotions are seen as important elements of the healthy person (Sidell et al. 1997). Sidell et al. (1997) believe that any worthwhile theory must take into account an individual’s motivational state and sense of self-empowerment to make health changes. It is one thing for the nurse to offer health promotion programmes to the workforce and another for those programmes to have positive health outcomes. The Health and Safety Executive (1998) concurs with this by stating that behavioural change is central to the challenges of dealing with occupational health and health promotion. It is even suggested by the HSE that consideration be given to research to understand these behavioural change factors, and also to explore methods of providing information to employees regarding the risks to which they are exposed at work (HSE 1998). Mills (1998) argues that the positive impact of workplace health promotion has been achieved with low recruitment rates; however, he believes that success in stimulating sustained behaviour change has been relatively poor. Sustained behaviour change is important in order to gain meaningful disease risk reduction (Mills 1998). One of the
Selfrealisation
Esteem
Social
Safety
Psychological
Figure 12.2
Maslow’s Hierarchy of Needs
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challenges of health promotion is for the practitioner to help the employee to make change in not only the short but the longer term.
Avoiding Value Judgements Tinson (1997) includes another caution: that practitioners offering health promotion advice often make value judgements about the advice that they give and the strategies that they encourage others to adopt. For example, a nurse may feel frustrated when an employee fails to make progress as part of a weight-management programme. The nurse can convey these feelings to the employee, who may then feel a failure and possibly not seek help from occupational health at a later date. To counteract and provide best clinical interventions, Smith (1996) encourages occupational health nurses to network and share good practice. Unfortunately, she feels that professional isolation has given rise to a diverse range and quality of interventions. The fact that many occupational health nurses work either in isolation or in small teams can make networking, participating in further education and attending conferences very difficult. Poorman (1985) says that nurses ‘cannot know it all’, but should strive to ensure that their interventions have a solid theoretical base and should know the resources available to obtain specific information when needed. Every occupational health nurse should develop the ability to access key evidence-based practice.
The Cycle of Change Behaviour Model Another important aspect of health promotion understands that individuals generally go through a cycle of change when making health improvements. Most of the population at some point will have tried and failed to make health behaviour changes. The occupational health nurse would be well placed to remember their own struggles with lifestyle changes when supporting others during this time. Prochaska and DiClemente (1984) offer a well-known behaviour change model for practitioners, known as the ‘Stages of Change’ model. The model offers five steps to behaviour change and shows that any change made is not final but part of an ongoing cycle of change (Naidoo & Wills 2000). Figure 12.3 illustrates this process and identifies the following stages:
r Precontemplation: those individuals who have not considered chang-
r
ing their lifestyle or become aware of any potential risks in their health behaviour. When they become aware, they may progress to the next stage. Contemplation: although the individual is aware of the benefits of change, they are not yet ready and may be seeking information or help to make the decision. This stage may last a short while or several years. Some people never progress beyond this stage.
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PRECONTEMPLATION individual not interested in change RELAPSE CONTEMPLATION individual is thinking about change
MAINTAINING THE CHANGE READY TO CHANGE MAINTAINING THE HEALTHIER LIFESTYLE
MAKING A CHANGE
Figure 12.3 The Stages of Change Model Source: After Prochaska and DiClemente (1984)
r Preparing to Change: when the perceived benefits seem to outweigh
r r
the costs and when the change seems possible as well as worthwhile, the individual may be ready to change, perhaps seeking extra support. Making the Change: the early days of change require positive decisions by the individual to do things differently. A clear goal, a realistic plan, support and rewards are features of this stage. Maintenance: the new behaviour is sustained and the individual moves to a healthier lifestyle. For some people, maintaining the new behaviour is difficult and they may revert or ‘relapse’ to any of the previous stages.
It has been argued that few people will follow this cycle in order, and inability to reach the maintenance stage at onset or on subsequent attempts is not a failure (Naidoo & Wills 2000). Occupational health nurses should be aware that it could take many attempts before change happens, if it does indeed happen. For example, in any attempt by the nurse to provide support in smoking cessation, they should try to be judgement free, particularly when the client fails or has a relapse. It is very important that the nurse does not withdraw support in this event but continues to encourage the client and help them to see that this is common when making change. Naidoo and Wills (2000) note that while this programme is popular, it does not state why some people find it harder to change than others, or take account of the role the environment plays in behavioural choices.
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Many occupational health nurses engage in a wide range of health promotion activities and knowingly or unknowingly use the Cycle of Change behaviour model. It is beneficial for the practitioner to be aware of all facets of behaviour change and to acknowledge that a ‘one-off’ canteen display may not necessarily promote and sustain a healthy lifestyle.
Seeing Health Promotion in a Wider Societal Context In the past 10 years, health promotion has risen in prominence in the UK health care system. It would be difficult to find a practitioner who does not agree that it is better for an individual and more cost-effective for society to prevent ill health in the first place than to wait to treat the symptoms of disease. Many occupational health nurses have embraced the world of health promotion, whether in promoting work-related health issues, e.g. ergonomic education, or other health issues in a workplace setting, e.g. alcohol/drug awareness, healthy eating. However, health promotion has been criticised for taking on a mainly ‘lifestyle’ intervention programme and failing to take into account other key areas that affect the population’s health (HEA 1997). The Black Report (1980) and other health research (Ebrahim & Davey Smith 1997; Healy 1998; McLaren & Bain 1999; Page 1999) demonstrate a clear link between poorer health and lower socio-economic class. In other words, these reports provide good evidence that lower-paid occupational groups are more likely to suffer from higher morbidity and mortality rates. The United Nations Development Programme recognises the UK as one of the most ‘unequal industrialised countries in the world’ due to its continuing unequal distribution of wealth (Arber 1987). An occupational health promotion quantitative study examining over 13 000 employees’ risk factors for coronary heart disease confirmed that people in lower social classes had a higher rate of cardiac risk factors than those at the upper end (Chatterjee 1997). Work-related health also appears to be affected by socio-economic circumstance. Ballard (1998) reported that injuries to employees are much higher in blue-collar than white-collar workers and the evidence demonstrates that work-related injuries and ill health disproportionately affect lower-paid workers. This information seems to imply that occupational health nurses should be aware of the extra health pressures on low-paid workers. So is it important for the occupational health nurse engaging in health promotion activities also to consider other factors affecting health than lifestyle? Naidoo and Wills (2000) argue that the overwhelming evidence of the effect of social and economic disadvantage on health and disease has led many health promoters to recognise that the choice to change
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behaviour is not an easy one for many people. If we reconsider Maslow’s hierarchy of needs (Maslow 1954), an individual may understand that eating a diet high in sugar and saturated fat is unhealthy, but due to a lack of money for other life pleasures, they may decide that it is a risk worth taking in the pursuit of simple gratification. In trying to encourage behaviour change, the occupational health nurse may not only need to emphasise the health benefits of healthy eating, but to discuss other positive benefits of change, e.g. an increase in self-esteem or the pleasure of eating a healthy, balanced diet. Indeed, it could be suggested that any occupational health department engaging in a health needs analysis should include the wider social and environmental determinants of the health of the employees (e.g. job type, salary banding and environment, geographical location) (Swage 1999). In an already under-funded service, this could prove to be, in simple terms, unrealistic and unmanageable. Nevertheless, the occupational health nurse should be aware when engaging in health promoting work that ‘lifestyle’ modification is only one aspect of behaviour change and that other factors such as socio-economics, environment and job title may have a significant impact on an employee’s ability to modify and promote their own health. McHale (1996), although speaking primarily of the nurse’s role in promoting sexual health behaviour, encourages nurses to take on a more active political role, engaging with the government to address social deprivation in society and therefore help to reduce inequalities in health. Occupational health nurses should strive to see all the contributing factors affecting health, even though without political and health policy change this may be problematic.
Evidence Base With myriad issues to consider, perhaps the most challenging aspect of health promotion is ensuring that activities are based on best practice. The Scottish Intercollegiate Guidelines Network (SIGN) (1999), a government-funded body setting clinical standards in Scotland, recommends that health professionals should continually assess their practice and base it on the most recently emerging evidence-based research (www.sign.ac.uk). The equivalent organisation for England and Wales is the National Institute for Health and Clinical Excellence (NICE) (www.nice.org.uk). White (1997) states clearly that with an emphasis on evidence-based practice, clinicians must be able to identify a problem, ask questions, search the literature for answers, and then decide what interventions to adopt, based on the evidence available. This of course is not always the easiest thing for a busy occupational health nurse to do! Waghorn et al. (1993) have also cautioned occupational health nurses that they must examine their rationale for health
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promotion and identify a genuine need for a particular programme, which should have measurable benefits, or else efforts may be a waste of time. Hughes (1998) asserts that a more challenging task for occupational health services is establishing a clear and credible ‘evidence base’ for the effectiveness of their services. This could be viewed as the gold standard for occupational health promotion activity. However, Piper and Brown (1998) have argued that many health promotion strategies do not have a sound theoretical base and are rarely evaluated. Discussing health promotion activity with other occupational health nurse colleagues, it would appear that evaluation rarely takes place, for a variety of reasons such as lack of time, knowledge, training and resources. The lack of research available in occupational health nursing agrees with the opinion that exists among many researchers regarding health promotion in general. Some researchers say that we know a lot about how to persuade people to change behaviour, while others suggest that the outcomes are exaggerated and we know little about how to promote health (DeWit et al. 1997; Goodrich et al. 1998; Hardman et al. 1998; Mills 1998). Tannahill (1998), a well-known health promotion academic, states that part of the problem of research is that those practitioners who are engaged in health promotion are asked to evaluate their programmes in cost-effectiveness terms. He claims that the diverse nature of the activity and the uncertainty about its parameters make a simple cost–benefit analysis unrealistic. With many of the health promotion academics struggling to find valid research assessment tools, is it any wonder that evaluation of occupational health promoting activities has been slow? Springett and Dugdill (1995), in their literature review of the action–research approach to workplace health promotion, conclude that providing guidelines for evaluation is not sufficient; training is needed to improve the quality of evaluation and make learning and reflection about health part of organisational culture. Indeed, training should not be limited to a one-off course or degree qualification but should be an ongoing part of every OHN’s personal development programme.
Conclusion As mentioned at the start of the chapter, this is but a taster of health promotion and occupational health nursing. You, like me, may have struggled to find out whether your practice interventions make positive changes in the workforce that you serve. While I have tried to encapsulate what I believe is involved in best practice, I think that in small ways we can make a difference, and do make a difference every day. Think of the occupational health nurse who supports a stressed worker in contacting community support services, or provides ongoing emotional support in the workplace during an employee’s life crisis,
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or prompts a worker to contemplate smoking cessation; or the occupational health nurse who helps to prevent employees from suffering noise-induced hearing loss by engaging them in regular audiometry and then enables them to understand the importance of using personal protective equipment by engaging in regular, aggressive training programmes. These, I believe, all have an impact in promoting health. Perhaps as occupational health nurses the thing that we lack most is the confidence to assert that we can and do make a difference to the nation’s public health. Anecdotes and gut feelings can no longer work in the health care setting. Occupational health has to fight for its place in the funding hierarchy with many other health care specialities and even business interests. Perhaps, with our numbers being so few, we need to work more passionately and politically, not only to have our voice heard but to have our merits recognised at the top of government policy-making tiers. My own vision of the future sees every worker in the UK having access to an occupational health service. This service may be based locally in the workplace or within another primary care setting. Accessibility is the first step in promoting health outcomes. My vision for the occupational health nurse is that they will have access to sustained training opportunities and support to engage in workplace health promotion research. This can only be achieved if politicians, managers and occupational health nurses actively believe and produce evidence to demonstrate that positive health outcomes can be achieved at work. This is a difficult task but the profession must seek to overcome the obstacles that stand in the way of producing evidence-based practice. Not every nurse wants to engage in research but it is my hope that some national occupational guidelines will be set to provide the specialty with clear guidance on best clinical practice. It is important that this is not dominated by a medical model, but that it instead takes in the wide range of specialists involved in workplace health, i.e. nurses, health and safety officers, occupational hygienists, ergonomists, trade unions, staff advisory boards, managers and, of course, the workforce. As I said in my introduction, recommendations slip from the pen easily. My own practice has illustrated the great opportunities for promoting health in the workplace, and although I, like many others, struggle to ensure my interventions are based on the best evidence and are systematically evaluated, I have seen employees make a difference to their health both in and outside a work context – this change has been supported by many experienced occupational health nurses. Just the other day, a colleague in another company told me of a client interaction: the employee had a heroin addict son and she was off work due to the stress; my colleague put her in contact with local agencies to help her learn coping strategies for her son’s addiction. The nurse encouraged her to return to work and pursue her own external interests. The nurse met the employee on a regular basis and advised her
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on a weight-management programme. The woman has reported that life is tough, but coping is easier and she has returned fully to work. The colleague was not bragging about her interventions but genuinely wanted to express joy at the progress that the employee had made. I sat in my office and listened – there is not much to say except that this story demonstrates occupational health promotion practice at its very best and most humane. Simply, it’s the new public health agenda in action. We have a long journey to travel, but I believe one of the most effective areas of promoting health can and should be within a workplace setting.
References and Further Reading Acheson P. (1998) Inequalities in Health, London: TSO. Arber S. (1987) Social Class, Non-Employment, and Chronic Illness: Continuing the Inequalities in Health Debate, British Medical Journal 294(6579), 1069–73. Aw T.C., Whitaker S. and Harrington J.M. (2006) Protecting and Promoting Health in the Workplace. In: Pencheon D., Guest C., Melzer D. and Muir Gray J.A. (eds) Oxford Handbook of Public Health Practice, 2nd edn, Oxford: OUP. Baggott R. (1994) Health and Healthcare in Britain, London: Macmillan. Ballard J. (1998) Our Healthier Workplace, Occupational Health Review, May/ June. Black D. (1980) Inequalities in Health Report, London: DHSS. Chatterjee D.S. (1997) A Multi-Centre Health Promotion Programme for Coronary Heart Disease, Occupational Health 49(1), 12–14. Department of Trade and Industry (2003) Flexible Working: the Right to Request and the Duty to Consider: a Guide for Employers and Employees, London: TSO. Developing Patient Partnerships (DPP), health education web site, www. dpp.org.uk; specific section on health at work for employees, www. dpphealthatwork.org.uk. Dewit R., Van Dam F., Landbelt L., Van Buuren A., Van Der Heyden K., Leenhants G., Loonstra S. (1997) A Pain Education Program for Chronic Cancer Patients: Follow Up From Randomized Controlled Trial, Pain 11(73): 55–69. DoH (1999a) Making a Difference in the Workplace, London: TSO. DoH (1999b) The Health Workplace Initiative, London: TSO. DoH (2004) Choosing Health: Making Healthier Choices Easier, public health white paper, London: DoH. DoH (2005) Choosing Activity: a Physical Activity Action Plan, London: DoH. DoH (2006) Essence of Care: Benchmarks for Promoting Health, www.dh. gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAnd Guidance/DH 075613. Downie R.S., Tannahill C. and Tannahill A. (1996) Health Promotion: Models and Values, 2nd edn, Oxford: OUP. Ebrahim S. and Davey Smith G. (1997) Systematic Review of Randomised Controlled Trials of Multiple Risk Factor Interventions for Preventing Coronary Heart Disease, British Medical Journal 309, 1–2.
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Flaskerud J. and Winslow B. (1998) Conceptualizing Vulnerable Populations Health-Related Research, Nursing Research 47(2), 69–78. Golby H. (1996) Launchpad to Health, Nursing Times 92(3), 42–4. Goodrich J., Wellings K. and McVey D. (1998) Using Condom Data to Assess the Impact of HIV/AIDS Preventive Interventions, Health Education Research 13(2), 267–74. Greater Glasgow Health Board (1998) The Annual Report of the Director of Public Health, Glasgow: GGHB. Hardman A., Jones J., Scott D.A. and Stevens J. (1998) Unwanted Sexual Experiences Reported by Nursing Students: Implications for Nurse Education and Training, Journal of Advanced Nursing 28(5), 1158–67. HEA (1997) Health Update: Workplace Health, London: HEA. Healy M. (1998) Inequalities in Health: Effects of Socio-Economic Status, Nursing Standard 12(40), 26–8. Health and Safety at Work Act 1974, Chapter 37 (Reprinted 1991), London: TSO. HSE (1998) Developing an Occupational Health Strategy in Great Britain, London: HMSO. HM Government (2005) Health, Work and Well-Being: Caring for our Future: a Strategy for the Health and Well-Being of Working Age People, Department for Work and Pensions, Department of Health and HSE, www .dwp.gov.uk/publications/dwp/2005/health and wellbeing.pdf (accessed 15 July 2007). Holyroyd K. (1998) Staying Healthy in the NHS, Occupational Health 50(11), 25–7. Houtman I., Kornitzer M., De Smet P., Koynuncu R. and De Backer G. (1999) Job Stress, Absenteeism and Coronary Heart Disease European Cooperative Study (The JACE Study), European Journal of Public Health 9, 52–7. Hughes M. (1998) HIP Operation, Occupational Health, September, 25–7. McHale A. (1996) Risk Reduction Strategies in the Control of AIDS, Professional Nurse 11(11), 731–3. McLaren M. and Bain M. (1999) Deprivation and Health in Scotland, Edinburgh: ISD. Maslow A.H. (1954) Motivation and Personality, London: Methuen. Mills M. (1998) A Radical Approach to Health Promotion, Occupational Health Review, January/February, 9–14. Naidoo J. and Wills J. (2000) Health Promotion Foundations for Practice, 2nd edn, London: Bailliere Tindall. Naidoo J. and Wills J. (2005) Public Health and Health Promotion Developing Practice, 2nd edn, Philadelphia: Elsevier. NICE web site, www.nice.org.uk. NICE (2006) The Public Health Guidance Development Process: an Overview for Stakeholders, Including Public Health Practitioners, Policy Makers and the Public, www.nice.org.uk/page.aspx?o=299970 (accessed 15 July 2007). NICE (2007) Behaviour Change: NICE Public Health Programme Guidance, October, www.nice.org.uk/PH006. Page M. (1999) Social Class and Nutrition in Coronary Heart Disease, Professional Nurse 14(11), 750–2.
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Pickvance S. (1997) Health in the Workplace: a Primary Care Approach, Health Visitor 70(5), 32–4. Piper S.M. and Brown P. (1998) The Theory and Practice of Health Education Applied to Nursing: a Bi-Polar Approach, Journal of Advanced Nursing 2(7), 383–9. Poorman S.G. (1985) Human Sexuality and the Nursing Process, Connecticut: Appleton & Lange. Prochaska J.O. and DiClemente C.C. (1984) Towards a Comprehensive Model of Change. In: Miller W.R. and Heather N. (eds) Treating Addictive Behaviours: Process of Change, New York: Plenum. Rogers R., Salvage J. and Cowell R. (1999) Nurses at Risk: a Guide to Health and Safety at Work, 2nd edn, London: Macmillan. Scottish Executive (2000) Our National Health: a Plan for Action, a Plan for Change, Edinburgh: TSO. Scottish Executive (2001) Caring for Scotland: the Strategy for Nursing and Midwifery in Scotland, Edinburgh: TSO. Scottish Intercollegiate Guideline Network (SIGN) web site, www.sign.ac.uk. Scottish Intercollegiate Guideline Network (SIGN) (1999) Lipids and the Primary Prevention of Coronary Heart Disease, Edinburgh: SIGN. Scottish Office (1998) Working Together for a Healthier Scotland, Edinburgh: TSO. Sidell M., Jones L., Katz L. and Peberdy A. (1997) Debates and Dilemmas in Promoting Health, London: Macmillan. Smith N. (1996) The Rationale Behind Workplace Health Promotion, Occupational Health, 18–19. Springett J. and Dugdill L. (1995) Workplace Health Promotion Programmes: Towards a Framework for Evaluation, Health Education Journa1 54, 88–98. Swage T. (1999) Skills to Assess the Nation’s Health Needs, Practice Nurse 17(2), 79–82. Tannahill A. (1998) The Scottish Green Paper: Beyond a Healthy Mind in a Healthy Body, Journal of Public Health Medicine 20(3), 249–55. Thompson S. (1997) Thriving at Work: a New Agenda for Occupational Health, Health & Safety Practitioner, September, 40–1. Thompson S. (1998) A New Agenda for Occupational Health, Health & Safety Practitioner, 40–2. Tinson S. (1997) Health Principles, Practice Nurse, 389–90. Waghorn J., Fordyce I. and Russell E. (1993) Promotion of Health in the Scottish Work-Place, Health and Hygiene 14, 49–54. White S. (1997) Evidence-Based Practice in Nursing: the New Panacea? British Journal of Nursing 6(3), 175–7. Wilkinson C. (1999) Management, the Workplace and Health Promotion: Fantasy or Reality? Health Education Journal 58, 56–65. Williams S., Michie S. and Pattani S. (1998) Improving the Health of the NHS Workforce, London: Nuffield Trust. WHO (1946) Constitution: Basic Document, Geneva: WHO.
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Rehabilitation
Dorothy Ferguson
Introduction Contributing to the rehabilitation process has been a recognised part of the occupational health nurse’s role for many years. In 1982 the World Health Organisation listed ‘measures to encourage workers to use rehabilitation services at as early a stage as possible’ as being an essential function of an occupational health service (WHO 1982 p. 22). Slaney (2000) details a Royal College of Nursing leaflet, accessed in 1947, in which reference is made to the duties of industrial nurses in relation to employees returning after illness. Charley (1954) emphasises the important role played by industrial nurses throughout the process of recovery. More recently, the Royal College of Nursing (RCN) included ‘develop rehabilitation programmes for the sick or injured’ within their stated aims of an occupational health service (RCN 1991). Dorward (1993) identifies ‘rehabilitation and resettlement into work’ as one of twelve functions of the occupational health nurse, while Fingret and Smith (1995) suggest that occupational health professionals, being the only professionals with knowledge of both the medical condition and the job, have a particularly important role to play in this aspect of care. In a joint document, the Society of Occupational Health Nursing and the Association of Occupational Health Nurse Practitioners (UK) failed to acknowledge this role of occupational health nurses. It could, however, be argued to be implicit within the other functions addressed within the text (Society of Occupational Health Nursing and the Association of Occupational Health Nurse Practitioners (UK), 1997). Within the Occupational Health Nursing Edited by K. Oakley. C 2008 John Wiley & Sons, Ltd
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context of tackling accidents in the workplace, the ability of the occupational health nurse to ‘manage the rehabilitation process’ is recognised by the English National Board for Nursing, Midwifery and Health Visiting and the Department of Health (1998). This ability can, presumably, be generalised to other occupational contexts. Harrington et al. (1998) note that managing rehabilitation is one element of the work of occupational health departments. There would, then, appear to be support for the suggestion that occupational health nurses should be involved in, and actively contribute to, the process of rehabilitation. Strategy documents, such as one by the Health and Safety Commission (2004), emphasise the importance placed on rehabilitation in the context of the government’s agenda. This chapter, having first defined terms, explores this aspect of the occupational health nurse’s role and discusses some of the challenges that arise for the practitioner from involvement in rehabilitation.
Definition of Terms Before exploring the part played by the occupational health nurse in rehabilitation, it is essential to clarify the meaning given to the terms used in this context. Specific definitions of these terms are rare within the occupational health literature, most authors appearing to presume that some universally accepted definition already exists. ‘Resettlement’, although less commonly used in current practice, appears in some occupational health literature in tandem with ‘rehabilitation’ and so it is important to clarify their separate meanings. More recent literature refers to ‘vocational rehabilitation’, so this term is also explored. First, rehabilitation will be defined.
Rehabilitation Sinclair and Dickinson (1998) describe rehabilitation as a process that aims to restore personal autonomy in those aspects of daily living which clients, or their carers, consider most relevant. Floyd and Landymore (2000), while agreeing that rehabilitation is a process, propose that it is directed at ‘maximum health gain, the (re) establishment of skills, and job placement or retention in open employment.’ Lysaght (2004) indicates that one aim of rehabilitation is ‘to restore injured workers to productive working roles.’ The definitions of rehabilitation within the more general nursing literature offer some relevant insights into the process. Harris (2000), for example, suggests that rehabilitation is about rebuilding lives and takes place in three stages: preventing complications, promoting independence and maintaining independence. Hayes (1998) describes the process as a continuation of the assessment process with the aim of enabling
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patients to achieve their maximum potential. Wade (1998) proposes that the whole process of rehabilitation, which seeks to restore the person to a condition in which they can resume a near-normal life, comprises three activities: reactivation, resocialisation and reintegration. These activities can all be related to the work setting and so contribute to rehabilitation within occupational health. Rehabilitation, therefore, is here defined as the process by which an individual patient/client is enabled to achieve their maximum potential following illness, injury or impairment. Within occupational health this will include any preparation necessary to enable the employee to return to work, the actual return to work and the period of support required thereafter.
Resettlement The term ‘resettlement’ most frequently appears in the literature in conjunction with ‘rehabilitation’ and is now rarely used in practice. A remnant of an earlier approach, when sheltered workshops and employment rehabilitation centres existed within the United Kingdom, resettlement reflected the medical model of disability, centred on the incapacity or disease. A social model, focusing on the ability and capability of the individual, is now more commonly adopted (Finkelstein and Stuart 1996). The social model of disability views disability as a social construction, reduces the power of the medical model and facilitates a holistic interpretation of the situation facing the disabled person (Finkelstein 1993). Resettlement would appear to be a term, previously used within the context of retraining and redeploying employees through a system of sheltered workshops and centres, to describe the process of enabling an individual to function within some alternative work setting. The adoption of the social model makes the workplace the appropriate focus for the rehabilitation process, the aim being to remove any barriers to the employee’s return to work and to adapt the workplace to facilitate this, rather than to retrain the worker for an alternative setting. Resettlement should be seen as an integral part of the rehabilitation process, focusing specifically on the return to work of the employee and their reintegration into the workforce, and not as a separate element. Situations where return to the original job is not possible may still occur, as a result of either the demands of the specific work or the nature of the impairment. Gokal and Hobson (2000), for example, state that employees with irreversible renal failure should not work as firefighters or police on the beat because of the high energy demands, extended hours and flexibility required by emergency duty. When an employee is unable to return to their original post there should be an appropriate plan for preparing them for a new role. This may include elements of retraining, the need varying with the individual and the post.
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Rehabilitation in such situations requires a similar approach to that for employees returning to their original post. It would seem then, that the term ‘resettlement’ is, to an extent, redundant. Resettlement is an integral part of the rehabilitation process in every context.
Vocational Rehabilitation One qualitative study, focused on vocational rehabilitation, identifies the lack of clarity which surrounds this term (Irving et al. 2004). The authors see ‘the process of getting people who have been sick or injured back to work’ as forming the core of vocational rehabilitation (Irving et al. 2004 p. 3). According to Frank and Swaney (2003 p. 522), vocational rehabilitation describes an approach ‘now favoured by disability rights groups, the Government and the health professions’, the aim of which is ‘to facilitate working for those who are willing and potentially able’. They apply the term in the context of those whose ill health or disability has excluded them from the workplace. Such a definition occurs frequently in the literature. Beaumont and Quinlan (2002 p. 293), however, offer a wider one, suggesting that ‘vocational rehabilitation is the restoration to health and capability to work of individuals incapacitated by mental or physical disease, or by injury.’ This may refer either to employees who become unfit or to those who have been unemployed as a consequence of their health status. Such a definition indicates that any rehabilitation process to which the occupational health nurse contributes could be classified as vocational rehabilitation. To some extent, vocational rehabilitation in the context of those who have been unemployed could be seen to reflect aspects of resettlement, one important difference being that, in most contexts, vocational rehabilitation will occur within the workplace and not in separate sheltered workshops.
WHO Classification Before moving on to explore the occupational health nursing role in this process, other terms that require some exploration are ‘impairment’, ‘disability’ and ‘handicap’. Although the use of these terms is diminishing, they do still appear in literature and are employed in some care contexts. These terms were defined by the World Health Organisation (WHO 1980) to offer some consistency in classification. According to the WHO classification, illness or injury causes impairment. If the impairment leads to any reduction in, or loss of, ability to perform an activity, then that constitutes disability. Handicap is a social disadvantage and results from an impairment or a disability that limits or prevents fulfilment of a normal role. Harris (2000) interprets the WHO classification as meaning that ‘impairment relates to deficiencies at the organic level, disability relates to the functional consequences of organic impairment and
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handicap relates to the social consequences of deficient ability.’ It should be noted that, within the context of the WHO classification, impairment will not necessarily result in disability and that disability need not always lead to handicap. The social construction of disability is also of relevance when considering these definitions (Finkelstein 1993; Finkelstein and Stuart 1996; Oliver 2004). Rehabilitation is of relevance to impairment, disability and handicap and the occupational health nurse has a part to play across the spectrum.
Disability Discrimination Act 1995, 2005 The Disability Discrimination Act 1995 (DDA) and the Disability Discrimination Act 2005 (DDA 2005) must be considered when rehabilitation is discussed. In terms of the DDA, a physical or mental impairment that has a substantial and long-term adverse effect on a person’s ability to carry out normal daily activities constitutes a disability. This echoes the WHO’s inclusion of reduction in, or loss of, ability to perform an activity within the definition of disability, but extends it to include ‘substantial and long-term’. The DDA then applies to those who are more severely affected and who are affected over a long period of time, and the occupational health nurse should be actively involved in the rehabilitation of any such employees. The DDA 2005 removes the requirement in the DDA that a mental illness must be ‘clinically well recognised’, thus bringing mental illness into line with the requirements for all other mental and physical impairments. The other notable change in the DDA 2005 is that those with HIV, cancer or multiple sclerosis are covered from the point of diagnosis, rather from the point at which their condition has an adverse effect on their activities. The DDA is applicable in the pre-employment situation and aims to prevent discrimination on the grounds of disability. From 1 December 1998, the employment provisions of the DDA were extended to employers with 15 or more employees, down from the previous limit of 20 or more. The DDA brought a major shift of emphasis, with more onus being placed on the employer to make reasonable adjustments in the workplace to facilitate disabled employees. The one-time 3 % quota of registered disabled employees has been revoked. People are no longer required to register disabled unless they wish to do so. The Disability Services Team (DST) and the Disability Employment Adviser (DEA) (formerly the Disablement Resettlement Officer (DRO)) are based at local Job Centres and have access to funds via the Access to Work initiative (for clear and concise exploration of the DDA and its application, see Ballard 2000 and Howard and Cox 2000.) The occupational health nurse has a contribution to make to the rehabilitation process of both those defined as ‘disabled’ within the terms of the DDA and those so defined by the WHO classification, i.e. those
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on whom the impact of impairment is less severe or who are affected only in the short term.
The Rehabilitation Process The benefits of effective rehabilitation extend beyond specific considerations of the health of the employee, whose early return to work should help minimise the economic and social disruption experienced by themselves and their family. Indeed, Floyd and Landymore (2000) suggest that in some cases appropriate rehabilitation may enable the employee to remain in work during the rehabilitation process, thus benefiting the employee, the workforce and the employer. Economic evidence for effective rehabilitation comes from the RCN (2000), which suggests that early, workplace-focused rehabilitation programmes can reduce the cost of both ill-health retirements and sickness absence. Pickvance (1999) points out that sick workers are expensive to insurers as well as to the government. In many countries, he reports, employers’ liability insurers have attempted to reduce compensation bills for lost wages by encouraging their clients to rehabilitate their employees. Interest in rehabilitation has grown as awareness of the costs to employers has increased. The Chartered Institute of Personnel and Development (2006), in a survey of employee absence, found that, ‘on average, sickness absence costs employers £598 per employee every year and employee absence costs employers eight working days for every member of staff per year.’ Rehabilitation should focus on the employee and, by reducing costs such as those incurred through sickness absence, will benefit both the employee and the employer. It is essential that the occupational health nurse differentiates between those absences resulting from some form of incapacity and other short-term absences, in which context their contribution may be a very different one. O’Reilly (2006) distinguishes between the occupational health nurse’s role in the rehabilitative process, which may include case management, and in the management of absence. The provision of rehabilitation is multi-disciplinary (HSC 2000; Beaumont and Quinlan 2002) and should involve the professions working as a team (Snashall & Poulson 2000). There is also the crucial role of the employer and/or the manager in facilitating, funding or supporting the rehabilitation. Effective communication between the multi-disciplinary team, working in close cooperation, facilitates the rehabilitation process (Hayes 1998; Reynolds 2005). Pritchard (1995) suggests that effective teamwork is not difficult to achieve but requires cooperation from all the team members working towards a common goal: in this context, the rehabilitation of the employee. Some organisations have rehabilitation policies associated with their sickness absence policies. The Employers’ Forum on Disability (1998) subscribes to a rehabilitation policy for
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employees following long-term sickness absence. This Forum (1999) also recommends that employers establish a policy framework for disability management. Gates (2000) articulates the important role that supervisors can play in the rehabilitation process. Holroyd (2000) observes that organisations which represent disabled people or those with medical conditions have a wealth of experience of the employment challenges faced by their members and how to overcome them. This may include voluntary organisations, pressure groups and self-help groups as well as professionally run support groups, details of which can be found in local libraries, telephone directories, on the Internet and via national directories. Such organisations could be a valuable source of information for employers, occupational health staff and, indeed, employees, and the potential to consult them should be remembered within the team. The rehabilitation team may thus extend to include voluntary organisations, employers and managers, working in partnership with the relevant health and social care professionals, thus demanding skilled communication and liaison from the occupational health nurse. Leach (1996) suggests that disabled people, by demanding the right to control their own lives, have challenged the power of those professionals who previously made a living out of disability. There is, he warns, a danger that those professions may learn a new language to accommodate the social model but not significantly change their attitudes and practices. Within the context of occupational health, rehabilitation should be focused on the employee, whose needs should dictate the process and whose views must be respected. This relates as much to those with short-term impairment as to those with long-term disability. All those professions involved in the process should collaborate to facilitate the employee’s rehabilitation. Gardner and Campanella (1997) suggest that the rehabilitation process is the means by which outcomes are achieved. The identification of the outcomes becomes the responsibility of the individual; in the occupational health context, the employee. The professional’s role, Gardner and Campanella argue, is to listen and to understand the context and the reason for the employee’s decision, thus emphasising the central role of the employee and the supportive role of the professions. This is endorsed by Shaw et al. (2004), who note that including the consumer in the process leads to better health outcomes. There is no single process for rehabilitation, every employee requiring their own unique plan. This will be influenced by the physical, social and psychological needs of the employee as well as by the cause of the impairment, the job undertaken and the work setting. Full assessment of the individual should form the starting point of the rehabilitation process. This may be within the context of the pre-employment assessment of an applicant with a disability under the terms of the DDA, or during the health assessment of an employee who becomes unwell or
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sustains an injury in the workplace. Hayes (1998) emphasises the need to commence rehabilitation as soon as possible, supporting Bearer’s observation (1993) that the process should never be delayed until after the period of acute care is over. Early intervention is preferred, whether or not the impairment or injury is work related, with the aim of restoring the person to the highest possible level of function as soon as is appropriate (RCN 2000). In their systematic review of literature, Waddell and Burton (2001 p. 129) note strong evidence ‘that the longer a worker is off with low back pain, the lower their chance of ever returning to work.’ A randomised control trial, funded by the Department for Work and Pensions, undertaken in six areas of the United Kingdom, tested three interventions aimed at increasing the return to work of those off sick for six weeks or more (Purdon et al. 2006). The finding ‘that none of the interventions tested were successful in improving the return-to-work rates of those off sick’ emphasises the need for prompt intervention and the early implementation of the rehabilitation process. This links in with a good sickness absence management policy. The occupational health nurse, drawing on nursing knowledge of the disease process and awareness of the demands of the specific job, is uniquely placed to commence the process, in collaboration with the employee and other relevant professionals (Floyd and Landymore 2000), and to employ communication skills, which Reynolds (2005) stresses are essential for successful rehabilitation. In addition to studying the individual’s job description, a detailed job analysis should be undertaken (Floyd and Landymore 2000). All areas of occupational performance that require the physical doing of activity should be assessed and rehabilitation should address all the roles that the individual fulfils (Innes 1997). When permitted by the employee’s condition, and in consultation with the manager involved, the assessment may be undertaken within the work setting. Jones and Hughes (2000), for example, point out that the fairest way to judge the capability of an employee wearing a hearing aid is under the actual working conditions. (They also note that most occupations are compatible with the wearing of a hearing aid, although only certain aids are safe in coalmines or other flammable atmospheres.) The interaction between the person and their environment should also be considered; Innes and Staker (2003) warn that the assessment of performance components in isolation can be problematic. Following assessment, rehabilitation can be planned to meet the identified needs of the individual employee. Setting realistic goals helps motivate the employee, as does involving them in the decision-making process (Hayes 1998; Shaw et al. 2004). Motivation of the employee influences the outcome of the rehabilitation process. The occupational health nurse, by working in partnership with the employer and/or manager, can ensure that the employee receives encouragement from a variety of sources and thus enhance their motivation.
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In the field of myocardial infarction, Petrie et al. (1996) demonstrated that attendance at the rehabilitation course was significantly related to a stronger belief during admission that the illness could be cured or controlled. They further demonstrated that return to work within six weeks was significantly predicted by the perception that the illness would last a short time, and that a patient’s belief that their heart disease would have serious consequences was significantly related to later disability. Work focused on patients with stroke has demonstrated that motivation influences clients’ participation in rehabilitation, those who are highly motivated being more likely to view rehabilitation as an important means to recovery and to become actively involved in the process (MacLean et al. 2000). While these studies are not specific to the occupational health setting, they do highlight the impact that motivation can have on the rehabilitation process and emphasise the need to encourage and motivate the employee from the outset of the process. Involvement in the rehabilitation process requires the application of all the skills of the occupational health nurse, not merely their nursing knowledge and awareness of the workplace. Familiarity with the legislation, undertaking of relevant risk assessment and application of ergonomic principles will contribute to the process. Collaboration with other professionals will require the occupational health nurse to work in partnership and to communicate with these colleagues. Skills in liaison are demonstrated as the occupational health nurse communicates with relevant external agencies, including the voluntary sector, and develops partnerships with internal resources, for example the manager, employer and human resources, all of whom contribute to the rehabilitation process. The approach to the employee and, where relevant, the family is facilitated by the use of counselling and communication skills. The nurse’s health promotion skills are also applied within the rehabilitation context. Ferguson and Whyte (1996) offer rehabilitation as an example of the tertiary level of care and prevention, aiming to minimise the effects of disease and to promote adaptation. Ewles and Simnett (1999) suggest that rehabilitation programmes contain a considerable amount of tertiary health education, the aim of which is to avoid unnecessary restriction and complications. They do, however, acknowledge that it is not always easy to separate primary, secondary and tertiary levels of education. Health promotion should, according to Downie et al. (1996), be empowering and encourage people to develop autonomy. Rehabilitation, therefore, may be viewed as a health promotion activity through which the occupational health nurse seeks to empower the employee and thus enhance positive health. This may involve health education, health protection and activities that prevent any deterioration in health status. Education within the context of rehabilitation may go beyond the individual employee to include the employer or the work colleagues.
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If socially-erected barriers lead to the social construction of disability, then education within the workplace should seek to reduce, if not remove, such barriers. Social support is one of several barriers to early return to work identified by Duijn et al. (2004). Barnes (1996) states that his visual impairment has caused him few real difficulties but that the problems he has encountered have been socially created. Napolitano (1996) warns that removing one barrier can create another, offering the example of toilets provided for the disabled being frequently kept locked. She also draws attention to the need to consider the psychological dimension of provision, commenting on the number of buildings where access via ramps is available only at the rear. Education of employers may help to reduce the inequality that such provision perpetuates. The occupational health nurse has the potential to impact on sociallyconstructed barriers and so to assist in the early rehabilitation of the employee.
Case Studies Occupational health nurses have a major role within the rehabilitation process. Their involvement should commence as early as possible within the process but will vary with the individual situation. There will be collaboration with other professionals, the employee being central to the setting of goals and the planning of the process. The aim is to empower the employee to achieve their maximum potential and to support them through this time. All the skills of the occupational health nurse will contribute to the process. Each employee’s rehabilitation will be unique. The diversity of rehabilitation may be indicated by exploration of a range of case studies.
Case Study 1 Sue is employed as a secretary within a large organisation and has been with this employer since she left school 11 years ago. Sue’s workstation was assessed, in accordance with the 1992 Display Screen Equipment Regulations (HSE 1992), six years ago and found to meet the requirements. Sue recently complained about intermittent periods of tingling in both wrists. This was drawn to the attention of the occupational health nurse, who arranged to speak with Sue, initially within the occupational health department, thus ensuring that confidentiality was respected in accordance with the NMC guidelines (NMC 2004). The initial health assessment indicated that Sue had become aware of the tingling sensation developing over the past few months, never having had such symptoms before. Sue reported that the discomfort was relieved by rest. The health assessment did not reveal any other associated problems. During the discussion the occupational health nurse discovered that Sue
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had moved into a new office two years ago. The new workstation had not been assessed. The occupational health nurse advised Sue on relevant conditioning exercises and discussed the need for regular breaks during the working day. With her consent, the occupational health nurse went with Sue to her workstation, to review the various aspects of Sue’s job and to undertake postural and ergonomic assessment (HSE 1992; English and Bird 2000). Based on the findings, a new chair and a footrest were ordered. These interventions were accompanied by comparatively minor alterations to the workstation layout. Regular contact was maintained between Sue and the occupational health nurse throughout this time and over the following months. The symptoms gradually resolved. All staff were reminded of the necessity of having any new workstation assessed, which may have helped prevent other employees from developing similar problems. The occupational health nurse, by intervening promptly in this situation, may have prevented a period of absence. Keyserling (1995) notes that discomfort, such as that manifested by Sue, may be the precursor of more serious conditions. Sue was impaired within the terms of the WHO classification. She was enabled to remain at work and rehabilitated within the workplace, thus saving both Sue and the employer the potential economic implications of sickness absence. In accordance with NMC guidelines (NMC 2004), a record of the entire process, from initial assessment through intervention to follow up, was created within the occupational health department. Dimond (2000) stresses the importance of maintaining high standards in record keeping, both to ensure good quality of care for the employee and to protect the practitioner. This is of importance within rehabilitation as in all other aspects of practice.
Case Study 2 Crowther et al. (2001), in their review of literature, note that although unemployment rates amongst those with a severe mental illness are high, most do want to work. Following the violent death of his young brother eight years previously, Jay became depressed and lost his job as a shop assistant. After three years of unemployment he was referred for a psychiatric opinion, received support and made a slow but steady recovery. When he applied for the post of porter within a large department store he was still on medication (although his dose was being steadily decreased) and he still attended the outpatient department. At pre-employment assessment, Jay openly discussed his experience with the occupational health nurse. He was optimistic that he would soon stop taking any medication. According to the DDA, Jay could be defined as disabled as he had had a mental impairment that had a longterm effect on his ability to carry out normal day-to-day activities. Jay
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could not be rejected simply because of his past history (Howard 2000). He could not, within the terms of the DDA, be treated less favourably because of that disability and so was assessed by the same criteria as those applied to all other applicants. The DDA 2005 would have entitled Jay to protection from discrimination on the grounds of his illness had he applied for work before the clinical diagnosis was made, but he had not been aware of that provision. The occupational health nurse’s knowledge of the requirements of the post Jay had applied for enabled identification of the skills required. Cox (1993) demonstrated that the psychological environment should be included in the riskassessment process, and this was of relevance within this context. Health assessment, knowledge of the skills required for the job and familiarity with the work environment were all factors contributing to the occupational health nurse’s decision-making process. The occupational health nurse, with Jay’s consent, worked in collaboration with the general practitioner, the psychiatric nursing team and the occupational therapist to facilitate Jay’s return to employment. ‘Work hardening’, a highly-structured and goal-orientated process which uses conditioning tasks to gradually improve function, can provide a transition between acute care and return to work (Perron and McKay 1997; Schonstein et al. 2002). The occupational health nurse, through collaboration with the other team members, participated in this process and facilitated its implementation within the work setting. Jay was thus able to return to the world of work, supported by the professionals involved in his care. The employer successfully recruited a highly-motivated member of staff and complied with the law.
Case Study 3 Anna had been off sick for several months when the occupational health nurse, newly arrived in the company, made contact with her. Anna worked as a packer in the bottling hall of a distillery and had injured her back when she tripped over a loose cable at home. Waddell and Burton (2001 p. 128) recommend that a worker with low back pain should be helped to continue at work, or to return as soon as possible. They also note the importance of liaison between occupational health and other primary-care health professionals. However, the general practitioner had advised Anna to stay off work, to rest and ‘not to worry’. No other professionals had been involved in her care. With the consent of the employer and the employee, the occupational health nurse visited Anna at home. Anna felt that she was in too much pain from her back to return to all the pressures of work. She thought her job was hard physical work and sometimes hectic. MacDonald and Haslock (2000) note that it is essential to base rehabilitation programmes for those suffering from back pain on a bio-psychosocial model,
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incorporating a holistic view of home and work. With this in mind, the occupational health nurse assessed Anna’s health, noting that this was the first episode of back pain. The tasks necessary to undertake work were discussed and those aspects which Anna felt she was currently unfit to tackle were identified. During the discussion it became clear that Anna was worried about returning to work as she believed that back problems only ever got worse. The health promotion and education skills of the occupational health nurse enabled her to advise Anna about current thoughts on back care and to encourage her to accept an appointment with the physiotherapist at work. Thus, based on the assessment of the employee, the job and the skills required, the occupational health nurse was able to prepare a plan suitable for the employee to enable rehabilitation. Collaborating in her care, the physiotherapist and the nurse initiated an exercise programme for Anna. She visited the workplace and the need for a chair of an appropriate height was identified. Negotiation with the employer made it possible for Anna to return to work on a part-time basis, building up to full-time hours over an agreed period. As the conveyor belt was a fixed structure, the height of which could not be adjusted, a step – designed specifically for Anna – was provided to assist posture. It was unfortunate that there had been no earlier contact with the occupational health department. Prompt intervention might have reduced the length of the sickness absence, reduced the economic cost for both Anna and the employer and minimised the back pain that she experienced.
Conclusion Occupational health nurses have an important contribution to make to the rehabilitation of both existing and potential employees. The rehabilitation process draws on the entire range of skills that occupational health nursing demands. Early intervention, full assessment and careful planning are essential. The process will be unique to each employee and should be based on a careful health assessment, job analysis and comparison of the skills of the individual. The actions taken during the rehabilitation process will be dictated by the needs of the individual. Team working should feature in the process whenever appropriate. The Health and Safety Commission (HSC 2000) aims to improve the work opportunities for people whose health or disability currently prevents them from working and to increase awareness of opportunities for rehabilitation and return to work. Occupational health nurses should be prepared for and involved in facilitating the meeting of these targets.
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References and Further Reading Ballard J. (2000) The Disability Discrimination Act, Managing Disability at Work, IRS Management Review 18, 28–32. Barnes C. (1996) Visual Impairment. In: Hales G. (ed) Beyond Disability, London: Sage, 36–44. Beaumont D. and Quinlan R. (2002) Vocational Rehabilitation, Case Management and Occupational Health, Occupational Medicine 52(6), 293–5. Bearer D. (1993) Reviews in Clinical Gerontology 3, 169–86. Charley I. (1954) The Birth of Industrial Nursing, London: Bailliere Tindall. Chartered Institute of Personnel and Development (2006) Absence Management: Survey Report, London: CIPD, www.cipd.co.uk/surveys. Cox T. (1993) Stress Research and Stress Management: Putting Theory to Work, London: HSE. Crowther R., Marshall M., Bond G. and Huxley P. (2001) Vocational Rehabilitation for People with Severe Mental Illness, The Cochrane Database of Systematic Reviews, Issue 2, London: John Wiley and Sons. Dimond B. (2000) Legal Issues Arising in Community Nursing, 7: Record Keeping, British Journal of Community Nursing 5(6), 297–9. Disability Discrimination Act 1995. Disability Discrimination Act 2005. Disabled Living Foundation web site, www.dlf.org.uk. Disability Rights Commission web site, www.drc-gb.org. Dorward A.L. (1993) Managers’ Perceptions of the Role and Continuing Education Needs of Occupational Health Nurses: Research Paper 34, Sudbury: HSE. Downie R.S., Tannahill C. and Tannahill A. (1996) Health Promotion: Models and Values, 2nd edn, Oxford: OUP. Duijn M., Miedema H., Elders L. and Burdof A. (2004) Barriers for Early Return to Work of Workers with Musculoskeletal Disorders According to Occupational Health Physicians and Human Resource Managers, Journal of Rehabilitation 14(1), 31–40. DWP (2004) The Framework for Vocational Rehabilitation, www.dwp.gov.uk/ publications/vrframework. Employers’ Forum on Disability (1998) Employers’ Briefing Paper 5: A Practical Guide to Employment Adjustments for People with Mental Health Problems, London: EFD. Employers’ Forum on Disability (1999) Employers’ Briefing Paper 8: a Practical Guide to Disability Management and the Medical Adviser, London: EFD. English C. and Bird H.A. (2000) Rheumatalogical Disorders. In: Cox R.A.F., Edwards F.C. and Palmer K. (eds) Fitness for Work: the Medical Aspects, 3rd edn, Oxford: OUP, 274–88. English National Board for Nursing, Midwifery and Health Visiting and Department of Health (1998) Occupational Health Nursing: Contributing to Healthier Workplaces. London: ENBNMHV/DoH.
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Ewles L. and Simnett I. (1999) Promoting Health: a Practical Guide, 4th edn, London: Bailliere Tindall. Ferguson D. and Whyte L. (1996) Levels of Care and Prevention: Implications for Practice. In: Twinn S., Roberts B. and Andrews S. (eds) Community Health Nursing, Oxford: Butterworth Heinemann, 156–68. Fingret A. and Smith A. (1995) Occupational Health: a Practical Guide for Managers, London: Routledge. Finkelstein V. (1993) Disability – a Social Challenge or an Administrative Responsibility? In: Swain J., Finkelstein V., French S. and Oliver M. (eds) Disabling Barriers – Enabling Environments, London: Sage, 34–43. Finkelstein V. and Stuart O. (1996) Developing New Services. In: Hales G. (ed) Beyond Disability, London: Sage, 170–87. Floyd M. and Landymore D. (2000) Vocational Rehabilitation Services. In: Cox R.A.F., Edwards F.C. and Palmer K. (Eds) Fitness for Work: the Medical Aspects, 3rd edn, Oxford: OUP, 62–80. Frank A.O. and Sawney P. (2003) Vocational Rehabilitation, Journal of the Royal Society of Medicine 96(11), 522–3. Gardner J. and Campanella T. (1997) Challenging Tradition: Measuring Quality as Outcomes for People. In: Pratt J. and Jacobs K. (eds) Work Practices: International Perspectives, Oxford: Butterworth Heinemann, 247–66. Gates L.B. (2000) Workplace Accommodation as a Social Process, Journal of Occupational Rehabilitation 10(1), 85–98. Gokal R. and Hobson J. (2000) Renal and Urological Disease. In: Cox R.A.F., Edwards F.C. and Palmer K. (Eds) Fitness for Work: the Medical Aspects, 3rd edn, Oxford: OUP, 399–414. Harrington J.M., Tar-Ching A.W., Gardiner K. and Gill F.S. (1998) Occupational Health, 4th edn, Oxford: Blackwell Science. Harris M. (2000) The Patient in Need of Rehabilitation. In: Alexander M.F., Fawcett J.N. and Runciman P.J. (eds) Nursing Practice, 2nd edn, London: Churchill Livingstone, 983–98. Hayes A. (1998) Keeping Active. In: Marr J. and Kershaw B. (eds) Caring for Older People, London: Arnold, 71–88. HSC (2000) Securing Health Together: a Long-Term Occupational Health Strategy for England, Scotland and Wales, Sudbury: HSE. HSC (2004) A Strategy for Workplace Health and Safety in Great Britain to 2010 and Beyond, Sudbury: HSE, www.hse.gov.uk/aboutus/hsc/ strategy2010.pdf. HSE (1992) Display Screen Equipment Work: Health and Safety (Display Screen Equipment) Regulations 1992: Guidance to the Regulations, London: HMSO. HSE (2003) Job Retention and Vocational Rehabilitation: the Development and Evaluation of a Conceptual Framework: HSE Research Report 106, London: HSE. Holroyd K. (2000) Disability: Employment Advice and Occupational Health Resources, Occupational Health Review 88, 29–33. Howard G. (2000) Dangerous Assumptions, Occupational Health 52(10), 12–13.
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Howard G.S. and Cox R.A.F. (2000) The Disability Discrimination Act 1995. In: Cox R.A.F., Edwards F.C. and Palmer K. (eds) Fitness for Work: the Medical Aspects, 3rd edn, Oxford: OUP, 42–61. Innes E. (1997) Work Programmes to Enhance Motor and Neuromusculoskeletal Performance Components. In: Pratt J. and Jacobs K. (eds) Work Practices: International Perspectives, Oxford: Butterworth Heinemann, 224–44. Innes E. and Staker L. (2003) Workplace Assessments and Functional Capacity Evaluations: Current Beliefs of Therapists in Australia, Work 20, 225–36. Irving A., Chang D. and Sparham I. (2004) Developing a Framework for Vocational Rehabilitation: Qualitative Research, London: HMSO. Jones C.M. and Hughes K.B. (2000) Hearing and Vestibular Disorders. In: Edwards F.C. and Palmer K. (eds) Fitness for Work: the Medical Aspects, 3rd edn, Oxford: OUP, 182–209. Keyserling W.M. (1995) Occupational Ergonomics: Promoting Safety and Health through Work Design. In: Levy B.S. and Wegman D.H. (eds) Occupational Health: Recognising and Preventing Work-Related Disease, 3rd edn, Boston: Little, Brown, 161–76. Leach B. (1996) Disabled People and the Equal Opportunities Movement. In: Hales G. (ed) Beyond Disability, London: Sage, 88–95. Lysaght R.M. (2004) Approaches to Worker Rehabilitation by Occupational and Physical Therapists in the United States: Factors Impacting Practice, Work 23, 139–46. MacDonald E. and Haslock I. (2000) Spinal Disorders. In: Edwards F.C. and Palmer K. (eds) Fitness for Work: the Medical Aspects, 3rd edn, Oxford: OUP, 210–34. MacLean N., Pond P., Wolfe C. and Rudd A. (2000) Qualitative Analysis of Stroke Patients’ Motivation for Rehabilitation, British Medical Journal 321, 1051–4. Napolitano S. (1996) Mobility Impairment. In: Hales G. (ed) Beyond Disability, London: Sage, 30–5. NMC (2004) The NMC Code of Conduct: Standards for Conduct, Performance and Ethics, www.nmc-uk.org. Oliver M. (2004) Disability and Dependency: a Creation of Industrial Societies? In: Swain J., Finkelstein V., French S. and Oliver M. (eds) Disabling Barriers – Enabling Environments, 2nd edn, London: Sage, 49–60. O’Reilly S. (2006) Attending to Absence, Occupational Health 58(5), 13–15. Perron J. and McKay M. (1997) Current Models and Trends in Work Practice Delivery. In: Pratt J. and Jacobs K. (eds) Work Practices: International Perspectives, Oxford: Butterworth Heinemann, 39–68. Petrie K.J., Weinman J., Sharpe N. and Buckley J. (1996) Role of Patients’ View of their Illness in Predicting Return to Work and Functioning after Myocardial Infarction: Longitudinal Study, British Medical Journal 312, 1191–4. Pickvance S. (1999) Occupational Health Issues and Strategies: a View from Primary Care. In: Daykin N. and Doyal L. (eds) Health and Work: Critical Perspectives, Basingstoke: Macmillan, 220–37.
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Pritchard P. (1995) Learning to Work Effectively in Teams. In: Owens P., Carrier J. and Horder J. (eds) Interprofessional Issues in Community and Primary Health Care, Basingstoke: Macmillan, 205–32. Purdon D., Stratford N., Taylor R., Natarjan L., Bell S. and Whittenburg D. (2006) Impacts of the Job Retention and Rehabilitation Pilot, Leeds: DWP. Reynolds F. (2005) Communication and Clinical Effectiveness in Rehabilitation, London: Elsevier. RCN (1991) A Guide to an Occupational Health Nursing Service, Harrow: RCN. RCN (2000) Workability – Injured, Ill and Disabled Nurses Can Return to Work, London: RCN. Schonstein E., Kenny D.T., Keating J. and Koes B.W. (2002) Work Conditioning, Work Hardening and Functional Restoration for Workers with Back and Neck Pain, The Cochrane Database of Systematic Reviews, Issue 4, London: John Wiley and Sons, Ltd. Shaw L., MacKinnon J., McWilliam C. and Sumsion T. (2004) Consumer Participation in the Employment Rehabilitation Process: Contextual Factors and Implications for Practice, Work 23, 181–92. Sinclair A. and Dickinson E. (1998) Effective Practice in Rehabilitation: the Evidence of Systematic Reviews, London: King’s Fund. Snashall D. and Poulson B. (2000) Trauma. In: Edwards F.C. and Palmer K. (eds) Fitness for Work: the Medical Aspects, 3rd edn, Oxford: OUP, 255–73. Slaney B.M. (2000) Nursing at Work, Bushey: Slaney. Society of Occupational Health Nursing and Association of Occupational Health Nurse Practitioners (UK) (1997) Occupational Health Nursing: a Professional Perspective, London: SOHN/AOHN. Spine Health web site, www.Spine-Health.com. Waddell G. and Burton A.K. (2001) Occupational Health Guidelines for the Management of Low Back Pain at Work: Evidence Review, Occupational Medicine 51(2), 124–35. Wade L. (1998) Adapting to Change. In: Marr J. and Kershaw B. (eds) Caring for Older People, London: Arnold, 254–69. Wind H., Gouttebarge V., Kuijer P.P.F.M. and Frings-Dresen M.H.W. (2005) Assessment of Functional Capacity of the Musculoskeletal System in the Context of Work, Daily Living, and Sport: a Systematic Review, Journal of Occupational Rehabilitation, 15(2), 253–72. WHO (1980) International Classification of Impairments, Disabilities and Handicaps, Geneva: WHO. WHO (1982) Evaluation of Occupational Health and Industrial Hygiene Services, EURO Reports and Studies 56, Geneva: WHO. WHO (2006) Declaration on Workers Health, www.who.int/occupational health/Declarwh.pdf.
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Case Management
Philip Roy Richardson
Introduction Over the years the changing responsibilities of the occupational health nurse, and their changing relationship with the patient, have been well documented. In fact the term ‘patient’ is rarely used nowadays in the occupational health environment and employees are more likely to be known as ‘clients’ or ‘cases’; in certain types of business, somewhat surprisingly I have heard the use of the terms ‘associates’ and ‘partners’. The relationship between the employer and the OHN has also changed. OHNs no longer have a purely clinical function concentrating on pre-employment screening and health surveillance or treatment service issues. Instead, these functions are gradually being fulfilled by OH technicians and community support workers (Perry and Walton 2005), allowing OHNs to change their focus and move away from traditional OH medical models to a multi-disciplinary approach (Downey 2003). This situation enables OHNs to fulfil many of the roles formerly undertaken by physicians, roles in which OHNs traditionally have little experience or competence (Bannister 2006). These include fitness-to-work assessments and rehabilitation planning. For this reason, the prospect of ‘case management’ for a student or newly-qualified OHN may seem extremely daunting, as senior autonomous OH practitioners often work diversely. Case management will also depend on the type and size of the organisation and the management structure in place. This has led to the development of an OHN competency framework, setting out the skills required to perform this developing role; which may include absence management (Bannister and Maw 2005). Occupational Health Nursing Edited by K. Oakley. C 2008 John Wiley & Sons, Ltd
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History The history of case management in nursing, public health and social work in the United States dates back to the 1900s. It has been evolving ever since, through a number of discipline-specific and multidisciplinary groups (Huber 2002). Case management models achieved prominence in the 1990s in response to rapid changes in health care, with cost-containment at the forefront. The generic term ‘case management model’ can apply to a multi-disciplinary team approach to care, as opposed to pure nursing or medical models. In hospital settings the health care models address every aspect of care, from pre-admission work-up to discharge planning. Designated models, which include health care, insurance, social work and inter-disciplinary case management, are firmly embedded in the US health care systems. Many UK private sector hospitals are adopting the same case management approach, with a gradual infiltration into the NHS. Nursing case management models have tended to focus on acute care hospital settings and the community, rather than OH practice in organisations. While there are many models in OH showing the association between OHNs and the multi-disciplinary team, the documentation of case management models in OH is fragmented and inclined to be organisation-specific.
Aims In this chapter I will explore the process of managing a case from referral to discharge by the use of a sequential model based on primary nursing methodology. At the end of the chapter I have devised various case studies using common workplace scenarios to demonstrate the role of the OHN in case management and highlight the skills required. Firstly it must be understood that case management is not merely ‘sickness absence management’ or ‘attendance management’, which is the preferred name of today, though it does play a significant part in facilitating the return to work of absent employees. It is the responsibility of the organisation, human resources and line managers, through policies and procedures, to govern this area. However, OH professionals are in a unique position operationally not just to work alongside HR and line managers to influence policies but to share responsibility without having to police the system (McFadzean 2006). Therefore, it is important to acknowledge who the key stakeholders are in attendance management (Figure 14.1). Within larger organisations specialist advisers known as employee relations advisers (ERAs) are often appointed to deal with attendance management. Case management models present the opportunity for standardisation of care and the ability to adapt to commercial pressures and costeffectiveness. The primary aim of case management in an OH setting
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Occupational Health ERA/HR Adviser HR Manager Line Managers
Executives
Senior Managers Organisation
Company
Public
Shareholders
Safety Officers Trade Unions
Figure 14.1
Key Stakeholders in Attendance Management
is the return of an absent employee who has suffered a health problem into productive employment. Organisation-specific case management models may also target individual groups of workers depending on the job demands and tasks of the employees.
Referral to Occupational Health The process of referral to OH will depend on the company or organisation and whether OH services are provided internally or by external contractors. The following routes are the most widely used:
r Self-referral: when an employee contacts the OHN directly with an enquiry or health problem.
r Management Referral: telephone advice or formal written referral. r Human Resources: when an HR or employee relations adviser contacts the OHN directly for occupational health input.
r The Safety Officer: when an accident or incident occurs. r External Health Providers: such as GPs, specialists or employee assistance programmes, direct to OH. Similarly, the length of time for referral to OH depends on absence triggers set by the company or organisation absence policy, including the time and frequency of absence. A referral may automatically be generated when there is a health and safety issue. It is worth remembering that OHNs are not there to manage shortterm or short-term-persistent absence; that is for the organisation to
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Discharge Assess Rehabilitate CASE
Document
Liaise
Facilitate
Support
Following referral the OHN will: Assess the employee using the sequential model. Document the consultation and subsequent interventions. Support and monitor the employee through their illness/condition. Facilitate the care of the employee through advice or referral to specialist health care professionals. Liaise with line manager/HR/ERA/specialists/voluntary sector. Devise an individual phased rehabilitation plan, including any reasonable adjustments for the employee to return to work. Discharge and record the outcome.
Figure 14.2
The Role of the Occupational Health Nurse in Case Management
deal with (O’Reilly 2006). OHNs face a constant challenge to educate and update the key stakeholders regarding their role (Figure 14.2).
Sequential Model The use of a case management sequential model (Figure 14.3) enables the OHN to deliver a planned system of care, promoting communication across the inter-disciplinary team and benchmarking across internal departments and external organisations. The model allows the OHN to work independently and to take responsibility for their decisions.
Referral The referee should complete a written referral form to OH containing the essential information required, as stated in the sequential model (Figure 14.3). The referral form should always contain the employee’s
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Figure 14.3
Discuss information to be disclosed to referee. Liaise with GP/specialist/health care professionals. Contact necessary parties. Consider requesting medical report. Follow-up appointment. Rehabilitation plan. No. of weeks. Workplace adjustments.
Case Management Sequential Model
medication investigations employee assistance programme/counsellor. Support at home: partner/dependants social district nurse/CPN. Planned future operations/ appointments/investigations?
Current:
Review date. Discharge. Record outcome. Record data. Audit.
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Past medical/surgical/ psychological/occupational history. Nature of present illness/condition. Is this a first occurrence? Does the employee believe this to be work-related? If an accident/incident at work, was this reported? Consider if employee is covered under DDA.
Assessment
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Action Plan
Introduction: your name and preferred name of client. Explain who you are and the role of an OHN. Reason. Call/appointment/letter. Confidentiality. Establish relationship. Outside work activities? Period leading up to sickness absence? Contact with line manager?
Preliminary
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Name. Date of birth. Employee no. Contact nos: work/home. Contractual hours. Actual hours worked. Absent at present? Reason? How long? Role/title. Tasks/demands. People manager? Remote/home worker?
Referral
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written consent, specifying permission for the OHN to contact them in accordance with company policy, with the exception of self-referral. It may seem evident, but it is imperative to ensure you have the correct employee; so check the correct spelling of the name, the date of birth, the employee number and the contact details. Recording the contractual hours and the actual hours worked may shed light on a potential health problem if the employee is working excessive hours. The reason for absence is crucial and will enable you to decide on how to make the first contact with your case. For example, when an employee has been off work for a number of weeks with a mental health issue it may not be convenient or appropriate to ring them without prior notice and expect them to engage in conversation with a stranger. An introductory letter prior to direct contact explaining your role and possibly asking the employee to contact you would be more beneficial (see Figure 14.4). The employee’s role, including the job tasks and demands, will allow you to understand the nature of the work they undertake and the pressures they may be subject to. This may include excessive mileage per day, overseas business travel and shift work patterns. Knowing whether the employee is a people manager may also be significant, for example if the number in their team is exceptionally high, this may set alarm bells ringing as a possible contributory reason for their absence. This is particularly true of sales, which is a high-pressure environment, both for the employee and the manager, due to the targets that need to be met. Remote and home workers often experience different
Dear .................... This is to introduce myself as your Occupational Health case manager at .................... Your line manager has referred you to me, so I am aware of your condition and appreciate this must be an extremely difficult time for you and your family. If I can be of any assistance please do not hesitate to contact me at any time either by e-mail or by telephone on .................... I enclose some information on your condition that you may find helpful. Yours sincerely
Dear .................... This letter is to introduce myself as your Occupational Health case manager. I am here to assist you during your illness and to facilitate your return to work when you are ready. Please contact me to make an appointment for consultation on .................... I enclose some information on the Employee Assistance Programme (EAP) that you may find helpful. Yours sincerely
Figure 14.4
Examples of Introductory Letters from Occupational Health
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pressures, including social isolation (Parliamentary Office of Science and Technology 1995).
Preliminary Having decided the mode of contact, it is important to build a good relationship with your case from the beginning in order to realise the best outcome. Introduce yourself, find out the employee’s preferred name and explain your role as OH case manager and the function of the OH department. The key points to emphasise when summarising the OHN’s role are:
r supporting r facilitating r rehabilitating. Normally this is much easier to do in a face-to-face consultation; however, telephone consultations are becoming more frequent with the rise in numbers of remote and home workers and the increasing distance involved in travelling to and from work. Often a face-to-face consultation will be impracticable and as a result telephone skills are becoming an essential part of an OHN’s development. These skills can be learnt by acknowledging some basic principles. A pre-arranged time to make contact is best, though it is always pertinent to ask the employee if this is still a suitable time to call each time you do so. Bear in mind that you are potentially invading their personal space and you do not know what sort of day they may be having; the last thing they may want to be reminded of is work. You should make yourself sound friendly by smiling and expressing warmth in your voice. If you notice a lot of background noise it may be a good idea to ask the employee to contact you at a more suitable time as neither party will benefit if one or the other is distracted. Remember to ask open questions that require more than a yes or no answer. Ensure the employee understands your relationship with the organisation, establish the confidentiality of the consultation and your impartiality, and endorse the fact that you will not disclose any personal or medical information without their permission, in accordance with the code of professional conduct (NMC 2004). Discussion of the period leading up to the employee’s absence will help you in your assessment of their workload, their relationship with their line manager and their attitude towards the company or organisation. Ask whether there has been contact from the line manager as this is a good indicator of how a case may progress. Except in particular circumstances, such as an alleged bullying or harassment issue, encouraging the employee and line manager to make regular contact will improve the likelihood of an earlier return to work. Identifying
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barriers that may impede the employee’s return to work at this early stage will help you to address them individually. Enquiring after the employee’s outside interests and activities will assist you in gaining a full picture of their normal lifestyle, enabling a comparison with their current daily routine. This may be particularly relevant in the assessment of stress or depression, where many usual activities are dropped. It is also appropriate to ask if the employee has support mechanisms either at home or socially.
Assessment Having gained the employee’s consent, it is good practice to document the mode of consultation, whether face-to-face or by telephone, and to take notes as you proceed. Use key words as an aide-memoire, so that you can concentrate on actively listening during the session and write up contemporaneous notes when you are finished. A delay in transcription should be avoided at all costs to avoid omission of important details. During a telephone consultation the use of a headset will allow you to concentrate further and release your hands to write or type notes. Beware the client does not hear you tapping on a keyboard throughout the consultation as this could be most off-putting. Always record significant past medical, surgical and psychological history as this will help establish whether the current illness is a first episode or developing into a chronic condition. This information will also help in providing you with an informed opinion on whether the employee is covered under the Disability Discrimination Act 1995 (DDA). Documenting the occupational history is particularly significant if the condition is thought to be work-related, e.g. upper limb disorder or an accident possibly reportable under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 (RIDDOR).
Interventions Central to the employee’s return to work is the treatment they are receiving. Sometimes the treatment process can be slow. Referral to health care specialists can be delayed and waiting lists for treatments such as physiotherapy can be prolonged. The progress of the client’s illness, particularly in mental health conditions such as stress and depression, cannot be rushed. When treatment is particularly prolonged, employees often feel isolated and let down by the company. Remember the critical part of the consultation is the contact with the OHN, who may be the only link with the employer. Maintaining contact with employees during long periods of absence will facilitate the their return to work (Paton and O’Driscoll 2005). Within some companies or organisations you may be able to liaise with other health care professionals and refer employees directly for
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treatment. There may also be the opportunity for access to in-house treatments such as osteopathy, or counselling through employee assistance programmes. Ask the employee if there are forthcoming investigations or further treatments planned; this may be an indicator of the seriousness of the illness and also point towards the likelihood of a return-to-work date. Informing the employee of support available from other health care professionals, for example a community psychiatric nurse (CPN) or Macmillan nurse, should be actively encouraged.
Action Plan Confirm with the client what you are going to do with the information you have obtained. The notes you have written will form part of the employee’s OH records; these are confidential and will be maintained by the department. Reassurance that clinical notes do not form part of the employee’s personnel file will assist in building trust with the employee. However, it is important to remember the employee may request access to the OH records at a later date, and they may be used in litigation in respect of a grievance with the employer (Access to Medical Reports Act 1988). Be specific about what you will communicate to the referee to avoid disagreement with the client later; copying in the employee in writing would be considered best practice (see Figure 14.5). Relate your assessment to the employee’s fitness to work rather than giving anecdotal responses, keeping the content professional and concise. A frequent dilemma for OHNs is whether to request a medical report from a GP or specialist. You may even experience pressure from HR or the referee to do so. In my experience, it is preferable to limit the request
To: Line manager CC: HR/employee relations adviser/employee Thank you for referring John Smith to Occupational Health. This is to inform you I am his case manager and I am here to support John during his absence and to facilitate his return to work. Following telephone consultation with John today, it is evident he will be off work for a further 6 weeks. I would suggest you maintain regular contact with John either by telephone or visit so that he does not feel isolated during his absence. I have arranged a follow-up consultation with John in 4 weeks’ time when I shall obtain a clearer picture of a return to work date and devise his rehabilitation plan to accommodate his recovery. Kind regards
Figure 14.5
Example of an Email to a Line Manager
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of medical reports to where the case is prolonged or there is a conflict regarding diagnosis. Furthermore, medical reports do not always contain the information you require, such as a predicted return-to-work date, unless you request this specifically. In your decision-making process as to whether a request is justified, ask yourself if the additional information you are requesting will change how you manage the case or alter the advice you will give to the referee or employee. If it changes nothing, it may be best to save yourself time and the company money and forgo this request. Remember you are helping the employee get back to work, so an external opinion is no substitute for a well-informed OH opinion. Writing to general practitioners and specialists is a costly and lengthy business, taking a minimum of 3–4 weeks for a reply, and the fee for the report may be required in advance. There are many barriers that can impede the return to work of an employee (see Figure 14.6) and it requires excellent communication skills and equanimity from the OHN to overcome these problems. This is particularly true of relationship difficulties between the employee and line manager, and even more so if there are performance issues or grievances pending. This often creates multiple loyalties and ethical dilemmas for the practitioner, with the potential for conflict ever-present (Grytten 2004). It is imperative that you remain impartial and work within your remit, and it is inappropriate to be drawn into disputes. Discussion of a phased rehabilitation plan at an early stage of the employee’s absence will help to alleviate any fears they may be experiencing about their ability to cope on their return. Removing barriers that may impede the employee’s return to work one by one will not only facilitate an early return but reduce the possibility of a relapse during the coming months. Involvement of the line manager as well as the employee in planning their return ensures commitment to the returnto-work plan. The plan may include travel restrictions and the ability to work from home where possible to ease pressure. Having designed a phased rehabilitation plan, all parties should be sent a copy to avoid misinterpretation. When health and safety or environmental issues need to be addressed, a risk assessment may need to be performed and specific workplace adjustments may be necessary. Under these circumstances it is advisable to quote the relevant legislation in the recommendations to emphasise its importance. It may also be sensible to suggest appropriate training for the employee. When an employee has been off work with a mental health issue, a worrying question that often impedes their return to work is: ‘What should I tell my colleagues?’ The manager may also need guidance in this area. In my experience, being honest is preferable; this normally puts paid to gossip and rumours, which may occur if the employee is evasive. Social issues such as alcohol and drug dependency can cause similar concerns. It comes down to choice and the strength of the individual.
281 Debt Alcohol/Drug Dependency
Boring/ Repetitive Work
Barriers that may Impede an Employee’s Return to Work
Childcare
Bullying/ Harassment
Long-Hours Culture
Organisational Change
Travel/ Exhaustion
Length of Time Absent
Work/Life Imbalance
Chronic Illness Inability to Perform Role
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Figure 14.6
Relationship Problems
Line Manager/ Colleagues
Stress/ Depression
Awaiting Treatment
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Social
Work-Related
Emotional
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An empathetic environment allowing attendance of support groups during the employee’s return is a necessary part of their rehabilitation. Failure to address work–life balance will undoubtedly increase the likelihood of a relapse if the employee has a mental health condition. Therefore, the line manager should be encouraged to perform a stress risk assessment to identify possible hazards, including workload, work patterns and the work environment, under the Management of Health and Safety at Work Regulations 1999. An indicator tool for work-related stress is available on the Health and Safety Executive web site (www.hse.gov.uk). When an employee has experienced a bereavement it may be useful for the OHN to advise the team on handling loss. Network support groups such as Cruse and Seasons for Growth give excellent advice on coping mechanisms and grief education. Failure to address any of the issues that might impede the employee’s return to work will delay recovery and their return.
Conclusion A common question often raised is: at what point should you close a case? There are no advantages to holding on to cases for the sake of it, as dependence on an OHN can become draining, especially in mental health issues. Though counselling skills are indeed an essential component of the OHN’s role, the employee should always be encouraged to seek out a professional counsellor, either through their GP, privately or, if they are fortunate enough to have an employee assistance programme, through this route. Empowering the employee to be responsible for their own health is the definitive objective – not reliance on the OHN. A key question the OHN may ask when in a prolonged interaction with a client is: ‘How does my ongoing involvement actively advance this case?’ Following compliance with an appropriate rehabilitation plan for a set number of weeks, plus any workplace adjustments if necessary, it should be possible to close the case on completion of the phased return to work. This will depend on the OH department or company policy and whether the employee is likely to suffer a setback to their health problem, particularly in chronic illnesses and mental health issues. However, be aware of the potential to close a case immediately the employee returns to work, which is the policy with many OH service providers. This will depend on the size of the company or organisation – follow-up appointments may be a luxury that cannot be afforded – and whether the occupational health provision is over-stretched. If the OHN does review a case, it does not necessarily have to involve a one-to-one appointment; perhaps a simple e-mail enquiring after the employee’s health will suffice.
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When closing a case it is important to record the outcome, so that it is clear to read if and when the employee commences a further episode of sickness absence that requires case management.
Benefits of Case Management The recording of outcomes generates important data for demonstrating the value of the occupational health service, enabling the measurement of OH activity and the response times, from referral to discharge, of each case. Collating and analysing data enables the identification of trends in work-related health, such as stress and musculoskeletal disorders. This valuable information can generate research into specific work-related diseases among groups of employees, including social classes, and blue and white-collar workers. Even the simplest data separating male and female employees can help identify specific gender-related health concerns. Aggregate figures will also enable calculation of reported absence figures and trends from one area of the business to another, from diverse types of employment and from company to company. Similarly, safety issues and areas that demand risk assessments for the prevention of accidents can be recognised by critical analysis of data. Evidence-based practice gives OHNs the power to exert influence within the company or organisation and is congruent with corporate governance. Case management also has a part to play in quality assurance through strategic planning and evaluation of OH services, and promotes cooperation throughout the inter-disciplinary team. The gathering of information allows OH services to measure their success and benchmark across the business and nationwide. OH is heading for a new era in the UK following the publication of the government’s white paper ‘Work and Well-Being: Caring for our Future’ (DoH 2005), which places emphasis on access for all employees to OH services. Additionally, the Department for Work and Pensions has been examining welfare reform with the main objectives of getting long-term employees back to work (Paton 2006). There is growing scientific evidence that absence from work can be damaging to health and shorten life expectancy (Waddell and Barton 2006), so the initiative to rehabilitate employees as soon as possible is beneficial to all (DoH 2004). Alongside the appointment of the first UK National Director for Work and Health in 2006, OH is finally getting the recognition it deserves, with OHNs at the forefront of negotiations, shaping their own future and making a real contribution to public health. Case management does not abandon the fundamental principles of health protection, health surveillance and health education; instead it offers a new dimension to those autonomous practitioners who want to specialise within this
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field. It should not be viewed as de-skilling OHNs, but as a positive step to their becoming experts who really do make a difference. Unplanned absence places a huge burden on employers (Bevan et al. 2004); if OHNs are acknowledged as part of the solution by case managing employees back to work, this is a positive step toward employers valuing OH services and helping us to secure our future.
Case Studies Apply the sequential model to your consultation and assessment of the following case studies. At the end of each scenario discuss your interventions.
Case Study 1 John, a 36-year-old sales executive, has been signed off work by his GP for the past two months with a diagnosis of ‘work-related stress’. He is referred to occupational health by his line manager, who has not had any direct contact with John other than receiving his absence certificates. His line manager informs you he has only met John once this year and John’s absence coincided with the day of his annual appraisal. John had not reached his sales targets for the past two quarters. In confidence, his line manager says he heard rumours that John’s marriage was in difficulty. As John’s case manager, consider this case, with particular reference to the following:
r How helpful do you think the delay in referral to occupational health has been?
r Following consultation and assessment, what effect do you believe r r r r r
John’s relationship with his line manager has played upon his current absence and performance issues? How will you approach your first contact with John: by letter of introduction or telephone call? Suggest a suitable rehabilitation plan. At what stage would you consider involving an HR adviser? What support mechanisms could you recommend for John during his absence? What is your plan of action to facilitate John’s return to work?
Case Study 2 Louise is a 44-year-old business analyst and home-worker who is due to return to work after eight weeks’ absence following hysterectomy. Her line manager refers her to occupational health for advice.
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As Louise’s case manager, consider this case, with particular reference to the following:
r Following consultation you recommend a four-week rehabilitation r
plan. Would you recommend a follow-up consultation and at what point would you discharge Louise? How necessary is this referral to occupational health and how may Louise benefit?
Case Study 3 David is 58 years of age and has been diagnosed with bowel cancer. Following referral, his line manager tells you he is a good friend and has known David for 19 years, and that David is a popular member of the team. Following successful surgery, David wishes to return to work during his six months of chemotherapy. However, much of David’s work involves driving long distances and is customer-facing. As David’s case manager, consider this case, with particular reference to the following:
r What support can you give to David’s line manager and his team members?
r What role adjustments could be made to allow David to continue working while having chemotherapy?
r How will you monitor David’s capability if he is fit to return to work?
Case Study 4 Karen is a 29-year-old IT consultant for an investment bank, works 60 hours per week and is a frequent flyer to Europe, making up to six flights per week. Karen e-mails you asking for advice regarding her upper back and neck pain, which she has suffered for the past eight months. Karen makes a point of saying she cannot lose any time off work as she is in the middle of negotiations with a major new client. Karen says the pain is causing insomnia and feels she is becoming reliant on sleeping pills and pain killers. As Karen’s case manager, consider this case, with particular reference to the following:
r What assessment would you ask Karen to complete prior to consultation?
r How would you approach the subject of Karen taking some leave of absence?
r Would you recommend Karen sees a specialist and if so, who? r What do you believe to be the long-term health effects of Karen’s lifestyle?
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Case Study 5 Jason is a 19-year-old council employee who works at a recycling depot. He has developed acute back pain and has been off work for six weeks. His manager refers Jason to occupational health but does not seem to be very sympathetic, complaining about youngsters always going off sick for minor ailments. As Jason’s case manager, consider this case, with particular reference to the following:
r How would you assess Jason’s fitness to return to work? r What advice would you give Jason regarding long-term employment?
r What training recommendations would you make to Jason’s line manager?
Case Study 6 Myrna is a 24-year-old secretary in a large insurance company and has been off work with depression for nine weeks. During this time Myrna refused anti-depressants from her GP and has been waiting to speak to a counsellor. While Myrna has been away she has changed teams and therefore acquired a new manager. Myrna complained to one of her colleagues of sexual harassment from her previous manager but did not put in a formal grievance. Myrna feels she would like to return to work; however, she has her doubts, as her new manager is a good friend of her previous manager, who received a promotion in the reorganisation. As Myrna’s case manager, consider this case, with particular reference to the following:
r How will you know if Myrna has overcome her depression? r What role can you play in facilitating Myrna’s return to work? r Would you recommend to Myrna she follows the formal grievance procedure?
r In a teleconference, who would you ask to be present?
Case Study 7 Julie is a 36-year-old production line worker on permanent night shifts at a car plant. She is 14 weeks pregnant and has lost weight recently due to her constant nausea and vomiting. Julie would like to change her shift to mornings as she feels constantly tired, but her line manager is reluctant to do so as she is on a disciplinary for previous frequent sickness absence. Julie says she is also finding the work too heavy.
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As Julie’s case manager, consider this case, with particular reference to the following:
r r r r
How would you assess Julie’s fitness to work? Would you support Julie’s request to change her shift? Should Julie’s disciplinary affect her manager’s decision? What is the legislation that governs women in pregnancy?
Case Study 8 Jay is a 63-year-old with type II diabetes who works as a section manager for a large supermarket chain. Recently he suffered a severe myocardial infarction and has been signed off sick by his GP for three months. On referral to occupational health, the store manager informs you he feels it is time Jay retired. It is only three weeks since the commencement of Jay’s absence and the store manager mentions to you that he has already found someone to fill Jay’s position. As Jay’s case manager, consider this case, with particular reference to the following:
r How and when would you first approach Jay? r Is it legal to give someone’s job to another person while they are off sick?
r If Jay wants to return to work, how would you decide if he is fit to do so?
r Should Jay’s age play a part in your decision? r At 63 years of age, would Jay be covered under the Age Discrimination Act?
Acknowledgements Dr Julie Beaumont, Medical Services Manager, IBM UK Portsmouth and Elizabeth Griffiths, Senior Lecturer OH, Brunel University.
References and Further Reading Access to Medical Reports Act 1988. Bannister C. and Maw J. (2005) Competencies: an Integrated Career and Competency Framework for Occupational Health Nursing, London: RCN. Bevan S., Dench S. et al. (2004) The Institute for Employment Studies: Employee Relations Research Series, Number 25, Department of Trade and Industry, 77. Bristow S. (2001) Tackling Work-Related Stress, Occupational Health Review, November/December, 12–15. CBI/AXA (2005) Who Cares Wins: Absence and Labour Turnover, London: CBI.
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Cochrane P. (2006) Telephone Skills Coaching Manual, Gower. Cox S. (1999a) Managing Sickness Absence Within the Law: Part 1, Occupational Health Review, January/February, 33–5. Cox S. (1999b) Managing Sickness Absence Within the Law: Part 2, Occupational Health Review, March/April, 25–8. Cruse Bereavement Care web site, www.crusebereavementcare.org.uk. Curran K. and Williams G. (1997) The Manual of Remote Working, Gower. Curry M. and Wynn P. (2006) Missing Persons, Occupational Health, February, 17–19. Data Protection Act 1998. Disability Discrimination Act 1995. DoH (1998) Occupational Health Nursing: Contributing to Healthier Workplaces, www.dh.gov.uk. DoH (2003) Taking a Public Health Approach in the Workplace: a Guide for Occupational Health Nurses, www.dh.gov.uk. DoH (2004) Choosing Health: Making Healthy Choices Easier, www.dh.gov.uk. Downey J. (2003) Working Together in Close Partnership, Occupational Health, August, 19–21. Finnish Institute of Occupational Health (2001) People and Work: Survey of the Quality and Effectiveness of Occupational Health Services in the European Union, Norway & Switzerland, Research Reports 45, Helsinki: Finnish Institute of Occupational Health. Grytten S. (2004) In: Westerholm P. et al. (eds) Practical Ethics in Occupational Health, Oxford: Radcliffe Medical Press Ltd, 133–50. HM Government (2005) Health, Work and Well-Being: Caring for our Future: a Strategy for the Health and Well-Being of Working Age People. HSC (2000) Securing Health Together: a Long-Term Occupational Health Strategy for England, Scotland and Wales, Sudbury: HSE, www.dwp.gov.uk/ publications/dwp/2005/health and wellbeing.pdf (accessed 15 July 2007). HSE (1995) The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations, Sudbury: HSE Books. RIDDOR web site: www.riddor.gov.uk. HSE (2007) Management Standards for Occupational Stress, www.hse.gov.uk/ stress/standards (accessed 27 February 2007). Huber D. (2002) The Diversity of Case Management Models, Lippincott’s Case Management 7(6), 212–20. McFadzean M. (2006) Beyond the Quick Fix, Occupational Health, July, 17–18. NMC (2004) The NMC Code of Conduct: Standards for Conduct, Performance and Ethics, www.nmc-uk.org. NMC (2006) Record Keeping, www.nmc-uk.org. O’Reilly S. (2006a) Attending to Absence, Occupational Health, May, 13–15. O’Reilly S. (2006b) Cultivating Health, Occupational Health, August, 15–18. Parliamentary Office of Science and Technology (1995) Working at a Distance: UK Teleworking and its Implications, POST Report, June. Paton N. (2004) Policing Sickness Absence, Occupational Health, February, 18–20. Paton N. (2006) Health of a Nation, Occupational Health, January, 13–15.
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Paton N. and O’Driscoll E. (2005) Getting Back on the Job, Occupational Health (Extra), January, 10–11. Perry A. and Walton P. (2005) Means of Support, Occupational Health, June, 22–3. Roney A. and Cooper C. (1997) Professional on Workplace Stress: the Essential Facts, Chichester: John Wiley & Sons, Ltd. Seasons for Growth, Grief Education Programme not Counselling or Therapy, www.seasonsforgrowth.co.uk. Thompson N. (2000) Tackling Bullying and Harassment in the Workplace: a Personal Guide, Birmingham: Pepar Publications. Thornbory G. (2005) Back to Work, Occupational Health, February, 14–15. Waddell G. and Burton A.K. (2006) Is Work Good for Your Health and WellBeing?, London: TSO. Westerholm P., Nilstun T. and Ovretveit J. (2004) Practical Ethics in Occupational Health, Oxford: Radcliffe Medical Press.
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Education and Research
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Education, Clinical Supervision and Professional Development Patience D. Kenny
Introduction This chapter covers the training of occupational health nurses and the continuing education of the qualified practitioner, and discusses current trends and possible future developments, including multi-disciplinary training and education. The developing role of the occupational health nurse is discussed in the Introduction to this book, where the focus is on the unique contribution that the occupational health nurse brings to health in the workplace. Occupational health nurses work in a variety of settings and, accordingly, have varying duties and responsibilities. It follows from this that their training and education needs may also vary, and this theme is discussed in depth in this chapter. Before considering these educational issues associated with occupational health nursing and the professional occupational health nurse, we first need to clarify the meaning of the terms ‘profession’ and ‘education’.
Concepts of Professions It has been argued (Houle 1980 p. 20) that, originally, professionals were privileged members of society who were allowed to acquire Special Knowledge, the possession of which was a source of power and control.
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The professions developed as a result of the division of labour, which was itself dependent on economic conditions, rather than on any particular characteristics of a set of individuals following a particular occupation. Sociologists have attempted to clarify the concept of a ‘profession’ by seeking to identify criteria, other than a specific body of knowledge, that distinguish the professions from other occupations. Flexner (1915) gives six such criteria: 1. Involvement in essentially intellectual operations with large individual responsibility. 2. Extraction of raw material from science and learning. 3. Development of this material for a definite practical purpose. 4. Possession of educationally communicable technique. 5. A tendency to self-organisation. 6. An increasing tendency to be motivated by altruism. Prior to the 1950s, these criteria could be used to prove that nursing was not a profession because, although generally accepted as altruistic in motivation, it had no distinctive purpose of its own and therefore no unique educational content, but merely acted as ancillary to the profession of medicine, with little individual responsibility being felt by its practitioners. However, the idea of professions arising out of the division of labour may be seen at work in nursing. Tasks which had previously been regarded, and guarded, as part of the esoteric art of medicine have been gradually transferred to nursing. This has been in the wake of the rapidly increasing body of knowledge, new technology and the incorporation of both medicine and nursing in a bureaucratic organisation, the National Health Service. In the same way, the other professions allied to medicine have developed. In all cases, economic factors have played a part as the fees/salaries paid for services rendered by these new professions are far lower than those demanded by medical practitioners. More recently, the organisational changes within the NHS and social services, with the emphasis on efficiency, skill mix and cost-effectiveness, have led to further divisions of labour and the passage of nursing, or caring, tasks from the relatively highly paid professional nurse to the less expensive care assistant or the unpaid voluntary worker or family member. Other writers have suggested the professions might also be characterised by association with a university education, with high social class and with beliefs in processes that have acquired a high degree of mystique. These criteria for the identification of occupations as ‘professions’ seem to have been developed from an exanimation of the characteristics of the most prestigious, long-established professions, such as law or medicine, rather than from an abstract ideal. Indeed, what may be viewed as the ideal characteristic of a modern profession, for example continuing professional development of
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practitioners, may not be met in the established professions (Hoyle and John 1995). This view is supported to some extent by the fact that nursing, in seeking to be a profession, has for many years encouraged nurses to undertake formal, post-registration education accredited by the national boards of the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC); more recently, the UKCC has also required nurses to show evidence of continuing education prior to renewal of registration (UKCC 1994). By contrast, medicine, an established profession, did not formally acknowledge the need for continuing education until 1993. The reasons given for it becoming a professional obligation included ‘the rapid advance in medical science; the greater expectations of an increasingly informed public and the growing tendency to apportion blame; and the need to not only keep abreast of the latest developments, but also that we are seen to do so’ (Royal College of Physicians 1994). The foregoing suggests that there is a dynamic relationship between a profession and its environment, but seems to place the emphasis on the protection of members of the profession rather than of the public. The UKCC’s Code of Professional Conduct and its standards for post-registration education and practice rightly place the emphasis on protection of the public and on the need to deliver safe and effective care (UKCC 1994) by the maintenance and development of professional knowledge and competence. However, the dynamic relationship between a profession and its environment means that there are significant actors other than members of the profession and their organisations who have a role in the development of the profession. These actors include the state and legislature; educational institutions and systems; clients, the media and public opinion; and, in the case of nursing (and medicine), the employer. All of the actors are themselves influenced by the political culture and ideology of the time, and by the economy. It would appear, therefore, that specialist knowledge, autonomy and responsibility as the key criteria of the professions are influenced by all the significant actors and are open to criticism by a society affected by rapid change. Nursing as a profession seems to conform to the idea of a profession fulfilling a social function central to the well-being of society, which Hoyle (1980) summarised in ten points: 1. A profession is an occupation that performs a crucial social function. 2. The exercise of this function requires a considerable degree of skill. 3. The skill is exercised in situations that are not wholly routine, but in which new problems and situations have to be handled. 4. Although knowledge gained through experience is important, this recipe-type knowledge is insufficient to meet professional demands, and the practitioner has to draw on a body of systematic knowledge.
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5. The acquisition of this body of knowledge and the development of specific skills require a lengthy period of higher education. 6. This period of higher education and training also involves the process of socialisation into professional values. 7. These values tend to centre on the pre-eminence of clients’ interests and, to some degree, they are made explicit in a code of ethics. 8. Because knowledge-based skills are exercised in non-routine situations, it is essential for the professional to have the freedom to make their own judgement with regard to appropriate practice. 9. Because professional practice is so specialised, the organised profession should have a strong voice in the shaping of relevant public policy, a large degree of control over the exercise of professional responsibilities, and a higher degree of autonomy in relation to the state. 10. Lengthy training, responsibility and client-centredness are necessarily rewarded by high prestige and a high level of remuneration. In the present climate, the rewards, in the form of remuneration, may be less than expected or deserved by nurses, because of ideological and economic factors influencing pay structures.
Concepts of Education Education is another changing concept. It is usually associated with teaching in schools, but in fact is a process that can occur without the involvement of teachers or educational institutions. Education is about learning, that is, the acquisition of knowledge, skill or attitude, and of understanding. It is normally a planned process but may occur whenever an individual deliberately reflects upon experience in order to learn from it. Formal education for the professions, including nursing, has been used for the transmission of the requisite knowledge for practice, the skills to perform the job, and the values and attitudes necessary for professional practice. Assessment procedures, whether by national examinations or by institutions’ own procedures, have been concerned with competency to practise. Competency itself is a concept difficult to define. Jarvis (1983) argued that it involves three elements: knowledge plus understanding, skills and attitudes; all leading to good practices; based on sound theory. Knowledge and technical skills have expanded rapidly in recent years. The attitudes associated with the ideology of professionalism may be the key element in maintaining competence, by demanding that the professional practitioner actively seeks to ensure continuing good practice. This has implications for initial professional education. The
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rapid expansion and obsolescence of knowledge, the onslaught of new technology and the development of specialist branches within professions have led to major educational changes.
Initial Professional Education Nowadays, it seems relevant for the initial professional education process to enable the student to acquire a mastery of basic knowledge and principles, plus the theories on which they are based, sufficient for safe initial practice; and to gain those basic skills which may, in modern jargon, be termed ‘transferable’. These skills include those required for accessing information, critical analysis and synthesis, problem-solving, decision-making, good interpersonal relationships and last, but most importantly, for learning. The role of reflection in both learning and good practice may be viewed as integral to the state of being a professional. Schon ¨ (1983) differentiated between reflection that follows action and that which occurs during action. The former may range from the informal, mental assessment of practice to the formal, systematic assessment of practice outcomes, which may also be used to assess accountability and to audit performance. Reflection in action may be seen as ‘thinking on one’s feet’ and is difficult for practitioners to articulate, and therefore hard to transmit, except by observation of a ‘successful’ practitioner. The introduction of Project 2000 altered the status of learners from employees-in-training to full-time students and required that practical experience be supervised by expert practitioners and lecturerpractitioners. One advantage of the NHS internal market is that educational institutions can influence the quality of the learning environment by refusing to purchase poor practical placements. Nursing education has also moved into the realm of higher education – another characteristic associated with the professions. The curricular changes involved in achieving the goals of this new, initial nurse education not only reduced content but changed the mode of learning, from mainly instructional to mainly enquiry; and changed teaching methods from didactic to participative problem-solving plus innovative, practice-related assessment of learning and competence, followed by a period of mentorship, or internship in practice, supported by a qualified, experienced nurse – described by the UKCC (2001a) as a ‘preceptor’. Questions may be raised as to whether students should be allowed to become practitioners without demonstrating an enquiring mind and self-directed learning, if it is accepted that these, and reflectivity, are
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essential elements of being a professional, and therefore of being a registered nurse.
Modern Continuing Professional Education Traditionally, post-basic or post-initial professional education was viewed as a means of updating knowledge and skills and was acquired via attendance at professional conferences and seminars or through short courses. Learning was not assessed. The certification improved practice, but did not improve the status of the individual nurse. Participation was voluntary and it was often limited by managers’ inability, or refusal, to allow nurses time off to attend lectures. Changes to the initial professional education of nurses with the introduction of Project 2000 led to a major reorganisation of post-registration education. The changes associated with Project 2000 resulted from the fulfilment of the long-expressed wish of the nursing profession to change from an apprenticeship type of training, combining education with provision of service, to one of full-time study. However, wish-fulfilment had a price. In this case, the need to provide the service previously given by student nurses resulted in the creation of a new workforce of health care assistants and a reduced number of nursing students – and, therefore, of future registered nurses. It also increased the responsibilities of the registered nurse to include supervision, guidance and management of a workforce with specific, but limited, skills and knowledge. It may therefore be argued that the professionalisation of nursing has actually detracted from the holistic care of the person previously given by nursing, because care has become more taskorientated again. Changes in disease and in health care systems, and the key role allocated to the primary health care teams have also affected both initial and continuing nurse education. Health promotion and disease prevention or limitation now take precedence over treatment. Therefore teaching skills and management skills are regarded as essential. For over a decade, health promotion and disease prevention and limitation were seen as major issues in the development of proactive occupational health nurses; in 1990, both the English and Welsh boards identified the key occupational health nurse role and its required skills and learning outcomes in the 1990 revised Occupational Health Nursing Certificate (OHNC) syllabus. This followed the transfer of validation of OHNC courses from the Royal College of Nursing to the national boards in 1988. Thus, occupational health nurses could be regarded as being in the vanguard of the profession in terms of preparation for primary health care practice and prevention of ill health and injury. The transfer of initial nurse education from hospital schools to higher education and the requirement for it to be at diploma level or above
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affected post-registration education by requiring it to be at a higher academic level. After 1994, the UKCC required all practitioners to seek opportunities to learn and to improve their level of competence with regard both to their professional registration and field of practice and to their role. Five categories of learning were indicated: patient, client and colleague support; care enhancement; practice development; risk reduction; and education and development. These categories reflected the diversity of professional nursing practice and were intended to assist practitioners to tailor their study time and activities to their personal, professional responsibilities. To maintain effective registration, a minimum of five days’ study every three years, with clearly identified learning objectives and experiences, must be recorded in a personal professional portfolio. This provides a framework for continuing professional development (CPD), which, while not guaranteeing competence, acts as a key component of clinical governance (UKCC 2001b).
Specialist Professional Education
Historical Overview: The UKCC (Now NMC) and Occupational Health The profession and the UKCC have recognised a need in most areas of practice for specialist practitioners to exercise higher levels of judgement, discretion and decision-making in clinical care. Programmes of study in eight areas of community practice, including occupational health, were set to UKCC standards and approved by a national board. The programmes are flexible, with a system of credit accumulation and transfer (CATS) in place. Each programme is of no less than one academic year, 50 % of which is to be in supervised practice prior to registration of the qualification. The academic level of study is no lower than first degree level, to ensure that additional knowledge is of a higher order than that required at registration. Other factors may also influence specialist education and practice. Sometimes, the drive to improve efficiency and reduce costs occurs with little regard for the quality of care and its effectiveness in promoting health. This has worked against specialist practitioners in the NHS; for example, following the introduction of clinical grading in the late 1980s, their specialist knowledge and extra responsibilities should have been rewarded but were not, when it was realised that the cost would have been far in excess of that forecast. The criteria for determining the grading of nurses have been altered on many occasions to reduce NHS salary costs, and this has affected occupational health nurse grades and
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salaries in all sectors of industry, as employers make comparisons with NHS salaries. Furthermore, specialist knowledge and skills which add quality to holistic care but are not directly applicable to the specialism receive no recognition, with the result that nurses favour narrow, specialist courses. This may be viewed as very utilitarian and non-professional, and possibly as unbeneficial to the client or patient, with the emphasis being placed on dysfunctional parts rather than on the individual as a whole. At the same time, the reorganisation of the NHS into self-governing trusts, at a time of financial constraint, has tended to increase the power of the employer in determining the post-registration education required to meet rapidly changing service needs rather than the needs of the professional nurse. The community health care nurse specialist framework has enabled what is, in effect, a new discipline to emerge, which bases the education of its practitioners on a ‘streamlined and cost effective means of preparation, consisting of common core and specialist modules’ (UKCC 1994). The core programme, intended to be shared by all community health care nurses, may be seen as cost-effective in terms of educational provision. It conforms to government employment policy regarding possession of transferable knowledge and skills. At the same time, there is no statutory requirement for registered community health care nurses to be employed in the field. Registered nurses who have completed an initial Project 2000 programme are considered competent to practise within both institutional and community settings. The above raises questions about the number of specialist practitioners required and therefore about the number who should be given access to specialist education. There is evidence that funding is very limited for nurses wishing to undertake specialist education in district nursing. Trusts argue that money needed to train specialists would be better used increasing the number of registered nurse (RN) hours available for nursing in the home. In the field of occupational health nursing only ‘blue chip’ companies are likely to employ occupational health nursing specialists or to fund their education. There is consequently a danger that the introduction of higher professional education standards might in fact reduce the professional advice and expertise available to the workforce, thereby reducing the quality of care. On the other hand, any RN working in a specialist field who, during initial education, has acquired the characteristics of a professional will endeavour to gain sufficient new knowledge and skills. This might entail the RN’s completing only specific specialist occupational health modules of a community health nursing programme or attending relevant short courses. Consideration of all these issues leaves doubts about the desirability of the professionalisation of occupations if, instead of leading to increased autonomy, status and reward in return for the acquisition
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and application of specialist knowledge and skills, it leads to increased responsibility for the actions of others and fewer opportunities for employer or state-funded education. The expansion of the National Vocational Qualification (NVQ) scheme to include the professions may be viewed as a means of controlling professional education by government, the emphasis shifting from the professional bodies and academic institutions determining programmes of study to industry, via the lead bodies, which are setting standards of a very mechanistic, behavioural type. Occupational health nurses must be able to demonstrate their competence to employers who are demanding NVQs, in addition to academic professional qualifications, from other professionals in the field of health and safety, in order to survive in the marketplace. Modularisation, credit accumulation and NVQ schemes, which may be encouraged by market philosophies as cost-effective educational provision, also assist the post-modern needs of industry, and ultimately of the state, for a flexible, multi-skilled workforce at all levels. In the same way, power is shifting from educational institutions to individual professionals, who are able to use modularisation and credit accumulation to design their own educational programmes to satisfy their personal and professional learning needs. Many academics view this independence as a threat to their discipline, fearing that the creation of new knowledge within the discipline will be diminished and that coherence will be lost. Although recognising the validity of these fears, we may question which is of greater importance, the discipline itself or professional education. If professional education is the more important, then it can be argued that the individual who is sufficiently self-directed to identify, and to take steps to satisfy, their own learning needs in terms of their practice, is demonstrating key characteristics of the professional and should therefore be encouraged. Shared learning has been adopted by many professions to enhance collaborative practice and teamwork in problem-solving, and to reduce the cost of educational provision. Such is the case in nursing, but problems have arisen in relation to specialist community nursing. It may be argued that these problems were predictable following the publication of the UKCC Report on Proposals for the Future of Community Education and Practice (UKCC 1991). The report demonstrated a lack of awareness and understanding of the essential differences between occupational health nursing and the other community nursing specialisms. These differences include:
r The ‘community’ served, where the majority of the workplace community may consist of workers who live in various, distant neighbourhood communities, reducing any possibility of collaborative practice and teamwork with other members of the worker’s primary health care team.
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r The actual team with whom the nurse needs to collaborate, i.e. the ocr r r r
cupational health nurse’s team comprises managers and other workplace health and safety practitioners. The legislation guiding practice. The variety of organisations that employ occupational health nurses. The fact that there is no statutory requirement for their employment (nor education). The body of new knowledge and understanding required by occupational health nurses, which was previously untouched by preregistration education.
This lack of awareness persisted in the UKCC’s 1994 Standards for Education, where the specialist module might be as little as one-third of a taught programme. Other specialisms build on existing knowledge and skills that may be applied in community settings, while occupational health nurses have to acquire the new body of knowledge referred to above, and gain understanding of rapidly developing health and safety legislation, within the same time span. Other dangers in programmes of shared learning with other community nurses arise from the lack of awareness of occupational health practice of teachers from other disciplines, who assess learning in the common core programme, being unaware of the organisational, legal and ethical issues governing the practice of occupational health nurses. This may cause poor, illegal or unethical practice to be accepted as correct. There is also a risk that theory associated with the common core is presented in such a way, often biased towards the needs of the NHS, that its application to occupational health practice is not apparent, thus impeding the occupational health nursing student’s achievement of the required learning outcomes. Another risk, associated with all shared learning, is that class sizes can be so large as to reduce teacher–learner interaction and impoverish the learning experience. It could also be argued that over-large classes provide not shared ‘learning’ but shared ‘reception of information’. For shared learning to be of real value there should be opportunities for small, mixed-discipline group work and role play; common core elements should be shared not only with other community nurses but also with professions outside nursing to promote a wider view of the ‘community’; and specialist occupational health elements should be shared with professions concerned with health, safety, welfare and environmental issues at work. This would assist in team approaches to problem-solving in the workplace and improve relations between nurses and other health and safety practitioners. Assessment of learning should place greater emphasis on its application to practice, rather than on academic value. The ability to write academically-acclaimed essays may not transform easily into the
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production of effective reports that will prompt managerial action to protect the health of the worker, or of the wider community.
The Nursing and Midwifery Council and the Specialist Community Public Health Nurse Following the establishment of the Nursing and Midwifery Council in 2002 as successor to the UKCC and four national boards, it was determined that there should be three parts of the Register, for nurses, for midwives and for specialist community public health nurses. The specialist community public health nurse (SCPHN) part of the Register was established because ‘this form of practice has distinct characteristics requiring public protection. These include the responsibility to work with both individuals and populations, which may mean taking decisions on behalf of a community or population without having direct contact with every individual in that community’ (NMC 2004). Having developed standards of proficiency required to enter the Register, the NMC went on to develop the relevant standards for education for SCPHN programmes, which have to some extent addressed the deficiencies of the UKCC’s 1994 Standards for Education. Programmes are required to:
r Have an overall length of 52 weeks (of which 45 are programmed,
r r r
with 50 % theory/50 % practical). Delivery may be full or part-time and must be completed in not more than 78 weeks full-time or 156 weeks part-time. Consist of practical and theoretical learning transferable to different settings. Distinguish common core learning and its applications in different settings and through different roles. Require experience in all fields but not assessment for competence in all fields.
A consolidation period of practice equivalent to 10 weeks is required to consolidate education and competence in the chosen field of practice. An occupational health nurse will be required to do 10 weeks of consolidated practice plus a minimum of ‘6.3’ weeks within occupational health settings. Additionally, three weeks must be spent gaining experience in other settings. Recognition is given to the need for distinction in theoretical learning according to the field of practice, for example risk management might be in the context of environmental pollution for occupational health practitioners, but in that of child protection for health visitors. Academic standards are unchanged, with the minimum being that of a first degree.
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Curriculum content must enable students to gain sufficient learning within their particular area of practice. Contemporary theoretical perspective and public health standards should be explored. Students should be supported by ‘appropriately qualified teachers’ who hold practice qualifications in the same area of practice as the qualification sought by the student. Assessment strategies should be used throughout the programme to test knowledge and proficiency and must include at least one timed examination under invigilated conditions. This is seen by the NMC as a benchmark for public protection. Provision must be made to ensure that part-time students working in their chosen area of practice are able to obtain suitable learning experience.
Lifelong Learning and Clinical Supervision The pace of change in the provision of health services, including those for the working population, has resulted in challenging new roles and opportunities for all nurses. It is essential that nurses develop throughout their careers the professional knowledge and competences to cope with these. At the same time, they need to demonstrate leadership skills and the ability to work in partnership with other agencies; to help others to develop their own practice; and to set and monitor standards to promote health and prevent illness and injury (DoH 2001). Nurses are required to take responsibility for their own learning, to accept accountability for the quality and standards of care provided by a service and to adhere to the NMC Code of Professional Conduct (NMC 2004). Two interrelated processes may be used to enhance both learning and standards of practice. These are clinical supervision and governance. Clinical supervision is an integral part of a nurse’s lifelong learning (UKCC 2001a). Clinical governance is the term applied to the systematic quality improvement process used within the NHS and includes patient experience, clinical effectiveness and research, risk management, clinical audit, education and training, use of information and human resources (Nicholls et al. 2000). Quality improvement systems, as adopted by many organisations in the service and manufacturing sectors, usually include performanceappraisal and objective-setting elements geared to the needs of the organisation as a whole, rather than to those of an individual or a professional group. They are often driven by a quest for efficiency rather than effectiveness. While acknowledging this, the nurse may make use of the data gathered and reviewed during audit to highlight deficiencies
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in care or in personal knowledge or competence. This, in turn, may enhance personal learning and guide clinical supervision. The UKCC (2001a) describes clinical supervision as aiming ‘to bring practitioners together to reflect on practice, to identify solutions to problems, to increase understanding of professional issues and, most importantly, to improve standards of care.’ It supports clinical supervision as an important part of clinical governance, which is best developed at a local level and according to local needs. It advocates no specific model but provides a set of principles to underpin any system of clinical supervision. These are:
r Clinical supervision supports practice, enabling you to maintain and improve standards of care.
r Clinical supervision is a practice-focused professional relationship, r
r r
r
involving a practitioner reflecting on practice guided by a skilled supervisor. The process of clinical supervision should be developed by practitioners and managers according to local circumstances. Ground rules should be agreed so that you and your supervisor approach clinical supervision openly and confidently, and are both aware of what is involved. Every practitioner should have access to clinical supervision. Each supervisor should supervise a realistic number of practitioners. Preparation for supervisors should be flexible and sensitive to local circumstances. The principles and relevance of clinical supervision should be included in pre-registration and post-registration education programmes. Evaluation of clinical supervision is needed to assess how it influences care and practice standards. Evaluation systems should be determined locally (UKCC 2001a).
It is only to be expected that these principles will be more easily adopted within the NHS and within a culture of clinical governance. This was recognised by the UKCC, which emphasised the practitioner’s personal responsibility for developing an appropriate model of supervision. Most occupational health nurses (the RCN estimates 70 %) do not work in the public sector (verbal communication 2007). Some work in independent practice or in isolation. OHNs therefore need to be creative, for example by developing a model using the shared experiences of members of their local OH group. The issue of time available for supervision or for the preparation of supervisors needs to be considered. Methods of evaluation of clinical supervision need to be determined, and some form of confidential record keeping developed. It is to be hoped that the Nursing and Midwifery Council will ensure that aspects of good practice in clinical supervision within the independent sector will be shared widely, and further guidance provided.
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Case Study: Clinical Supervision in Occupational Health One senior occupational health nurse manager ‘L’, who runs a national service and is herself a clinical supervisor to teams of occupational health nurses, arranged her own clinical supervision by simply ringing several people to ask if they would supervise her. The third person she approached, ‘K’, agreed to try it, although she did not have previous experience of supervision and it was logistically difficult as the two nurses lived at different ends of the country. Both travelled regularly throughout the UK for their jobs and managed to meet at various locations, including their own homes, a library and a hotel restaurant. They agreed to use the Proctor Interactive Framework of Clinical Supervision, incorporating learning, support and accountability. Their first meeting involved a contract setting group rules and plans for subsequent meetings. Four years on, the arrangement still works, with meetings on average twice a year. The arrangement has been of mutual benefit. The supervisor, K, says, ‘I wondered what practical help I could possibly be to L, who is an extremely competent and experienced occupational health manager. Also there was so much jargon in the literature on supervision. However, once we started it all seemed simpler and made sense. We concentrate on one or two issues for each session. I am trying to find a supervisor myself.’ The supervisee, L, says, ‘It does take time but I think it is worth it as part of reflective practice and improving the service to the clients.’
The Way Ahead Many factors affect the employment, role and practice of occupational health nurses, and therefore their educational needs. These include changes in the economy and in employment, resulting in an increasing number of home-based workers, part-time workers and women workers; changes in legislation, with an emphasis on self-regulation, risk assessment and reduction, and health surveillance; and changes in occupational health service provision, from full services – incorporating most of the functions recommended in the International Labour Organisation (ILO) Convention 161 and Recommendation 171 adopted by the International Labour Conference in 1985 – to a limited service, often for specific items that comply with UK legislation, for example lungfunction testing of workers exposed to isocyanates; and from in-house services to purchased external provision of service. These external providers include general practitioners, and the introduction of the Faculty of Occupational Medicine’s Diploma in Occupational Medicine for non-specialists has increased the number of GPs generating income by providing occupational health services to local
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businesses. Frequently, health surveillance is undertaken by the practice nurses, who have little or no knowledge of the individual worker’s workplace hazards. It should be appreciated that many of the tasks undertaken, and much of the advice provided, by occupational health nurse specialists can be, and indeed are, undertaken effectively and efficiently by other practitioners. The process of ensuring health, safety and welfare at work is a generic one, with similar performance criteria (frequently determined at NVQ Level 3 or 4) expected of various practitioners, including RNs, in an organisation. Occupational health nurse specialists must be able to demonstrate their unique contribution to the health and safety of the workforce in order to persuade organisations to purchase their services. This unique contribution, founded on the philosophy of nursing and the acquisition of specialised health, hygiene and safety expertise, comprises the ability to assess the health needs of working populations and to take responsibility for the management of worker health and safety, including that of vulnerable groups or individuals, with due consideration of ethical, cultural, legal and organisational issues, including the confidentiality of an individual’s health data and records. This involves the occupational health nurse specialist adopting many roles, including those of clinician, educator, researcher, expert adviser of management and workforce, workers’ advocate, health-programmes planner, implementer and evaluator, and collaborator with other professionals, employers and employees. All of these roles are adopted by an autonomous practitioner, guided by a frequently reviewed and revised professional code of conduct and ethics that respects the rights of the individual and encourages empowerment of individuals, or of groups, to take control of the determinants of their own health, and which holds the practitioner accountable for all aspects of their practice. It follows that the occupational health nurse is obliged not only to maintain and improve knowledge and skills but also to keep abreast of current issues in relation to research, legislation, workplace hazards and risks, employment trends and organisational change; and to collaborate with other health and safety team members, frequently taking a leadership role, in the management of health programmes at work. This leadership role requires higher levels of judgement and decision-making, of negotiation and of inter-personal and communication skills. It may be argued that all of these roles could be undertaken by a registered nurse who is not a specialist or a graduate, but who has acquired, by reading and attending short courses, the health and safety knowledge and skills relevant to the context of their own place of work, and has developed the higher-level skills, to which reference has been made, in a variety of settings and learning experiences. It is difficult to refute this argument if, as it appears, the unique contribution of the occupational health nurse within the health and safety team is related
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to the profession, ethics and values of nursing as a whole and not to any particular specialist branch. As a member of that profession, the registered nurse is accountable for their practice and is responsible for acquiring the relevant specialist knowledge and skills to be competent. As a whole, the occupational health nursing profession must consider whether the present NMC standards for occupational health nursing within education and practice are promoting or hindering the health, welfare and safety of the working population. It must also consider whose needs should take precedence: those of the profession or those of the discipline of occupational health, and therefore the health needs of workers. If the profession’s needs are deemed to be of prime importance then it is in danger of being accused of protectionism, concerned only with retaining the source of power and control for its members, and of disregarding both the health needs of workers and the educational needs of the registered nurse employed in the field of occupational health. If, on the other hand, the needs of the discipline are seen as being of prime importance then perhaps the existing occupational health nursing educational standards and programmes of study should be revised. This revision should take account of the fact that, although there is no statutory requirement for organisations to purchase the services of any nurse, it is highly unlikely that even those that do employ a nurse will choose to recruit the relatively more expensive, graduate specialist, even if they are aware of their existence. Therefore, it would seem that the enrolment of registered nurses on modules of specialist learning should be encouraged and afforded professional recognition. Perhaps it is time to reconsider occupational health nursing’s position as a branch of post-registration nursing. It could be argued that it does not sit easily within the circle of the other community nursing disciplines, and that its true place is within the team of professionals concerned with workplace health and safety. Occupational health nursing does, however, as described in the Introduction, impinge upon other branches of community nursing in many important ways, sharing their philosophy of nursing and utilising some similar skills. It is clearly important for occupational health nursing to collaborate and liaise with other community nurses as it does with GPs and other health care professionals external to the workplace. OHNs frequently work in isolation as sole nursing practitioners within an organisation, with little or no opportunity for contact with other nurses, even those working in occupational health, except that provided by informal networking. A strong case could be made for the NMC to regard occupational health nursing as a separate specialist discipline in its own right. This would afford recognition of its unique characteristics in relation to its client population, its specific knowledge base, its sharing of tasks with non-nurse members of the workplace health and safety team, and the terms under which its practitioners are employed.
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As a separate specialist discipline, occupational health nursing would be entitled to its own post-registration standards for education, based on the demands of occupational health practice. Programmes of learning could be delivered in different ways. Common core modules could be shared with members of other professions working within the field of health and safety. This specialist health and safety learning could be assessed at different academic levels, from NVQ Level 2 to postgraduate level, and at different levels of professional competence, from that required of a registered nurse working in occupational health to that required of a specialist practitioner. Elements specific to nursing and clinical practice could be shared with other nurses and medical practitioners under the direction of a qualified, specialist occupational health nurse teacher. Within the proposed educational framework, assessment of learning should involve innovative methods, allowing the student to negotiate practice-based assignments that not only demonstrate their knowledge and skills but are of value to the employing and/or sponsoring organisation. Credit accumulation and transfer should enable nurses to enter and leave this modular programme at times and levels suited to their personal, professional and workplace practice needs. This would ensure the nurse’s competence in specific activities and interventions and therefore protect the working population. Any nurse working in the field of occupational health would have the opportunity to progress, if they so wished, from novice occupational health nurse to competent practitioner to specialist practitioner. However, competence should be encouraged, recognised and recorded on the NMC Register separately from the specialist qualification. This proposed creation of two levels of occupational health nurse may be viewed by some as a retrograde step, but it would appear necessary in order to provide the foundation of health and safety knowledge upon which to build specialist qualifications. This flexible system could be seen as valuable in ensuring the competence of all occupational health practitioners and therefore in protecting the public, in aiding employers when recruiting suitable health and safety personnel, and last, but not least, in providing nurses with a relevant qualification that meets NMC standards, by giving credit for learning appropriate to their level of practice. This may be particularly suitable for those nurses working in general practice as either RNs or specialist practitioners who undertake occupational health functions.
Conclusion The age of post-modernity is one of rapid change in all aspects of life, and there is no reason to believe that occupational health practice
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and education will be immune. Organisation of practice will need to change in response to changing employment patterns and the increasing number of small businesses and home-based workers. In order to serve this worker population it will be necessary for occupational health nursing specialists to act as consultants, not only to employers but also to primary health care teams and to school and college health services within a defined geographical area. They will require IT, business and marketing knowledge and skills to enable them to market and provide flexible, high-quality, professional services that are relevant and responsive to the needs of workers, prospective workers and employers. The rapidly expanding telecommunications technology and the availability of computers means that multi-media distance learning will become a reality in most parts of the world. This will probably lead to professionals choosing to undertake specific modules of learning in their own home and on their own time, using the new technology to acquire or update their specialist knowledge, take responsibility for their own learning and develop problem-solving skills. Educators (and the professional bodies) will need to be flexible and respond rapidly to the changing needs of the professions and of society. This essential flexibility and rapid response rate, allied to the academic’s research skills, creativity and problem-solving, means that the present, increasingly bureaucratic systems of control in higher education may need to be relaxed. This could lead to more autonomy for the nurse teacher within a very loose management structure. Quality of education will continue to be monitored by the professional bodies, employers and the state; the standards used to judge the quality would prove to be very mechanistic and quantitative unless the profession and its educators were involved at all stages. Changes in higher education funding, with the cost of professional education being borne by the individual rather than by the employer or the taxpayer, seem likely to increase the demand for personalised educational programmes using distance-learning materials. Will there come a day when peripatetic teachers spend time working alongside distance-learning students to encourage the integration of theory and practice and to provide the necessary role model for students working as sole occupational health nursing practitioners? This provision of what is, in effect, a lecturer/practitioner might be seen as attractive and cost-effective by students and employers. Professionally, it should ensure relevant preparation for practice. We live in an exciting time of change. Perhaps the greatest learning need of occupational health nurses is to develop the skills to manage and cope with the change itself, and to help workers develop the same skills in order to reduce stress and improve and maintain their health status.
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References and Further Reading Association of Occupational Health Nurse Educators web site, www.aohne .org.uk (with links to UK Higher Education Institutions running courses in occupational health for nurses, some leading to registration on the third part of the NMC Register as ‘Specialist Community Public Health Nurse – OH’). DoH (2001) The NHS Plan: an Action for Nurses, Midwives and Health Visitors, London: DoH. Flexner A. (1915) Is Social Work a Profession?, Proceedings of the National Conference of Charities and Corrections, Chicago. Houle C.O. (1980) Continuing Learning in the Professions, London: Jossey-Bass. Hoyle E. (1980) Professonalization and Deprofessionalization in Education. In: Hoyle E. and Megarry J. (eds) The Professional Development of Teachers: World Year Book of Education, London: Kogan Page. Hoyle E. and John P.D. (1995) Professional Knowledge, London: Cassell. Jarvis P. (1983) Professional Education, London: Croom Helm. Maynard L. (2003) Under Supervision, Occupational Health, June. Nicholls S., Cullen R., O’Neill S. and Halligan A. (2000) Clinical Governance: its Origins and its Foundations, British Journal of Clinical Governance 5(3), 172–8. NMC (2004) Standards of Proficiency for Specialist Community Public Health Nurses, London: NMC, www.nmc-uk.org. Royal College of Physicians of the UK (1994) Continuing Medical Education for the Trained Physician, London: Royal College of Physicians. Schon ¨ D.A. (1983) The Reflective Practitioner: How Professionals Think in Action, London: Temple Smith. UKCC (1991) Report on Proposals for the Future of Community Education and Practice, London: UKCC. UKCC (1994) The Future of Professional Practice: the Council’s Standards for Education and Practice Following Registration, London: UKCC. UKCC (1999) Draft 29: a Higher Level of Practice: Draft Descriptor and Standard, London: UKCC. UKCC (2001a) Supporting Nurses, Midwives and Health Visitors through LifeLong Learning, London: UKCC. UKCC (2001b) The PREP Handbook, London: UKCC.
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Research
Jan Maw and Stuart Whitaker
The purpose of this chapter is to provide occupational health nurses in practice with an insight into the development of research in occupational health nursing, and to highlight some of the key issues facing occupational health nurses as they move towards becoming more researchbased professionals. The chapter aims to stimulate critical thinking and reflection, and to offer practical advice on getting started in undertaking research.
Introduction and Background
Research and Research-Based Practice Research – the systematic and scientific process of enquiry that produces valid results from which accurate conclusions can be drawn – and research-based practice – the use of research findings to underpin and guide clinical practice – have become buzz words in the world of nursing. However, research in nursing is not new. Florence Nightingale, in the midst of the Crimean War, involved herself in collecting statistics on mortality rates to show that more soldiers were dying of wound infections than on the battlefield itself. This is a good example of a nurse collecting reliable scientific evidence to influence decision makers. However, influencing decision makers or those who might fund additional services is often not so easy. Identifying clearly the type of information required to adequately inform or influence others is a key consideration at the planning stage in any research undertaking.
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In more recent years there has been an explosion of interest in nursing research, and the growing number of research journals aimed specifically at nurses, as well as the number of senior academic appointments in nursing circles, point to a rapid development of research in nursing. This development is not limited to generic research carried out by nurses, possibly directed by others, but includes the development of nursing researchers; nurses who are interested in investigating nursing interventions in order to improve the quality of nursing care. This can be seen as research ‘on’ nursing, carried out by nurses, with the aim of improving nursing practice and building a unique body of knowledge with which to underpin the profession. However, while many occupational health nurses do use research findings and other types of evidence as a basis for their professional practice, when we come to look at the level of research activity in occupational health nursing and the development of an evidence base specifically for occupational health nursing practices, these are often much less well developed than for our counterparts in other nursing disciplines. In contrast to the expansion in academic nursing departments, research positions open to nurses and the appointment of professors of nursing within the UK, there is still not a single professor of occupational health nursing in this country. The development of an academic base for occupational health nursing practice lags far behind many other nursing specialities. An increasing value is now placed on evidence-based practice in nursing, and on the research that underpins it. Research literacy skills, such as searching for evidence, critically appraising it and utilising it in practice have become important for occupational health nurses today. Some progress has been made since the first editions of this book were published. However, when we look at the development of evidence-based practice, specifically for occupational health nursing practices, this has not proved easy. Many experienced occupational health nurses have worked in relative isolation, sometimes with limited opportunity to attend further training courses to equip themselves with the skills necessary for practising in this way. Others who have tried to access information on which to base their nursing practice have run into difficulty in finding reliable sources of evidence or in finding evidence that is directly relevant to their own context and setting. When discussing the evidence base for occupational health nursing specifically, the situation is made difficult due to the lack of high-quality research carried out into occupational health nursing practices. There are many reports in the journals of interventions carried out by occupational health nurses in practice, sometimes with the introduction of quite innovative ideas, but more often than not these are simply descriptive articles with little or no attempt at rigorous evaluation. The evidence from these publications is sometimes not generalisable to other
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populations or settings. Therefore, we are often left wondering what the evidence to say that one approach is better than another really is, or what outcomes are achieved at what cost. In part this situation is due to the absence of research carried out by occupational health nurses in practice and to the very limited number of occupational health nurses who work in academic centres where such research might be expected to be carried out. In addition, the economic pressures to deliver routine services, rather than to objectively investigate the efficiency or effectiveness of those services, can divert attention away from undertaking research. Research is not always an activity that is highly valued by our customers, employers or professional colleagues, and this can make it difficult for those who are interested and motivated to undertake research to actually achieve their goal. If a research agenda is to develop in occupational health nursing in the UK, this will require innovative individuals, with access to supportive academics with experience of research, to pursue different areas of interest. These people will need to be helped and supported by practitioners in the field, both in gaining access to research funding and in accessing populations or settings in which their research can be carried out. The introduction of the nurse consultants in occupational health in the NHS offers a possibility for a research agenda to be identified and pursued. Other groups of occupational health nurses, for example those in local authorities, the police, prisons and large-scale commercial providers of occupational health services might also be in a position to join together to undertake research into the efficiency and effectiveness of their own nursing practices. It is important that the results of these studies are presented for wider discussion within the profession and published in high-quality journals where others can develop these ideas further. Only in this way can we develop a sound research base for our professional practice.
Research Guidelines This section aims to provide a brief overview of the key steps that you will need to be familiar with in order to carry out and critique basic research, and to provide guidance on the production of effective reports. The information is presented in a simple, user-friendly format with the intention of demystifying the research process. The objectives are to define research, outline the research process, consider some common approaches and their application, and finally to provide guidance on writing effective reports to management. At the end of the chapter, you will find a selection of texts for guidance. It is recommended that the frameworks presented here are supplemented by further reading of the numerous texts devoted solely to the principles and application of research, statistics and report writing.
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Definitions Broadly, there are three main categories of research activity: funded research, research projects as part of an academic course of study and personal research to underpin and inform occupational health nurse activities. It is the last type of research that is primarily the focus of this section of the chapter: research that you undertake as a part of your day-today activities as an occupational health nurse. The thrust of this activity is your personal and professional judgement about the need for more evidence to underpin practice and/or the need for evidence to support your recommendations for services and/or interventions. Whether you decide to carry out your enquiries in isolation or to recruit the help of others, the rigour with which you undertake the enquiry and the way in which you present the findings will affect how seriously your findings are taken and your professional credibility.
Why Should Occupational Health Nurses Be Interested in Research? Occupational health nurses practise in diverse settings and with increasing competition from other professionals. It is therefore crucial that occupational health nurses are able to provide sound, evidencebased arguments which demonstrate ‘added value’ to their employing organisations. Further, nursing as a whole has recognised that there is an urgent need to examine the basis on which care is founded, and all nurses should function as reflective practitioners, continually assessing practice by asking the following fundamental research questions:
r r r r r r r r
What are we doing? Why are we doing it? Is it being done efficiently? Is it effective? When and where is it inefficient or ineffective? What does it cost? Is it acceptable to the client and customer? Can it be done better?
Research Design Empirical research is based on the results of experiment, observation or experience, and may be quantitative or qualitative in nature. Quantitative research is concerned with hard facts and quantification of the results by statistical analysis, whereas qualitative research is concerned with the quality of experience, beliefs and attitudes, and seeks to gain in-depth understanding of concepts. Qualitative research can help to
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Quantitative
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Qualitative
DEDUCTIVE
INDUCTIVE
physical sciences
social sciences
objectivity
probe deeply depth of understanding
POSITIVIST
ANTI-POSITIVIST
HARD DATA
SOFT DATA
build and generate laws
unique and difficult to generalise
generalisation
cannot be generalised
RESEARCH IN NURSING REQUIRES BOTH
Figure 16.1
Common Approaches in Research
generate hypotheses or give insight into a situation as experienced by individuals. Quantitative research can test these hypotheses, and investigate how widely individual experiences might be mirrored in a larger population. The nature of occupational health nursing lends itself to both types of enquiry (see Figure 16.1). Quantitative research is a top-down approach and aims to establish laws, to control, to predict, to be objective, positivist and inductive. The purpose of quantitative research is to test theory. It is concerned with measurements that can be analysed by statistical methods, for example comparing sickness absence rates, accident rates, uptake and use of services, etc. This type of research sets out with a firm picture of what is to be measured or observed, and uses specific instrumentation to record data; all data are ultimately converted to numerical form and subjected to statistical testing. Epidemiology, the large-scale study of disease in a population, is one example of quantitative research carried out in occupational health. Findings are always based on data from samples that are large enough for statistical manipulation and that are selected by random sampling, i.e. by giving everyone in the study population an equal chance of becoming one of the sample, thus making the sample representative of the population as a whole. The purpose is to minimise bias through the application of rigorous controls, so that the results can be generalised, going beyond interpretation to prediction. Examples of quantitative research in occupational health nursing might include: the study of sero-conversion rates over a five-year period for hepatitis B vaccine; study of rate of compliance for using personal protective equipment following training and instruction, by comparing a group that has been trained with another that has not; comparison of back injury rates before and after the introduction of new lifting equipment.
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Qualitative research, which might be considered a softer form of research because it does not focus on numbers and statistical analysis, attempts to illustrate and highlight the experiences, views, opinions and beliefs of those involved. Such issues as sample size, selection and generalisability of results are not key considerations, as they would be in quantitative research. Qualitative research is a bottom-up approach and aims to describe or give description to generate hypotheses, to illustrate and/or add more information, to understand relationships and/or causes, and to develop theory. Unlike quantitative research, where the researcher knows at the outset what is to be measured/tested, in qualitative research the researcher does not know what is being measured until late in the process. The focus is on the generation of important questions, with emphasis on the subjects’ experiences of phenomena. Data are rich with insight, depth and feeling, are contextual in nature and aim to go beyond the ‘what is’ to the ‘why it is’. Collection of data might, for example, include indepth interviews or observation. The approach and the depth of data mean that results cannot be generalised. In other words, you are able to say ‘what is’ only for the sample of the population you have studied, and you need to be cautious about inferring that the same conclusions could be applied to other groups without further testing. However, qualitative research provides insight and understanding, and generates important questions. Examples of qualitative research in occupational health nursing might include: perceptions and attitudes to the role of the occupational health nurse; the individual’s experience of working rotational shifts; beliefs related to compliance with personal protective equipment policies. Many research designs incorporate both quantitative and qualitative approaches and use a variety of methods of gathering information, described as ‘triangulation’ in research texts. When results are consistent in their support of each other, the evidence has stronger conviction, giving weight and credibility to conclusions and recommendations.
The Eight-Step Research Process Whatever the purpose of the investigation or the method used, the whole research process consists of the following eight steps: 1. 2. 3. 4. 5.
Defining the subject and purpose of enquiry. Literature search and review. Planning the methods of investigation. Pilot study. Data collection.
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6. Data analysis. 7. Conclusion. 8. Writing a report.
Defining the Subject and Purpose of Enquiry An example would be that you have observed a mismatch in the way that managers in your organisation perceive the role and function of the occupational health service. You may have heard or seen something, or have frequent requests for services that your department does not offer. Or it may just be a hunch, something that you feel needs further enquiry. At this stage it is important that you write down in clear and precise terms exactly what it is that you are asking. What exactly is the question? What exactly are you trying to solve? What hypothesis (a supposition used as a basis from which you will draw conclusions) do you want to test? The definition of the purpose of the research is crucial. The example given could provide you with several research questions. For example:
r What do managers perceive the role of the occupational health department to be?
r What beliefs and values have formed managers’ perceptions of the occupational health department?
r What are the rates of inappropriate referrals to the occupational health department?
r What factors generate inappropriate referrals to the occupational health department?
r What effect does the information about the role and function of the occupational health department have? Although these may seem basic questions, and all may seem relevant to your enquiry, you have to decide how many of the questions can be tackled given your resources and time scales. There must always be a balance between the breadth of your data collection and the depth of the material gathered. At this stage it is also worth considering what you will do with the results of your study. Do you hope to inform or influence others and can you test prior to your study that the information you are about to collect will be valued by them? For example, we as nurses may wish to know more about the lived experience of people who develop occupational asthma, and expect decision makers to be influenced by the tragic stories that some of our patients can tell. However, decision makers may be more interested in how many people are affected, what the costs are to the company and what the cost might be of reducing the risk. So consideration of the use of research findings, prior to deciding upon a particular approach or study design, might be worthwhile.
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Literature Search and Review At this stage, you should examine what others have found and said about the topic and which methods were used in previous research. This is particularly important if you want to compare and contrast your findings with what others have found in different populations. The literature search and review will provide you with a comprehensive knowledge of the subject under investigation, as long as you have searched all of the relevant data bases and identified the key papers. Designing and undertaking a comprehensive and thorough literature search is a key stage in starting your research. You may find answers to part of your enquiry and therefore decide to tackle the enquiry from a different angle, or to reproduce a good study with your own population. In addition, the search might provide you with examples of research design and data collection methods, such as questionnaires, that you could use within your own enquiry, saving valuable time and providing data against which you can compare your results. It is important to set clear parameters for your literature review and to explore books, journals and computer data bases for background information on the subject. In the example given, you may need to consider not only research on the role and function of the occupational health department, but also management systems and the role that perception and understanding play in establishing beliefs and values. At this stage it is wise to take stock and, if necessary, to redefine the purpose of the enquiry. You need to be quite clear about the value and use of the results of your research, about why it should be done, if you can feasibly do it and whether or not you want to do it.
Planning the Methods of Investigation Next you will need to decide on the type of research that is most appropriate to your enquiry, i.e. descriptive/qualitative or experimental/ quantitative, or maybe a combination of both. Owing to the nature of nursing work, the majority of nursing research is embedded in qualitative design. However, there is a very real need to be able to demonstrate, where appropriate, the statistical validity of comparative numerical data. Many nurses, including occupational health nurses, feel unable to tackle even the most basic statistical analysis. This may not be a problem if you work in a large department on large projects and have statisticians involved as part of the team. For smaller-scale projects and information-gathering for management reports it is still crucial that the correct methods are applied, so that the results are accurate. As with any other aspect of nursing, research should be undertaken only by those competent to do it; in other words, those with the training, skills and experience, or adequate supervision. Many universities and colleges
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run short courses that aim to demystify the research process and provide a basic understanding of the use of computer packages and of report writing. You will need to decide on the details of the data or information to be collected, and the relevant variables will need to be identified. By doing this, you will narrow the focus of your enquiry and begin to identify what might bias or confound (or confuse) your results. In the example given, you might examine records or monitor referrals to the occupational health department in order to count the number of inappropriate referrals, or ask managers directly about their perceptions of the role and function of the occupational health department. You will also need to decide what sample of people you will ask or observe, for example all managers, or a sub-section of managers, or managers from one location only. If you narrow the sample, consider what effects this may have on your overall conclusions. Once you have decided on the techniques you will use for collecting the data, for example observation, questionnaire or interview, you will need to be clear about your method of analysis. This can range from hand sorting to computer coding, using coded themes from interview transcripts and/or statistical analysis. The main questions you should ask yourself are:
r If I gather information in this way, will it capture what I want to know?
r If it captures what I want to know, will I be able to tease it out of the data or will I have so much data that it will be confusing?
r Can I be sure that I have asked or observed the right things, at the right time and in the right numbers, to be sure that what I have found is a true representation of the facts? Finally, before you undertake research activities in another person’s area, you must be sure that permission is obtained from the appropriate quarters and that all possible ethical and legal implications have been considered and understood by everyone involved. Gaining ethical consent from a local ethics committee can be a timeconsuming and complex process, but this is an important step and occupational health nurses must adhere to the committee’s guidelines, even if this adds an additional layer of complexity to their work. For many types of analysis of routinely-collected data that does not identify individuals or influence their care or treatment, an audit cycle can be used to help identify and improve standards. Clinical audit of this type does not generally require ethical clearance from the local ethics committee, so seek their advice early. The local NHS Trust will be able to supply you with the contact details for its ethics committee.
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Pilot Study When you are satisfied that you have a clear plan of action, it is important to carry out a pilot study. This, in essence, is a mini research project using a small sample that is as similar as possible to your intended sample. A pilot study gives you the opportunity to test your method of data collection and the feasibility of analysis, allowing you to identify weaknesses and modify parts of your method. The aim of the pilot study is to allow you the opportunity to identify and correct faults, limitations or difficulties in your larger study. Do not be afraid to change, adapt and tailor your research project in light of the findings of the pilot study. It is, for example, soul destroying to conduct several taped interviews only to find that your tape machine was faulty, or the background noise from the factory has been picked up and makes transcription impossible. The pilot gives you a chance to check out the logistics of the technique:
r Does the type of data collection you have planned actually work? r Does it capture the type of evidence/information that you need to answer the research question?
r Do you end up with a lot of information that, although interesting, does not help you solve the mystery you set out to solve? If you find that you have to adjust your original data collection tools significantly, it is worth spending a little extra time on additional pilots until you are satisfied with the results.
Data Collection When you are satisfied with the results of your pilot(s), you can proceed with the full-scale data collection (Figure 16.2).
Data Collection Methods Interview Observation Critical Incident Action Research Questionnaire Delphi Technique Multiple Sort Technique Repertory Grid Technique
Figure 16.2
Examples of Data Collection Methods
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Data Analysis You should have decided at the planning stage how you are going to analyse the data. In essence, at this stage you are sorting through the evidence to find clues that either support or refute your research question. Good detectives may go on hunches to seek out evidence, but they never draw conclusions without the facts. The facts emerge as you group, code and classify the data. You may have decided to count data to find out how many times a particular response occurred or a particular event took place, or to subject the data to statistical analysis.
Conclusion The inferences and conclusions that can be drawn from a piece of research depend mainly upon two factors: the sample (how it was taken and if it was representative) and the results (for example, differences between samples or against predetermined standards or previous research). Note that conclusions should be firmly tied to the research question. Do not be dismayed if you end up with as many new questions to answer as answers to the original enquiry. Research is a continual activity, and recommendations for further research activities form part of the learning process.
Limitations All research projects have limitations and it is part of the research process for you to identify and acknowledge the limitations of your own work. Do not overstate the case for your findings in your interpretation or discussion of the results. If there is more than one possible explanation for the results, or if there are gaps in knowledge, then it is useful to identify these and discuss them openly. Often research projects do identify the need for further work. Research projects often add a new piece of information but rarely the whole picture, so do not be afraid to set your findings in context.
Critical Appraisal of Research Reports Occupational health nurses will be expected to examine the reports of others and to analyse and comment critically upon the importance of their findings and recommendations. As with your own research and report writing, you should look for logical sequencing and an understandable and appropriate style that is clearly underpinned by a firm research base and leads to reasoned discussion and recommendations.
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You should look for: general information on the subject; analysis and criticism of the subject; other research activities related to the subject; comparison and contrast between authors; the eminence of the author(s); the value of the recommendations; the recency of the presented data. In judging the credibility of a research report, you will need to consider the following:
r Is the abstract a clear, concise and succinct summary of the research work?
r Does it provide an outline of the aims of the study/research question, the methodology used, brief overall results and the conclusion/ recommendations? r Does the literature review provide a comprehensive survey of relevant texts and papers that demonstrates up-to-date reading and analyses, and assimilates the information? The research question should be clear and well defined, so that you know exactly what the researcher was aiming to investigate, and should be linked to the reviewed literature and provide you with sufficient insight into the importance and relevance of the enquiry. The method chosen for the research should be clearly outlined, so that you have no doubt about how the researcher conducted and gathered information. The writer should have provided justification for the chosen approach, outlining its relevance to the research problem. There should be evidence to show how the method analysed the problems/issues, and what advantages or limitations there may have been. A succinct explanation of how data were collected and analysed should be given, as well as a discussion of the sampling plan. You will then be in a position to judge the appropriateness of the methodology and sampling. A good paper will also outline the limitations of the study, and discuss how these may have affected the overall results and conclusions. Results should be presented in a clear and simple way appropriate to the research method outlined, and should not be confused with discussion, presenting only ‘what has been found’ from the data collection. You should be able to see a clear link to the way in which the researcher stated the data would be collected and analysed, and to identify the links to the stated sampling frame. The discussion and conclusions should link the literature and methodology, and debate the relevance of the findings. There should be discussion of the possible disadvantages and limitations of the methodology and data collection, and of whether the research adequately answered the research question. Always check that any conclusions drawn are firmly rooted in the results. Ask yourself whether the conclusions are supported by reference to existing research and practice. If they are not, did the researcher provide adequate evidence from the literature to
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support ‘hunches’? Was the researcher able to provide tentative recommendations for practice in light of the results? Overall, were you able to understand what and who were being examined, by whom, how and where they were examined, and why and when the research might apply to your practice? These are also useful guidelines to follow when writing up your own project.
Effective Report Writing: Using Findings to Influence Decision-Making The purpose of the report is to make known the findings and to inform people how the study was carried out. This allows the reader to assess the value of the work and to use similar methods in future research if they so wish, and to avoid similar mistakes and limitations in future research. When writing the report, it is important to remember its purpose, and the people who will be reading it. In its simplest form, the report should be a summary of what you set out to investigate and why, how the data were collected, the findings and their significance (Parahoo and Reid 1988). Reports should be written in a clear and concise way. The language should be simple and straightforward, and you should be cautious about over-generalising your results. It is also dangerous to assume that the reader has the same level of understanding of the subject as you, so avoid the use of jargon and minimise abbreviations. The ultimate aim of seeking research-based evidence is to support and improve occupational health nursing practice. The final stage of condensing and disseminating the information into an effective management report is an essential part of occupational health nursing work, as reports are influential tools if produced and used effectively. Reports serve two main functions: they provide a permanent record and they provide information for decision-making. The form and quality of your report will determine how seriously the subject you have researched is taken and what actions will follow. Your professional ability and credibility will be judged by the written product. The form of the report should describe clearly and in logical sequence the steps that you have taken to complete the work/investigation/research. Effective reports will influence decision-making.
The Structure of the Final Report Think of the exercise in five phases: abstract, introduction and summary, conclusions, recommendations, references and appendices. The abstract is a synopsis of the whole research activity, and is often given
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a much wider circulation than the full report, acting like an information flier. It should be a maximum of one page in length and presented separately from the main report. Reference to the key words in the report should encapsulate its essence in a few lines. Give the title, date, author and where a copy of the complete report can be found. Include a brief outline of the problem, method, results, conclusions and recommendations. Also, give the names of any senior staff who commissioned the activity; the presence of a managing director’s or senior nurse’s name has a profound effect on whether recipients actually read or file the paper. The introduction and summary should give the purpose of the report and details of any authority/support for the research. As already stated, this can be a very important selling point to the reader. If the chief executive or managing director has sanctioned the report, it is more likely that line managers and supervisors will pay attention to the findings. The methods used to gather data should also be given. Avoid too much detail at this stage, giving only the main conclusions and recommendations, along with the objectives, which will set the scene for the reader. The reason for the presence of a summary at the beginning of a report is that repetition is helpful for complex or long reports. Some readers only ever read the introduction and summary of reports, so it helps to fix the most important points in their minds. The main body of the report is a series of chapters or sections in logical sequence. First present the findings or evidence, and then go on to the analysis. Discuss existing systems, such as plant or process; existing knowledge, including previous research findings; the existing situation and related legislation; and the importance to the subject under enquiry. Describe what is known, compare and contrast, and give a detailed analysis of the current problem or situation. The conclusion is where the main discussion takes place. This should come before the final recommendations and should contain two main components: first, the heaviest weight of evidence and information; second, the outcome of the interpretation and evaluation of your findings. The recommendations section gives the final touches to the report, drawing together the evaluation of the data, evidence and findings. It is worth discussing the report at the draft stage with the manager/clients or whoever has requested the report, as additional or alternative solutions may be offered. Managers and clients will be far more likely to accept and implement your recommendations if they do not come as a complete shock and if the logic of your recommendations is familiar to them. Note that main conclusions and recommendations should not be scattered throughout the report, as this weakens its structure. No new information or arguments should appear at this stage, only what can be concluded from the preceding data.
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References and appendices appear at the end of the report. In general, long or complicated tables and figures should not be in the main body of the report. There should be a reference in the report text to the appended materials. Where you provide tables or charts within the report, it is wise to ensure that any discussion or description also appears on the same page, for ease of interpretation. In the appendices you may also include sample documents, long extracts, supporting reports, a list of notes, etc. Remember that working papers should be available for inspection, but you do not need to put all the working papers in the appendices, only those which are required to support the discussion and recommendations.
Conclusion Every nurse should have an understanding of the research process and be able to retrieve and critically assess research findings and produce effective reports. This is an essential part of keeping abreast of developments within the profession and continually improving the practice of occupational health nursing. This does not mean that every occupational health nurse is expected to carry out their own research projects. The most useful approach for many occupational health nurses, in particular the sole practitioner, is to learn how to gather information competently for management reports, to participate in larger-scale projects where appropriate, and to use good published research to inform their own practice. We hope that this chapter will encourage you to continue the development of evidence-based practice with a deeper understanding in order to support and promote the well-being of the working population.
Acknowledgement LMU (1995/96) Research Guidelines; Professional Nursing Group, Faculty of Health and Social Care, Leeds Metropolitan University.
References and Further Reading Aw T.C., Whitaker S. and Harrington J.M. (2006) Protecting and Promoting Health in the Workplace. In: Pencheon D., Guest C., Melzer D. and Muir Gray J.A. (eds) Oxford Handbook of Public Health Practice, 2nd edn, Oxford: OUP. Clifford C. (1990) Nursing and Health Care Research: A Skills-Based Introduction, 2nd edn, Englewood Cliffs, NJ: Prentice Hall.
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Crabtree B.F. and Miller W.J. (1992) Doing Qualitative Research: Research Methods for Primary Care, London: Sage. Dempsey P.A. and Dempsey A.D. (1986) The Research Process in Nursing, New York: Van Nostrand. Field P.A. and Morse J.M. (1985) Nursing Research: the Application of Qualitative Approaches, Beckenham: Croom Helm. Gehanno J.F. and Thirion B. (2000) How to Select Publication on Occupational Health: the Usefulness of Medline and the Impact Factor, Occupational and Environmental Medicine 57(10), 706–9. HM Government (2005) Health, Work and Well-Being: Caring for our Future: a Strategy for the Health and Well-Being of Working Age People, London: HSE, www.dwp.gov.uk/publications/dwp/2005/health and wellbeing.pdf (accessed 15 July 2007). Kane E. (1991) Doing Your Own Research: How to do Basic Descriptive Research in the Social Sciences and Humanities, London: Marion Boyars. Kitson A. (ed) (1993) Nursing: Art and Science, London: Chapman & Hall. Leininger M. (ed) (1985) Qualitative Research Methods in Nursing, New York: Grune and Stratton. Kivimaki M., Leino-Arjas P., Luukkonen R., Riihimaki H., Vahtera J. and Kirjonen J. (2002) Work Stress and Risk of Cardiovascular Mortality: Prospective Cohort Study of Industrial Employees, BMJ 325(7369), 857. Monduzzi G. and Franco G. (2005) Practising Evidence-Based Occupational Health in Individual Workers: How to Deal with a Latex Allergy Problem in a Health Care Setting, Occupational Medicine 55(1), 3–6. Nolan B. (1994) Data Analysis: an Introduction, Cambridge: Polity Press. Parahoo K. and Reid N. (1988) Research Skills, Number 4: Writing Up a Research Report, Nursing Times 84(42), 63–6. Polit D.F. and Hungler B.P. (1991) Nursing Research Principles and Methods, 4th edn, Philadelphia: J.B. Lippincott. Read N.G. and Boore J.R.P. (1987) Research Methods and Statistics in Health Care, London: Edward Arnold. Robson C. (2002) Real World Research, 2nd edn, Oxford: Blackwell. Rowntree D. (1991) Statistics without Tears: a Primer for Non-Mathematicians, London: Penguin. Sackett D.L., Straus S.E., Richardson W.S., Rosenberg W. and Haynes R.B. (2000) Evidence Based Medicine: Hot to Teach and Practice, 2nd edn, London: Churchill Livingstone. Schaafsma F., Verbeek J., Hulschof C. and van Dijk F. (2005) Caution Required when Relying on Colleagues’ Advice: a Comparison between Professional Advice and Evidence from the Literature, BMC Health Services Research. Silverman D. (2001) Interpreting Qualitative Data: Methods for Analysing Talk: Text and Interaction, 2nd edn, London: Sage. Stevens P.J.M., Schade A.L., Chalk B. and Slevin O.D’A. (1993) Understanding Research: a Scientific Approach for Health Care Professionals, Edinburgh: Campion Press. Sussams J.E. (1993) How to Write Effective Reports, 2nd edn, Aldershot: Gower.
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Tierney A. (1993) Research Literacy: an Essential Prerequisite for KnowledgeLed Practice, Nursing Standard Nurse Researcher 1(1), 121. Treece E.W. and Treece J.W. (1977) Elements of Research Nursing, 2nd edn, St Louis, MI: C.V. Mosby. Westerholm P., Nilstun T. and Ovretveit J. (2004) Practical Ethics in Occupational Health, Oxford: Radcliffe Medical Press Ltd. Verbeek J., Husman K., van Dijk F., Jauhiainen M., Pasternack I. and Vainio H. (2004) Building an Evidence Base for Occupational Health Interventions, Scandinavian Journal of Work, Environment and Health 30(2), 164–70. Whitaker S. and Aw T.C. (1995) Audit of Pre Employment Assessments by Occupational Health Departments in the National Health Service, Occupational Medicine 45(2), 75–80. Whitaker S. (2001) The Management of Sickness Absence, Journal of Occupational and Environmental Medicine 58(6), 420–4. Whitaker S. (2004) Health Examinations on New Employment: Ethical Issues. In: Westerholm P., Nilstun T. and Ovretveit J. (eds) Practical Ethics in Occupational Health, Oxford: Radcliffe Medical Press Ltd. WHO (2006) A Practical Guide for the Use of Research Information to Improve the Quality of Occupational Health Practice: Protecting the Workers’ Health Series, Number 7, Geneva: WHO.
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Access to Medical Reports Act 1988 62, 186, 188–9, 192, 279 accidents 4, 39, 58, 77, 131, 152, 159, 163, 165, 167, 171, 176, 183, 210, 217, 239, 242, 254, 283 accountability 1, 2, 11, 13–14, 88, 297, 304, 306 adjustment reaction 208 affective disorders 208–9 AIDS see HIV/AIDS allergies 243 alcohol 13, 30, 49, 185, 206, 208, 210, 246, 280–1 Allitt Inquiry 20 American Association of Occupational Health Nurses (AAOHN) 141–4, 153–4 Angus Council v Edgley 49 anthrax 7 anxiety disorders 208–9, 212 arsenic 7 asbestos 32, 78, 193, 240 Association of Occupational Health Nurse Practitioners (AOHNP (UK)) 9, 46, 99, 134, 253, 269 asthma 13, 98, 103, 183, 319 audiometry 37, 41, 79, 81, 128–9, 182–4, 188, 242, 249
audit 4, 16, 43–7, 68, 72, 80–1, 87–102, 114, 121, 128, 144, 170–4, 179, 203, 275, 297, 304, 321 type 1 89 type 2 89, 92 autonomy 11–12, 28, 148, 199, 207, 254, 261, 295–6, 300, 310 back pain 19, 95, 98, 100, 173–4, 218, 260, 264–5, 269, 286 baseline assessments 33, 89, 92, 185, 221 Basingstoke and Dean Council v J. Sainsbury plc 170 Beck Depression Inventory 209 benchmarking 11, 46, 88, 90, 99, 100, 274 bias 189, 302, 317, 321 biological hazards 121 biological model 200 biological monitoring 179, 284 bipolar affective disorder 209 Black Report 6, 246 blood pressure 189–90 brain 204–5 British Safety Council 205 budgeting 75–7, 85 Business Link 111, 132
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business objectives 28, 30, 35, 39, 75, 129 business plans 70–3, 75, 80, 83, 85, 96, 102, 111–13, 123 see also planning and control caffeine 206 cancer 7, 19, 257, 285 catecholamines 204, 206 Chadwick, Edwin 6–7 Chambers of Commerce 111, 169 chemical hazards 12–13, 29, 32, 121, 181, 184 childcare facilities 200, 205 cholera 5 clinical audit 81, 89, 93, 179, 304, 321 clinical governance 15, 88, 299, 304–5 cold calling 115 communication 1, 28, 38, 121, 258–61 community health care 300 community public health nurses 2, 8, 303–4 compensation 29, 30, 41, 200, 258 competent persons 11, 159, 167, 169–70, 175 Computer Misuse Act 1990 62 computers and IT 38, 51–2, 62–3, 70, 77, 106, 109–10, 114–15, 181, 187, 193, 218, 222, 227, 285, 310, 320–1 conclusions of research 191, 313, 318–9, 321, 323–6 Confederation of British Industry (CBI) 191 confidentiality 2, 13–14, 53–5, 63, 100, 117, 128, 182, 188, 192–5, 262, 275, 277, 307 consultancy 2, 19, 108–9, 114, 116 contracts 16, 112, 115–16, 119, 126, 131–2, 146 Control of Lead at Work Regulations 180, 186, 193 Control of Noise at Work Regulations 125, 164 Control of Substances Hazardous to Health Regulations (COSHH) 29, 32, 55, 78, 82, 164–5, 167, 180, 183, 186 coronary heart disease 238, 242, 246
corrective action 81–2, 85 cortisol 204, 206–7 cost-effectiveness 77, 89, 95, 151, 248, 294 costs 27, 35, 71, 95–6, 102, 107, 116, 130–1, 218, 223, 245, 258, 278, 299, 319 Council of Ministers 146–7 counselling 3, 11, 34–5, 95, 125, 127–8, 144, 204, 241, 261, 279, 282 credit accumulation and transfer (CATS) 299, 309 Critical Success Factors (CSFs) 75, 80 culture 16, 28–9, 34, 39, 41, 72, 88–9, 123, 126, 132, 160, 168–9, 171–3, 199, 203, 225, 241, 248, 281, 295, 305 Cycle of Change model 144, 146 see also Stages of Change model damages 13 data collection 166, 173 Data Protection Act 1998 61–2, 182, 190, 192–3 deafness and hearing loss 30, 40, 181, 183, 249 degrees and universities 141, 143, 149–53, 182, 248, 299, 303, 320–1 delirium tremens 210 Department for Work and Pensions 112, 260, 283 Department of Health 16, 18, 50, 165,186, 254 depression 197, 209, 263, 278, 281, 286 dermatitis 183 disability 6, 10, 13, 187, 191, 207–8, 255–62, 264 Disability Discrimination Act 14, 179, 185–9, 207, 211, 224, 257, 278 Disability Services Team 257 display screen equipment 29, 109, 187, 221 distance learning 310 Diving at Work Regulations 186 doctors (including GPs) 5, 7, 16–17, 36, 48, 50, 55–6, 58–60, 63, 65–7, 70, 80, 83–4, 94, 100, 163, 182, 184–9, 207, 212, 215, 273, 275, 279, 282, 284, 286–7, 306, 308 document control 51, 81
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Douglas v Bexley and Greenwich Health Authority 174 drugs 30, 95, 185 see also alcohol education 2, 4–5, 12, 16, 19, 32, 38, 47, 65, 83–4, 129, 140, 142–53, 190, 238, 241–2, 244, 246, 250, 261–2, 265, 282–3, 293–310 Effort and Effect Model 207 Employment Medical Advisory Service (EMAS) 5, 17, 163 employment rehabilitation centres 255 Employers’ Forum on Disability 258 employers’ liability insurance 112, 131 endorsement 28, 38–41 English National Board for Nursing, Midwifery and Health Visiting (ENB) 254 environmental health 49, 141, 144–5, 162 ergonomics and ergonomists 4, 19–20, 128, 147, 181, 217, 219–35, 240, 246, 249, 261, 263 ethics 9, 13, 71, 88, 97–8, 120, 125, 127–9, 133–4, 142, 144, 186, 191–2, 280, 296, 302, 307–8, 321 European Agency for Safety and Health at Work 141, 146–7 European Commission (CEC) 141, 146–9 European Foundation for the Improvement of Living and Working Conditions 141, 146–7 European Foundation for Quality Management (EFQM) business excellence model 89–90 evaluation 4, 16–17, 47, 68, 74, 84, 94, 96–7, 111, 149, 183, 199, 202, 205, 209, 223, 238, 248, 283, 305, 314, 326 exposure to hazards 29, 183–4 eye-irrigation facilities 33 Factory Acts 7, 47, 160 Faculty of Occupational Medicine 186, 306 Federation of Occupational Health Nurses within the European Union (FOHNEU) 141, 148
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Federation of Small Businesses 132 fees and charges 2, 17, 107, 109, 111–12, 116, 129, 133, 280, 294 first aid 3–4, 17, 19, 29, 33, 35, 92, 150, 187 Flowerday, Philippa 6–7 food poisoning 6 General Medical Council (GMC) 63, 133, 182 generalisability of research 318 Gregson Report 6, 17 group OH services 15 hand-arm vibration 226 handicap 256–7 handling, storage and packaging 81–2 health assessments 29, 32, 35, 37, 48, 78, 80, 126, 144, 150, 179, 185–90, 193–4, 208, 259, 262, 264–5 Health Education Authority 238 Health and Morals of Apprentices Act 7, 160 health promotion 3, 13, 17, 36, 71, 78–9, 100, 125, 128, 143–4, 149–50, 173, 237–50, 261, 265, 298 health protection 4–5, 10–11, 150, 241–3, 261, 283 health and safety 4, 7, 11, 13–15, 17–18, 20, 28–30, 32, 34–5, 37, 39, 48, 51, 57, 69–70, 78–81, 91–2, 98, 128, 142–4, 146–9, 159–75, 179–80, 182–6, 188–9, 192–3, 201, 242, 249, 273, 301–2, 307–9 Health and Safety Commission 165, 172, 180, 201, 254, 265 health and safety committees 4, 51, 159, 171–3 Health and Safety (Display Screen Equipment) Regulations 32, 165, 221 Health and Safety (Enforcing Authority) Regulations 162 Health and Safety Executive (HSE) 5, 10, 17, 160, 162–5, 167, 169–70, 174, 180, 182, 184–6, 189, 201–2, 213, 217–9, 221, 223, 233, 238–40, 243, 282–3
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Health and Safety (First Aid) Regulations 41, 164 health and safety inspectors 78 health and safety representatives 184 Health and Safety at Work Act 7, 159, 161, 163–4, 167, 242 health screening 3, 11, 16, 31, 34–5, 39, 41, 44, 74, 91, 128, 179–80, 189–90, 193–4 health surveillance 3, 9–11, 15–17, 30–2, 35, 40, 48, 57, 71, 79–80, 92, 100, 108, 114, 125–6, 134, 144, 166–7, 172, 179–85, 190–4, 242, 271, 283, 306–7 Health, Work and Well-Being 9, 164–5, 283 healthy eating and diet 13, 78, 242, 246–7 hearing conservation programme 30, 40–1, 242 hearing loss see deafness and hearing loss heavy industry 12, 239 see also manufacturing hepatitis 50, 57, 99, 160, 186, 317 HIV/AIDS 30, 186, 257 human resources 29–31, 35, 39, 44, 56, 62, 69, 76, 261, 272–3, 304 Human Rights Act 14, 61, 285 hygiene and hygienists 4–5, 11, 20, 29, 32–3, 49, 67, 172, 185, 249, 307
International Commission on Occupational Health (ICOH) 141–2 International Labour Organisation 140–1, 306 Investors in People Award 91 Ionising Radiation Regulations 186 isocyanates 160, 183, 306
ill-health retirement 29, 31, 49, 78, 80, 202, 211, 238, 258 illness behaviour 211–12 impairment 207, 211, 255–60, 262–3 Improvement Notices 162–3 independent occupational health providers 14–15, 17, 105, 108, 117 independent practitioners 9, 108, 117, 120–2, 126 injuries 3, 19, 29, 31, 33, 52, 150, 161, 163–4, 166, 173–4, 182, 198, 218–20, 222, 224–5, 227, 231, 241, 246, 255–6, 260, 278, 298, 304, 317 insurance 5, 7, 13, 19, 29–30, 54, 62, 112–3, 116, 130–1, 168, 170, 202, 272, 286
maintenance of equipment 4, 81, 128, 130 male health education 19 malingering 212 Management of Health and Safety at Work Regulations 32, 159, 164–5, 167, 169, 180, 183, 186, 192, 201, 203, 221, 282 Management Standards for Work-Related Stress 201 manual handling 17, 19, 52, 165, 173–4, 181, 218, 221–2, 226–7, 229, 231, 233 Manual Handling Regulations 29, 32, 52, 165, 174, 221 manufacturing 12, 34, 121, 124, 160, 200, 239, 304
Job Centres 257 key personnel 29–30, 36, 39, 41 King’s Fund Audit 91 Labour Force Survey 182, 197–8, 218 lead 7, 78, 184, 240 licences 106 lifestyle 79, 125, 180, 190, 202, 238, 242, 244–7, 278, 285 lifestyle screening 17, 19, 189–90 limited companies 106–8 literature search and review 47–9, 98, 126, 248, 318, 320, 324 litigation 28, 31, 35, 45, 49, 128, 131, 279 liver disease 210 Local Health Boards 6 long-term absence 29, 31 lung function tests 81, 129, 182, 188, 242
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marketing 19, 72, 102, 106, 109, 111–12, 114–16, 119–34, 144, 168, 310 marketing mix 126–7, 129, 132 Maslow’s hierarchy of needs 238, 243, 247 mechanistic model 200 mental health 10, 13, 16, 47, 56, 61, 181, 193, 197–213, 215, 225, 276, 278–82 mining 239 monitoring 28–9, 31–2, 35, 40–1, 74, 76, 82, 88, 91, 93, 121, 132, 141, 166–7, 171, 174, 179, 184 Mountenay and others v. Bernard Matthews plc 166 musculoskeletal problems 147, 160, 197, 206, 217–35, 238, 283 mustard factory 6–7 myocardial infarction 261, 287 national boards 295, 298–9, 303 National Director for Work and Health 7, 9, 165, 283 National Examination Board for Occupational Safety and Health (NEBOSH) 170 National Health Service (NHS) 5–6, 14, 16, 70, 84, 88–9, 91, 93, 121–2, 173, 238–9, 241, 272, 294, 297, 299–300, 302, 304–5, 315 National Institute of Occupational Safety and Health (IOSH) 141–2, 165 National Insurance (NI) 110–12, 116, 130 National Vocational Qualifications (NVQs) 301, 307, 309 negligence 14, 166 networking 9, 46, 91, 131–2, 165, 244, 308 Nightingale, Florence 313 NHS Knowledge and Skills Framework (NHS KSF) 84 NHS Plus 16, 121 NHS Trusts 16, 121–3, 130, 185, 321 noise 30, 32, 40, 165, 181, 183, 249, 277, 322 Nursing and Midwifery Council (NMC) 2, 63, 133, 182, 303, 305
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obsessive-compulsive disorder (OCD) 209 Occupational Health Advisory Committee 122 Occupational Health Nursing Certificate (OHNC) 298 occupational health physicians 5, 17, 20, 46, 48, 91, 184–5 occupational health project (OHP) 15, 17–8 Office Shops and Railway Premises Act 161 Ogden v Airedale Health Authority 13 panic disorder 208–9 partnerships 8, 106–8 part-time work 200, 265, 306 performance appraisals 75, 84–5 personal pensions 27, 31, 54, 113, 130 personal protective equipment 29, 33, 181, 249, 317–18 Personal Protective Equipment Regulations 165 personality disorders 208, 210 phobic anxiety 209 physiotherapy and physiotherapists 17, 34, 66, 128, 174, 265, 278 pilot studies 318, 322 planning and control 28, 33–4, 78 see also business plans policies and procedures 4, 15, 35, 43–53, 71, 98, 108, 114, 128, 272 positioning 124, 126 post-registration education 295, 298–300, 305, 308–9 post-traumatic stress disorder 208 preceptors 297 pre-employment health assessment 29, 31, 35, 41, 44, 48, 126, 186, 188 presenteeism 212 preventive health care 4, 6, 10, 152, 184, 242 primary health care 6, 18, 190, 298, 301, 310 process control 81–2 productivity 39, 68, 76, 130, 202, 205, 219–20, 239–40 professional indemnity insurance 13, 19, 112–13, 130
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Prohibition Notices 162–3 Project 2000 297–8, 300 Provision and Use of Work Equipment Regulations 32, 165 psychiatry 208 psychosocial hazards 29, 32, 147, 181, 223–5 public health 1–2, 5–6, 8, 11, 19–20, 58–9, 150, 153, 237–8, 240, 249–50, 272, 283, 304 Public Health Act 6–7 purchasing 19, 77, 81, 115, 132–3, 233 purpose of research 318–19 ‘Purpose and Values’ statement 72–3 qualifications 2, 20, 34, 38, 65–6, 83, 120, 127, 131, 133, 169, 248, 299, 301, 304, 309 qualitative research 316–18 quantitative research 316–18 radiation 78, 181 radiographers 13 Railway Safety Critical Work Regulations 186 records 3, 14, 35, 45, 54–64, 81–2, 88, 95, 100, 128, 133, 174, 182, 184, 188–9, 191–4, 279, 307, 321 recruitment 31, 44, 102, 164, 187, 243 see also pre-employment health assessment rehabilitation 2–5, 10, 15–17, 97, 121, 144, 191, 219, 253–65, 271, 274–5, 279–80, 282, 284–5 Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) 33, 58, 161, 164, 182–3, 218, 278 reports 3–4, 14, 40, 51, 57, 62, 80, 106, 101, 109–10, 115, 122, 126–9, 171, 188, 215, 246, 280, 303, 314–15, 320, 323–7 research 1–3, 5, 10–11, 17–18, 44–9, 58, 72, 81, 90, 95, 97–100, 108–10, 112, 115, 126–7, 140, 142–4, 147, 219, 238, 243, 246–9, 283, 304, 307, 310, 313–27
resettlement 253–6 respiratory sensitisers 70, 162 retraining 255 return to work 16, 35, 80, 159, 185, 191, 211, 218, 249, 255, 258, 260–2, 264–5, 272, 274, 276–87 risk assessment 16, 19, 29–30, 32–3, 47–8, 70–1, 78, 92, 109, 128, 134, 144, 150, 152, 159, 165, 167–9, 173, 175, 179–80, 182, 185–6, 188–9, 191, 194, 202, 221–4, 233–4, 243, 261, 280, 282–3, 306 Robens Report 161 Royal College of Nursing (RCN) 1, 7, 9–11, 13–14, 46, 58, 60, 84, 88, 90, 96, 121, 144, 148, 151, 174, 179, 253, 258, 298, 305 Royal Sanitary Commission 6 Royal Society for the Prevention of Accidents 165 Safety Representatives and Safety Committees Regulations 164 sampling for research 100, 317, 324 schizophrenia 208 school nurses 6 Scottish Intercollegiate Guideline Network 247 Securing Health Together 4, 70, 121, 134, 165, 190 segmentation 124–5 self-employment 15, 17–19, 105, 108, 110–12, 114, 167, 182, 240 self-esteem 197, 202, 205–7, 209, 243, 247 shared learning 301–2 sheltered workshops 255–6 short-term absence 29, 31, 258, 273 sickness absence 2, 4–5, 16, 27, 29, 37, 49, 71, 74, 78–9, 90, 100, 126, 128, 130–1, 144, 151, 159, 172–3, 187, 193, 202–4, 211, 218, 238–9, 258–60, 263, 265, 272, 275, 283, 286, 317 Single European Act 146 site visits 29, 31–2 skin problems see dermatitis
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small and medium-sized enterprises (SMEs)16–18, 70, 121–2, 129, 164, 185, 191, 283 SMART objectives 123 Smith, Richard 101 smoking 13, 30, 166, 202, 245, 249 Society of Occupational Health Nursing 9–10, 253 socio-economics 142, 246–7, 251 sole practitioners 5, 44, 108, 327 see also independent practitioners spirometry 189 staff turnover 49, 126, 203 Stages of Change model 244–5 see also Cycle of Change model standards 2, 9, 13, 15–16, 19, 29, 36–7, 40–1, 43–8, 50, 53–5, 63, 71–3, 80–1, 88–93, 95–102, 129, 132, 139, 141–3, 147–8, 152–3, 172, 179, 185–6, 188–9, 191, 201–3, 242, 247, 263, 295, 299–301, 303–5, 308–10, 321, 323 Standing Committee of Nurses of the EU (PCN) 148 statistics 4, 31, 35, 41, 49, 77–8, 100, 121, 128, 164, 171, 182, 238, 313, 315 stress 11, 15–19, 32, 49–52, 160, 166, 169, 197–9, 201–4, 207–8, 212, 223–5, 238–42, 248–9, 251, 278, 281–4, 310 strokes 261 suicide 210 supervision 3, 11, 38, 56, 67, 162, 210, 298, 304–6, 320 SWORD 182 SWOT analysis 74, 105–6, 115, 123 targeting 16, 91, 124–7, 162, 240 tenders 48, 132 textile factories 160 toxicologists 185 trade unions 29, 147, 165, 170, 241, 249, 273
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training 2, 4, 7, 10, 16–19, 29, 32–4, 38, 46, 79, 81–4, 88, 90, 92, 102, 108, 114, 129–30, 144, 148, 152, 155, 160, 162, 165–6, 168–74, 203–4, 221, 225, 229–30, 248–9, 280, 286, 293, 296–8, 304, 314, 317, 320 transport industry 124 tuberculosis 5, 186 typhoid 5 unemployment 146, 198, 206–7, 263 United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC) 11, 295, 297, 299, 301–3, 305 United Nations Development Programme 246 universities see degrees and universities vaccination 50, 57, 82, 98 value added tax (VAT) 110–11, 116 vision screening 17, 19, 36, 182, 188 Walker v Northumberland County Council 166, 200 well-being 165, 180, 198–9, 202, 212, 225, 241, 243, 295, 327 women 7, 19, 200, 287, 306 working conditions 5, 7, 139–40, 145–7, 160, 183, 260 working days lost 238 Workman’s Compensation Acts 7 Workplace (Health, Safety and Welfare) Regulations 32, 165, 221 work-related illness 29, 31, 33, 160, 238–9 workstations 4, 220–2, 226, 229–30, 262–3 World Health Organization (WHO) 3–4, 140–1, 144, 198, 241, 253, 256–7, 263 writing of reports 4, 10, 109, 315, 321, 323, 325
