Management might prefer that the OH doctor did not observe all the ethical standards, for example those relating to confidentiality.
The Standards document, which is based on Good Occupational Medical Practice already discussed, refers to knowledge of the law. Occupational physicians should be able to report to managers on occupational health performance and requirements in ways which are accessible, placing it within a business framework and also providing the medico–legal context. Occupational physicians should keep abreast of changes in legislation and Codes of Practice that affect their practice (and, I would suggest, relevant case law). Research published by the Health and Safety Executive in 2004 assessed the competencies of occupational physicians from the customer’s perspective (Competencies of Occupational Physicians). Readers may be surprised to learn that at the top of the list of required competencies as rated by their customers is advising on law and ethics. Training in law was not, however, highly rated by focus group participants.
1.6 The occupational health nurse
The first recorded occupational health nurse was Philippa Flowerday who was appointed in 1878 by Colmans of Norwich. She assisted the doctor at the factory and then visited sick employees and their families in their own homes. Her work reflected the treatment‐based philosophy of the time and also the ‘doctor’s helper’ attitude to nursing staff. There has been no statutory function for nurses comparable to that of the Appointed Doctors, so that OH nursing was centred very much around the role of providing first aid in the workplace. The sympathetic nurse with time to listen and guaranteed confidentiality was also a popular source of advice for such socio–medical problems as members of the worker’s family drinking too much, overtiredness caused by stress, menopausal symptoms and so on. A survey undertaken on behalf of the Royal College of Nursing (RCN) in 1982 showed that caring for the sick and injured and counselling were the two functions most often mentioned by OH nurses in describing their work. How times have changed! Occupational health nurses are now at the forefront of risk assessment, health surveillance, advice on health and safety, vocational rehabilitation and health promotion. The Royal College published Competencies – an integrated career and competency framework for occupational health nursing (2005). A comprehensive and up‐to‐date examination of the competencies needed was published by Public Health England in 2016: Educating occupational health nurses: an approach to align education with a service vision for occupational health nurses.
Because nurses command lower salaries than doctors, employers in times of prosperity were often willing to provide a nurse in the factory for the welfare of their workers. In more straitened times, they have been asking what the nurses can contribute that cannot be done equally well by first‐aiders and welfare officers. Treatment is available free from the NHS; why should the employer duplicate it? The occupational health nursing profession is, therefore, having to justify itself by demonstrating that nurses too have an important role to play in a system based on prevention rather than treatment. They find this much easier to do when they can show specialist training and qualifications and when they are able to work independently of the doctor, though under overall medical supervision. In practice, many OH services are managed by nurses, who tend these days to be termed Occupational Health Advisers, with physicians being employed part‐time.
The Royal College of Nursing was at one time responsible for training occupational health nurses. From August 1988, validation of courses and standards became the responsibility of the National Boards for Nursing, Midwifery and Health Visiting, since abolished and replaced by the Nursing and Midwifery Council. There were three recognised qualifications. The first was the Occupational Health Practice Nurse Award which was obtained after a practical course open to enrolled and registered nurses which demonstrated how nursing skills are adapted for use in an industrial setting. The Occupational Health Nursing Certificate could be obtained after a period of training, either one academic year full‐time or two years (six terms) on day release and covered all aspects of OH. Only registered nurses could become fully qualified OH nurses. The third qualification was the Occupational Health Nursing Diploma. In the 1990s transitional arrangements were created to enable nurses with at least five years’ experience in OH to undertake further training in order to obtain a post‐registration graduate qualification in OH nursing. From 31 October 1998 only the qualification of Specialist Nurse Practitioner in Occupational Health (SCPHN) (at first degree level) has been recorded in the NMC Professional Register, Part 3 (under review). The Council has issued the Standards of Proficiency for Specialist Community Public Health Nurses (2004). None of these qualifications has statutory recognition, so that any nurse can work in an OH department without having completed specialist training, though they may not be regarded as competent persons under the health and safety legislation without it, unless working under the supervision of a qualified OH nurse or physician. In 2016 the NMC introduced a mandatory revalidation procedure for nurses. Nurses must revalidate every three years to renew their registration.
The revolutionary changes in nurse education brought about by Project 2000 have had significant effects on the training of occupational health nurses. Courses are validated jointly by the NMC and the universities and have been upgraded to degree level. The syllabus has been planned using the framework of the Hanasaari model, developed at a conference in Finland. This stresses the need to regard the total environment in which the workplace is set, but has been criticised for not giving sufficient emphasis to topics specific to OH. The Faculty of Occupational Health Nursing (FOHN), already discussed, has set out to review training and the curriculum, and to negotiate with the NMC and the FOM, with the eventual aim of the creation of an OH nursing qualification which is fit for purpose in the changed health and work climate.
Occupational Health Review conducted an up‐to‐date survey of the work of OH nurses in 1996 with the assistance of the RCN Society of Occupational Health Nursing. The number of OH nurses then employed in the UK was estimated to be about 5000–8000. The majority were women, about 80 per cent full‐time; 95 per cent of respondents to the questionnaire had a formal OH qualification, including 10 per cent with a degree. The ratio of OH nurses to employees was three times higher in the private sector than the public sector; 95 per cent of OH nurses worked with a physician in the team. About one in six organisations employed only GPs with no formal OH qualification. Health promotion was a part of more nurses’ jobs than any other activity. Most time was taken up with routine health screening. Six out of ten nurses experienced conflict with the physician at least some of the time, and more than eight out of ten had problems with human resources departments and departmental managers. Nine out of ten nurses received at least some encouragement from their employer to undertake continuing professional development.
In 1993 the HSE published Anna Dorward’s study Managers’ perceptions of the role and continuing education needs of occupational health nurses. Predictably, lay managers had a far more limited perception of the role of the occupational health nurse than did doctor managers or nurse managers: they saw them only as providing treatment for illness and injury at work. Only 50 per cent of lay managers supported nurses taking time off to attend courses. It would seem that the occupational health nursing profession still had a need to sell itself to employers as a vital component in health and safety provision. Training initiatives have to take into account that the acquisition of more extensive qualifications involves significant sacrifice of time and money for most OH nurses. At the time of writing there is a significant shortage of qualified OH nurses, which is reflected in a rise in salaries.
More recently, research undertaken by John Ballard, the editor of Occupational Health at Work, published in 2006, showed that the OH services rated by nurses as most important were the confidential handling of health data, assessing fitness for work, health surveillance, disability management and assessing risks to mental health: Performance indicators and benchmarking in occupational health nursing (RCN).
The Employment Nursing Advisers are full‐time employees of the Health and Safety Executive and part of the Employment Medical Advisory Service. They are key figures in occupational health because many nurses are working on their own and have only EMAS to turn to for advice and information. In recent years, much of their time has been spent in advising employers about the provision and training of first‐aiders, who, as has been seen,