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A report conducted by the At Work Partnership for the Royal College of Nursing Society of Occupational Health Nursing
November 2005
A report by the At Work Partnership for the Royal College of Nursing Society of Occupational Health Nursing
The At Work Partnership Ltd 2005 The At Work Partnership Ltd 19 Bishops Avenue Elstree Hertfordshire WD6 3LZ info@atworkpartnership.co.uk
Acknowledgements
The At Work Partnership would like to thank all the OH nurses who dedicated time to completing the questionnaire and to attending the focus group, and Mike Duffy for his analysis of the data.
CONTENTS
Executive summary
Objectives Methods Survey findings
General information OH functions Essential services? Role and competence Generic skills OH performance indicators OH policies and policy development iii iii
iii
iii v vii viii xi xii xiii xv
Conclusions
3 4 4
i
Performance indicators and benchmarking in OH nursing Contents
85 85 85 86 87 87 88 89 90 90 91 91 92 95 95 95 97 100 103 103 103 104 105 105 106 106 107 108 109 119 121 123 125 125 126 127
128
129 129 130 134 136 136 138 141 142 144 144 144 146 147 150
Summary of sources
References Appendix
The performance indicators questionnaire
ii
156
157
EXECUTIVE SUMMARY
Objectives
The research aimed to establish the current scope and standards of performance in delivering occupational health nursing services throughout the UK, and the competences of OH nurses to deliver those services. It also aimed to provide a broad understanding of the facilities and opportunities available to OH nurses and establish target areas for professional development.
Methods
A 29-item survey was mailed to OH nurses in October 2004. All participants were chosen at random from membership of the RCN Society of Occupational Health Nursing. Questionnaire data were analysed across the whole sample and, where appropriate, within broad employment sectors: commercial OH providers; other private sector; NHS; other public sector; and self-employed. A limited number of cross-analyses were made, for example whether the OH nurse worked alone or as part of a team. Survey data was supplemented by information from a focus group held at the RCN Society of Occupational Health Nursing annual conference in November 2004.
Survey findings
General information
Survey and response A total of 473 OH nurses responded to the survey (24% response). Employment sectors Responses came from all employment sectors: 20% commercial OH provider; 38% other private sector; 28% NHS; 16% other public sector; 2% self-employed (some respondents worked across more than one sector). The survey covers organisations that employ, in total, nearly 2.2 million people. The median size of employer in the survey is 1,800 employees. Job titles and contracts The most common job titles are OH adviser/OH nurse adviser (44%), OH nurse (26%) and OH manager (23%). The term OH sister is very rare (just over 1%). Three-quarters of OH nurses work as part of an OH team, with one-third managing at least one member of staff. Two-thirds of OH nurses work full-time. More than two-thirds of respondents (69%) have responsibility for more than one workplace. Qualifications Eighty-five per cent of OH nurses responding to the survey have a formal OH qualification (the OH nursing degree and diploma are the most common qualifications). Around one-third of respondents report that at least one full-time nurse without a formal OH qualification works in their place of work in an OH nursing capacity; a third also report that at least one part-time non-OH qualified nurse works in an OH capacity. There was no universal
agreement in the focus-group discussion on whether those working in occupational health should be required to have a specific qualification in the discipline. Nursing provision There is large variation in the numbers of OH nurses working in different organisations, although the mean across all sectors is 3.7 full-time equivalent (FTE) nurses per place of work (includes fully qualified, non-OH qualified and OH nurses in training). There are around 4.5 nurses in total per workplace (full- and part-time combined). Numbers are highest in the NHS (just under five FTE nurses per place of work) and commercial OH providers. Nursing levels are lowest in the other public sector (just over two FTE nurses per place of work). The data gives crude estimates of roughly one nurse working in OH for every 1,140 employees, or one FTE for every 1,420 employees. However, taking only those nurses who are either fully OHqualified or who are in training, the ratios are much higher: one qualified or in-training OH nurse per 1,760 employees, or one FTE per 2,092 employees. Overall, there is around one fully qualified OH nurse for every 2,050 employees, or one FTE per 2,450 employees. The NHS employs the highest ratio of OH nurses per employee (1.28 nurses per 1,000 staff), with the other public sector the lowest ratio (0.52 per 1,000). Focus-group participants felt that it would be impracticable to prescribe a ratio for the number of OH nurses required for a particular size of workforce, since this would depend not just on the number of workers, but the nature of their work and the type of OH provision required. Access to occupational medicine Around 83% of OH nurses have access to a FOM-qualified OH physician at their place of work with access highest in the NHS and commercial OH providers. A fifth of respondents say that a full-time FOM-qualified OH physician practices at their place of work; just over two-thirds have access to a part-time FOM physician. Across all sectors, there are around 0.32 FOM-qualified OH physicians per 1,000 employees highest in the commercial OH providers (0.51 per 1,000 employees) and lowest in the other private sector (0.25 per 1,000). There are around 0.2 FTE qualified OH physicians per 1,000 employees across all sectors. OH facilities The vast majority (95%) of OH nurses have a dedicated OH facility or clinic at their workplace; almost a quarter describe the facility as excellent, while a similar proportion say the facility is unsatisfactory. Respondents from the NHS are most likely to describe the facility as unsatisfactory (31% of NHS respondents). Out-of-hours cover A fifth (21%) of OH nurses say their organisation provides OH cover outside standard daytime hours including just 11% of NHS respondents. Just over half of organisations say OH cover is provided for home and/or off-site workers, with one-fifth saying that such cover is not required.
OH functions
Absence Two-thirds of OH departments offer some form of attendance monitoring service, though only 38% say they offer a comprehensive service. Private sector OH departments are much more likely than those in the public sector to offer a comprehensive attendance monitoring service. However, private sector respondents are also much more likely to rate such a service as essential than are their public sector counterparts. Disability and return to work Three-quarters of OH services offer return-to-work interviews, with around half saying the service is comprehensive. Sixty-one per cent of OH services are able to provide home or off-site visits for employees on sick leave (higher in the private sector). The vast majority (94%) of OH services offer some form of disability assessments and advice on adjustments; two thirds say the service is comprehensive and four-fifths describe the function as essential. Most services (82%) offer vocational rehabilitation, but less than half of respondents describe the service as comprehensive public sector OH services outside the NHS are the worst performers in this respect. The majority of respondents (88%) describe vocational rehabilitation as essential. Pre-employment and fitness for work Nearly all OH services (95%) have some role in the analysis of pre-employment or pre-placement health questionnaires; 80% of respondents say the service is comprehensive. More than three-quarters of respondents describe the function as essential. Eighty-four per cent of OH services provide comprehensive analysis of fitness to work only four respondents across the whole sample say such a service is not offered. Most agree that the function is essential. Eighty-five per cent of respondents say that their OH service plays a part in developing fitness-for-work standards. Around half of all respondents describe the service as comprehensive, though respondents from the other public sector are less likely to report a comprehensive service. Health surveillance Nearly all services across all sectors provide health surveillance and interpret the results. Three quarters describe provision as comprehensive and around 85% say it is an essential function. Risk assessment Although most respondents (86%) report that the OH department provides health and safety risk assessments, only half of those offering the service describe the provision as basic rather than comprehensive. Two-thirds of respondents say the service is essential. Around 90% of respondents say their OH service offers some level of assessment of risks to mental health; however just half say this is comprehensive. Only one-third of other private sector respondents describe the service as comprehensive. By contrast, 91% of respondents say that provision of mental health risk assessments is essential.
Health and safety Most organisations offer some provision in advising on work organisation and design a third of respondents say their service is comprehensive. Nearly all respondents agree that this function is either essential or desirable. Less than two-thirds of services provide personal protective equipment and a majority of these describe such provision as basic. Nearly all OH services offer display-screen equipment assessments, with two-thirds describing the service as comprehensive. Just under two-thirds say the function is essential, and one-third desirable; very few say the service is not required. Three-quarters of OH services monitor work-related accident, injury and illness data. Eighty-three per cent of other private sector OH services monitor such data more than in the other sectors and 70% of respondents in that sector say that this function is essential. Costbenefit analysis Just over half (57%) of respondents say that their service carries out costbenefit analyses of OH interventions, with most of those that do offering only basic provision. By contrast, 90% of respondents rate this function as either essential or desirable. Infectious diseases Ninety-seven per cent of all NHS respondents report that their OH departments provide services to prevent and manage sharps and needlestick injuries four-fifths say the service is comprehensive. Most other public sector services offer at least some level of provision, while no service is offered in 43% of commercial OH providers and 36% of other private sector employers. Provision of immunisation is virtually universal among NHS respondents (85% comprehensive, 9% basic). More than half (53%) of other public sector respondents say that immunisation provision is an essential function in their organisations, and 23% say it is desirable; yet just 35% provide a comprehensive service and 35% no service at all. In contrast to the provision of immunisation and sharps/needlestick management, travel health advice is more commonly available in the private than public sector. Nearly two-thirds of commercial OH providers (63%) and other private sector respondents (61%) say that they provide some level of travel health advice and service, compared with just over half in the NHS (52%) and other public sector (53%). Private sector respondents are also more likely to rate this function as important than their public sector counterparts. Training Although two-thirds of respondents say their OH services offer some level of training and education in occupational health and safety (eg manual handling), less than half of those that do say the service is comprehensive. The majority of respondents consider the provision of training to be either essential (53%) or desirable (32%). Sixty per cent of OH services provide some level of first-aid organisation and first-aid training with such services more likely to be offered in the private than public sectors. Counselling Most OH departments (89%) offer confidential counselling though the provision of a comprehensive service is more likely in the NHS (66%) and other public sector (69%) than in either the commercial OH providers (46%) and other private sector (52%). More than two-thirds
of respondents rate confidential counselling as an essential function just 3% of all respondents consider it to be of nil or negligible value. Wellness Four-fifths of organisations offer some level of health and wellness screening, with commercial OH providers more likely than those in other sectors to offer a comprehensive service. Respondents from the NHS are more likely to perceive such services as desirable (57%) rather than essential (28%) a trend reversed among commercial OH provider respondents, 51% of whom see the service as essential and 38% desirable. OH law Ninety-one per cent of all respondents OH services provide advice on, and interpretation of, occupational health law, with three-quarters of respondents describing this function as essential. However, fewer than half of all respondents say they provide a comprehensive service. An even bigger percentage of respondents (98%) say that their OH service provides confidential handling of health and personal data and 88% describe the provision as comprehensive. Unsurprisingly, 95% of respondents describe the function as essential.
Essential services?
All of the OH service areas are ranked according to whether OH nurses perceive them as essential (box 1) and whether provision is considered comprehensive (box 2). The most important function according to OH nurses is confidential handling of health personal data. This is followed by assessment of fitness for work and delivering and interpreting health surveillance. Provision of personal protective equipment, general health and wellness screening, travel health advice/provision and home/offsite visits to workers on sick leave are the least likely to be rated as essential functions. Confidential handling of health and personal data, assessing fitness for work, analysis of preemployment/pre-placement questionnaires, and delivering health surveillance are the four functions where provision is most likely to be comprehensive. Provision of personal protective equipment, home/off-site visits to workers on sick leave, travel health advice/provision and costbenefit analysis of OH interventions are the least comprehensively provided. In many cases there is a good match between services considered as essential and where provision is viewed as comprehensive. For example, 95% of OH nurses rate confidential handling of personal data as essential, and 88% rate their service provision in this context as excellent. By contrast, 81% of respondents view assessing risks to mental health as essential, but just 42% of OH services provide comprehensive cover. Only 21% of organisations assess the costbenefit of OH interventions, yet 50% of respondents consider this as essential. Confidential handling of health and personal data and the assessment of fitness for work are ranked highest across all the employment sectors, both in terms of provision and perceived
importance. There are some difference between sectors. Notably, sharps and needlestick prevention and management is ranked as the fourth most important service in the NHS, but 20th by respondents from commercial OH providers.
Note: the figures show the percentages of OH nurses who rate each function as essential
Note: the figures show the percentages of OH nurses who rate each service as comprehensive
I 50%69% excellent assessment of fitness for work; delivering health surveillance; display screen equipment assessments; interpretation of health surveillance I 30%49% excellent general and health and wellness delivering screening; immunisation; interviews;
sharps/needlestick
prevention
management;
return-to-work
organisation of first aid and first-aid training; confidential counselling; disability assessments and adjustments; interpreting and advising on OH law; home/off-site visits to workers on sick leave; attendance monitoring I less than 29% excellent assessing risks to mental health; developing fitness-for-work standards; provision of training and education; health and safety risk assessment; vocational rehabilitation; monitoring work-related accident; injury and illness data; travel health advice/provision; advising on work organisation and design; provision of personal protective equipment; costbenefit analysis of OH interventions. OH nurses are more likely to be in a lead role in the confidential handling of health and personal data (77% in lead role) than any other function. They are least likely to have a lead role in the provision of personal protective equipment (just 8% in a lead role). The full list of functions can be ranked as follows: I at least 70% lead role confidential handling of health and personal data; analysis of preemployment/pre-placement questionnaires; assessment of fitness for work I 50%69% lead role delivering health surveillance; interpretation of health surveillance; general health and wellness screening I 30%49% lead role disability assessments and adjustments; display screen equipment assessments; interpreting and advising on OH law; immunisation, sharps/needlestick prevention and management; developing fitness-for-work standards; confidential counselling; assessing risks to mental health; vocational rehabilitation I less than 30% in lead role delivering return-to-work interviews; travel health advice/provision; organisation of first aid and first-aid training; home/off-site visits to workers on sick leave; provision of training and education; monitoring work-related accident; injury and illness data; attendance monitoring; costbenefit analysis of OH interventions; health and safety risk assessment; advising on work organisation and design; provision of personal protective equipment. Generally, as the percentage of nurses in lead roles in a particular job function increases, so does the respondents overall level of self-rated competence. For example, 77% of nurses have a lead role in the confidential handling of data, and 75% describe their competence as excellent. Similarly, 21% of respondents have a lead role in advising on work organisation and design, and
21% describe their competence in this area as excellent. However, there are some exceptions. Most notably, 46% of OH nurses have a lead role in disability assessments, yet just 32% describe their competence in this area as excellent. Across all job functions, OH nurses are more likely to rate their competence as excellent if they are personally in a lead role in delivering that service. Conversely, where nurses rank their competence as unsatisfactory it is generally (though not exclusively) in cases where they have only a negligible or no role. As an example, of those with a lead role in sharps/needlestick prevention and management, 69% describe their competence as excellent, 29% as satisfactory and none as unsatisfactory. For those in a support role, 36% believe their competence to be excellent, 60% satisfactory and 1% unsatisfactory. However, of those with no or negligible role, 13% describe their competence as excellent, 49% satisfactory and 26% unsatisfactory. The match between respondents rating of what functions they consider essential and their overall self-ratings of competence in delivering those services is less good. Although self-rated competence is relatively high in data handling, assessing fitness for work, health surveillance, analysis of pre-employment/pre-placement questionnaires and DSE assessments all of which are perceived as important functions of the OH service the proportion of nurses describing their competences as excellent is relatively low in some other functions rated as essential. For example, only 15% of OH nurses rate their competence in costbenefit analysis of OH interventions as excellent, yet 50% rate this as an essential service (a third of OH nurses describe their competence in this area as unsatisfactory). Significantly, while 81% of OH nurses say that disability assessments and adjustments are essential components of the OH service, just 32% rate their competence as excellent (and one in nine practitioners rate their competence as unsatisfactory). The situation is similar for mental health assessments (81% essential v 29% excellent), counselling (68% v 34%) and vocational rehabilitation (61% v 28%). By contrast, general health and wellness screening is ranked seventh out of the 26 OH functions in terms of competence, but 24th in perceived importance. Satisfactory competence does not imply that services are not being delivered. However, the fact that OH nurses tend to rate their competence lower in some areas compared with others supports the notion that there is room for improvement. For example, while, the majority of OH nurses rate their competence as excellent in handling confidential information, assessing fitness for work, DSE assessments, health surveillance and analysing employment health questionnaires, the majority of nurses describe their performance simply as satisfactory in disability assessment, assessing risks to mental health, advising on work organisation and design, interpreting and advising on OH law and the provision of confidential counselling. Assuming perceived competence relates to actual competence, these are clear areas for targeting training and professional development.
Generic skills
Nurses were asked to rate their competence in, and importance of, 12 generic skill areas. Excellent skills The most highly rated generic skills are, in descending order: communicating with clients and OH colleagues (81% of respondents rate their skills as excellent); team working (71%); presentation skills (45%); leadership skills operational level (44%); interpreting developments in OH practice (33%); coaching/mentoring (33%); clinical supervision (31%); resource management (27%); leaderships skills strategic level (25%); conflict management (23%); research skills (23%); and budget management (17%). Room for improvement Some skill areas are notable for the relatively large minority of nurses rating their competence as unsatisfactory, and these are cause for concern. More than a quarter (26%) of OH nurses say that their skills in budget management are unsatisfactory; 19% say they have unsatisfactory competence in strategic-level leadership skills; 15% in clinical supervision; 13% in research skills and awareness; 13% in conflict management; and 11% in coaching and mentoring. Essential functions Generic skills most likely to be viewed as essential are, in descending order: communicating with clients and OH colleagues (94% of respondents rate their skills as excellent); team working (87%); interpreting developments in OH practice (71%); leadership skills at the operational level (66%); presentation skills (65%); conflict management (58%); coaching/mentoring (55%); clinical supervision (55%); resource management (54%); leadership skills at the strategic level (52%); research skills (51%); and budget management (44%). Generally, as the level of importance increases, so does the overall level of self-perceived competence. Most OH nurses (94%) rate communication with clients and OH colleagues as essential, and 81% rate their competence as excellent (less than 0.5% say their competence is unsatisfactory). However, while 71% of OH nurses rate the interpretation of developments in OH practice as essential (the third highest-ranked skill), only 33% feel their competence is excellent. And while 58% rate conflict management as an essential skill, just 23% rate their competence in this area as excellent. OH nursing qualities An open question in the survey asked respondents to state what they consider to be the most important competency of the OH nurse. Of the 394 responses, by far the most common theme is that of communication and listening, mentioned by one-third of the respondents. The 10 qualities mentioned most often in the unprompted responses are, in descending order: communication and listening; interpersonal skills; knowledge and education; confidentiality; awareness of legislation; leadership; self-motivation and proactive working; knowing ones own limitations; teamwork; and evidence-based practice.
OH performance indicators
Respondents were asked to provide estimates of various performance measures, such as referral times and time taken to deliver OH reports. Referral times The average (mean) time taken between a management referral and a worker being seen by an OH professional is 6.05 days slowest in the NHS (8.2 days) and quickest in the other private sector (4.51 days). (Self-employed respondents reported mean referral times of 4.15 days, but with just 11 self-employed respondents, this figure is not reliable.) There is considerable variation in the data and the spread of reported referral times is even more revealing. Threequarters (73%) of private sector OH services report that mean referral times are no more than five days. This contrasts with the NHS where just 29% are seen within five days. Nearly one-quarter (22%) of commercial OH providers say that referral times are no more than two days (the equivalent figure for the NHS is 6%). Among commercial OH providers, other private sector and other public sector organisations, between 37% and 41% of all cases are seen by the OH professional between three and five days after referral. Forty per cent of referrals in the NHS take six to 10 days. Reports and external consultations Fitness-for-work reports take on average 3.0 days to be delivered from the time the worker has seen the OH professional (mean across all sectors). There is relatively little variation between sectors. The mean average time between a referral from OH to a person being seen by an external specialist is 13.4 days (slightly longer in the NHS and other public sector). Respondents were asked to select the factors most likely to delay referral to an external specialist. These are, in descending order: NHS waiting list (cited by 70% of respondents); time taken by employees GP (69%); time taken by private health consultant (35%); lack of cooperation by employee (16%); signing off by line manager (11%) and signing off by the occupational physician (10%). Post-exposure prophylaxis Respondents who work within either the healthcare sector or emergency services were asked to provide information on the provision of post-exposure prophylaxis (PEP) following a needlestick injury. All NHS respondents report that PEP is available, either through the OH department (46% provide this service) or through an accident and emergency (A&E) or other department (75%). PEP is provided both by the OH department and by A&E in some organisations. The vast majority (94%) of NHS respondents say that PEP is available outside normal working hours (8 am to 5.30 pm). Respondents were also asked how swiftly an OH professional sees a worker after a needlestick injury (this is not the same as the time taken to receive PEP). Within the NHS, two-thirds of cases (63%) are seen by the OH professional within two hours.
Clinical governance
Performance ratings Respondents were asked to rate 10 areas of OH nursing practice within their organisation as excellent, satisfactory or unsatisfactory. These were then scored according to an arbitrary rating +1 = excellent; 0 = satisfactory; -1 = unsatisfactory. A score of zero suggests, on average, that the performance is satisfactory, less than zero suggests that improvements are needed. The 10 performance areas are ranked in descending order. +0.48 access to occupational physicians +0.34 ethics +0.25 evidence-based practice
+0.18 opportunities for professional development -0.02 peer support and mentoring -0.08 legal support -0.14 clinical supervision -0.17 strategic planning -0.18 service delivery auditing -0.23 opportunities for trainee OH nurses Working as part of a team does improve the score for peer support and mentoring. The average score for respondents working as part of a team is +0.07; for those working alone it is -0.17. Nurses working as part of a team are more likely to rate opportunities for trainee nurses as good (score = +0.08) than are OH nurses working alone (score = -0.56). Opportunities for professional development are similar for both lone and team workers. There are few meaningful differences between sectors though there appear to be more opportunities for trainee OH nurses within the NHS (score = +0.01), compared with the all-sector score (score = -0.23). The difference is not statistically significant, however. OH support for the OH professional Nearly one-third (31%) of OH nurses report that they have no provision of OH support for themselves. Forty-two per cent of OH nurses report having access through in-house provision and just 27% can access OH services through an independent provider. Arguably provision through an independent provider either by buying in an external service or entering partnership arrangements with other organisations is the best way of avoiding conflicts, for example between the provision of healthcare and line-management issues. Nearly half (46%) of lone practitioners have no access to OH support for themselves, compared with just 21% of those working as part of a team. Competence of OH physician The vast majority (96%) of respondents report that they have access to occupational medicine. A large majority of respondents (87%) rate the occupational medicine competence as either excellent (46%) or satisfactory (41%). There is little variation between sectors. Using the arbitrary scoring system above, occupational medicine competence is given an average score of +0.38 (ranging from +0.33 to +0.42 between sectors). The focus group generally agreed that all occupational physicians should be OH-qualified. However, non-OH-qualified doctors may still have a role in undertaking certain functions where OH expertise is not required (undertaking driver medicals, for example).
Education Participants in the focus group were divided on whether OH nurses should be required to have a formal OH qualification. There was concern that OH nurse education was moving inflexibly towards degree-only qualifications. Some participants called for more flexible approaches that would suit nurses who either did not want to take a degree or who were selffunding and resource-limited. Vocational or core-competency approaches should continue to be encouraged.
Conclusions
OH nurses practice in a wide range of situations, from single practitioners working in isolation for medium-sized private sector businesses, to members of large multidisciplinary teams in the NHS, major companies and commercial OH providers. Others are self-employed and contract their services to several client organisations. The experiences of OH nurses are diverse and this research sheds light on the different situations and challenges faced by nurses. It also provides a comprehensive insight, for the first time, of the levels of OH services provided by organisations across all employment sectors, the value placed on those services by the OH nurses themselves, the different roles OH nurses have in delivering those services and nurses own perception of their competence in performing the functions required of them. Although many of the findings represent the subjective views of respondents, taken en masse the data provide a strong body of evidence on possible gaps in service provision, variable referralresponse times, and areas where the general level of OH nurse competences might be improved. The research identifies other wider issues, such as the inconsistent level of OH provision for OH nurses themselves and the perceived lack of training opportunities for nurses new to the field. The focus group raised issues concerning the need for OH nurses and physicians to be appropriately qualified and how best to deliver OH nurse education. Overall, the study provides a detailed picture of the work of OH nurses in the UK, how their practice differs between sectors, and evidence that OH providers, educators and policymakers can consider when deciding how to address gaps in OH nursing provision.
percentage of employers (15%) provide access to some kind of OH support (Pilkington and Graham, 2002). OH support often takes second place within health and safety, and has no distinct identity, the report says. The IOM identified the following key measures of OH support which could be used for benchmarking purposes: formal risk management; provision of information and training on health-related issues; rehabilitation or other programmes which modify work activities based on health needs; health surveillance initiatives; and associated monitoring in trends in health over time or across employee groups. A full literature review is given on pages 129155 of this report.
2
Performance indicator and benchmarking in OH nursing Introduction and background
METHODS
Questionnaire
A 29-item questionnaire was sent to 2,000 OH nurses taken from the RCN Society of Occupational Health Nursing (SOHN) membership database with freepost return envelopes. They were mailed in October 2004. The questionnaire is reproduced in appendix 1 on p.157. The sample was randomised by practitioners names. The surveys were completed anonymously enabling the respondents to provide objective information without fear of compromising their organisations. Respondents were required to tick appropriate multiple-choice boxes or provide numerical answers. There was only one open question requiring a descriptive answer. The questions were of the following types: I general information about the respondent (job title, formal qualifications, years OH experience, employers business) I extent of OH provision in general (number of employees covered, number of OH nurses, OH physicians, OH facility, out-of-hours provision, support for off-site workers) I availability of OH nursing services and competences for various generic OH services (eg basic/comprehensive/non-existent) I rating of the importance of the generic services (essential/desirable/nil or negligible) I respondents role in delivery of the generic services (lead/support/negligible or none) I respondents level of competence in delivering the generic service
(excellent/satisfactory/ unsatisfactory) I respondents self-assessment of competence in core OH nursing skills (excellent/ satisfactory/unsatisfactory) and rating of their importance for their work (essential/ desirable/negligible) I performance indicators as a function of the time taken to deliver the service (days/ weeks/months) and factors that limit the service delivery I role of OH nurse in policy development and delivery (lead/support/negligible or no policy) I clinical governance quality of OH nursing practice at respondents organisation (excellent/satisfactory/unsatisfactory)
3
Performance indicators and benchmarking in OH nursing Methods
I provision of OH services for the OH professional (in-house/independent provider/none) I rating of occupational medicine competence that respondent has access to (excellent/ satisfactory/unsatisfactory/non-existent).
Survey analysis
The survey responses were analysed across the entire survey response, by broad industrial sector, in-house and contracted services, according to whether the respondent was the lead or support practitioner, and by team or single-practitioner services. Skill areas, OH nursing services and selfrated competences were ranked across all sectors and within each sector. Most of the data are broken down into percentage responses. Where appropriate, medians, means and standard deviations are given.
4
Performance indicators and benchmarking in OH nursing Methods
Commercial OH provider Other private sector NHS Other public sector Self-employed
Forty-four per cent of OH nurses report that their job title is either OH adviser or OH nurse adviser. A further 23% are OH managers, 26% OH nurse and 1% (just seven nurses in total) describe themselves as OH sister (figure 2). The terms OH adviser or OH nurse adviser is less common in the NHS than in other sectors (27% of NHS OH nurses have this job title). By contrast, 33% of NHS OH nurses are OH managers and 35% are OH nurses both job titles are more common in the NHS than in any other sector.
5
Performance indicators and benchmarking in OH nursing Results and analysis
Around three-quarters (74%) of respondents report being part of an OH team; one quarter (26%) are the lone OH practitioner in their workplace (figure 3). Almost half (48%) describe themselves as being the lead nurse in the team (which includes those who are the lone OH practitioner). Onethird (32%) of respondents say that they manage at least one member of staff. Of those with management responsibilities, 13% manage one member of OH staff, 23% manage two members of staff, 25% three to five, 27% six to 10 and 13% more than 10. The mean number of staff managed is 2.1, but there is huge variation, with the majority having no OH staff to manage.
Two-thirds of respondents (64%) work full-time hours and 33% part-time (3% did not respond to the question) (figure 4). Of those who gave their total contracted hours, 11% of respondents are contracted to work 20 hours or fewer per week; 20% 21 to 30 hours; and 69% 31 hours or more (figure 5).
6
Performance indicators and benchmarking in OH nursing Results and analysis
70 60 50 40
Per cent
30 20 10 0
Full-time Part-time Not stated
80 70 60 50
The vast majority of respondents (85%) have at least one formal OH qualification, with the OH degree and OH nursing diploma the two most common qualifications (figure 6). The median length of time since being OH-qualified was 7.89 years. Nine per cent of the respondents had been OHqualified for one year or less; 19% for 15 years or more and 7% for more than 20 years.
7
Performance indicators and benchmarking in OH nursing Results and analysis
Almost a third (29%) of respondents report that at least one full-time non-OH qualified nurse works in an OH capacity at their place of work. Slightly more than one-third (34%) report that at least one part-time non-OH qualified nurse works in an OH capacity at their place of work. More than two-thirds (69%) of nurses have responsibility for more than one workplace; 31% work at just one workplace. Public sector respondents (58%) are least likely to have responsibility for more than one place of work, and NHS (78%) and self-employed (82%) the most likely (figure 7). More than one-quarter (27%) of commercial OH provider respondents have responsibility for a single place of work.
90 80 70 60 50 Per cent 40 30 20 10 0 Commercial OH provider Other private sector NHS Other public sector Self employed* All sectors
Yes
n = 473 * There were just 11 self-employed respondents
No
8
Performance indicators and benchmarking in OH nursing Results and analysis
Respondents were asked to report how many full- and part-time nurses worked at their place of work as well as their level of qualification. As shown in tables 1 and 2, the mean number of nurses working in an OH capacity in respondents organisations is 4.55 (or 3.66 full-time equivalents (FTE)), of which 2.53 (2.12 FTE) are OH-qualified (excluding OH nurses in training). However, this hides enormous variation and is skewed by the larger number of nurses employed, inevitably, by the commercial OH providers and the NHS. Commercial OH providers employ on average 5.82 nurses (4.79 FTE) of which 3.4 (2.9) are OH-qualified. NHS employers employ 6.14 nurses (4.83 FTE), of which 3.17 (2.61) are OH-qualified. Other private sector organisations employ, on average 3.6 nurses (3.0 FTE) of which 2.1 (1.9) are OH-qualified. Other public sector organisations employ 2.9 nurses (2.3 FTE) of which 1.7 (1.4) are OH-qualified.
Commercial OH provider Other private sector NHS Other public sector All sectors
75 146
5.82* 3.58
1.91* 1.22
0.45 0.22
0.56 0.48
1.41 0.58
1.13 0.92
0.13 0.05
0.16 0.10
3.40 2.13
127 68 416
n = number of survey organisations in sector * Excludes one commercial OH provider that employs 500 non-OH nurses (with this included, the average number of non-OH nurses in the commercial OH provider sector would have risen to 12.4, with 8.56 non-OH nurses per employer)
Commercial OH provider Other private sector NHS Other public sector All sectors
n = number of survey organisations in sector that provided information * Excludes one commercial OH provider that employs 500 non-OH nurses (with this included, the average number of FTE non-OH nurses in the commercial OH provider sector would have risen to 11.4, with 8.08 non-OH nurses per employer)
9
Performance indicators and benchmarking in OH nursing Results and analysis
Taking the entire sample, our respondents provide OH cover for 2,155,000 employees across the UK, with a mean size (where given) of 5,000 employees per organisation. The median size is 1,800 employees (figure based on the 431 respondents who answered this question). The median gives a more accurate picture than the mean since half the sample work in organisations smaller than the median, and half in larger employers. By contrast, the mean tends to be skewed by a few very large employers. It is worth noting that some focus group participants (p.125) commented that they felt unable to complete this question given that they work for OH providers and provide OH services for a number of client companies. Nevertheless, and given this constraint, our crude estimate for the number of nurses working in OH (qualified, non-OH qualified and in training) is one nurse for every 1,140 employees; or one full-time equivalent nurse for every 1,420 employees. The crude estimate for OHqualified nurses plus OH nurses in training is one nurse for every 1,760 employees (or one FTE for every 2,092 employees). There is an estimated one fully qualified OH nurse for every 2,050 employees, or one FTE OH-qualified nurse for every 2,450 employees. Table 3 gives the ratio of nurses (qualified and non-qualified) working in occupational health per 1,000 employees. The NHS employs the highest ratio of both total OH nurses working in OH (1.01 FTE per 1,000 employees) and fully qualified OH nurses (0.54 per 1,000). These ratios are almost twice as high as for the least-provided sector, the other public sector, which has around 0.40 FTE nurses (all levels) and 0.25 FTE fully qualified OH nurses per 1,000 employees. The other private sector organisations are better served than the other public sector with 0.55 FTE nurses (all levels) and 0.34 FTE fully qualified OH nurses per 1,000 employees; however, it must be borne in mind that the majority of private sector organisations have no OH support at all and the figures represent only those firms that have OH provision. The figures for respondents who work for commercial OH providers may give a reasonable picture of the organisations to which their services are contracted; however, the focus-group feedback noted that some respondents from this sector were unsure how to answer this question if they were contracted to more than one employer.
10
Performance indicators and benchmarking in OH nursing Results and analysis
All sectors
Commercial OH provider*
NHS
Mean employee size Total nurses per 1,000 employees (full- and part-time) Total nurses per 1,000 employees (FTE) Total OH-qualified** nurses per 1,000 employees Total OH-qualified** nurses per 1,000 employees (FTE)
FTE = full-time equivalent. Assumes that two part-time OH nurses = 1 FTE * Excludes one commercial OH provider that employs 500 non-OH nurses Based on respondents who provided information for this question ** Excludes OH nurses in training
Figure 8: Physicians in the workplace FOM-qualified and non-qualified (% where physicians operate all sectors)
70 60 50 40 Per cent 30 20 10 0 Full-time FOM Part-time FOM Full-time non-FOM Part-time non-FOM
11
Performance indicators and benchmarking in OH nursing Results and analysis
Table 4 shows the mean number of OH physicians qualified by the Faculty of Occupational Medicine (FOM) and non-OH qualified physicians/GPs per employer by sector and the proportion of employers without access to an OH physician. Access to an FOM-qualified OH physician is highest in the commercial OH provider and NHS sectors, with just 12% of respondents in both of these sectors reporting having no access in their workplaces. Commercial OH providers have 2.03 qualified OH physicians per employer (1.48 FTE). These figures are higher than in the NHS 1.57 physicians per employer (1.0 FTE). Access is lower in the private and other public sectors, and lowest of all among self-employed OH providers. Across all sectors, there are 1.45 qualified OH physicians per employer (0.92 FTE), with 17% of respondents reporting having no access to an OH-qualified physician in their workplace.
Commercial OH provider Other private sector NHS Other public sector Self-employed All sectors
FTE = full-time equivalent. Assumes that two part-time physicians = 1 FTE (likely to be an overestimate)
Table 5 gives crude estimates for the number of physicians both FOM-qualified and non-OH qualified per 1,000 employees by sector. Across all organisations in the survey, there are around 0.32 FOM-qualified physicians per 1,000 employees, with more than this mean in the commercial OH provider sector (0.51 per 1,000) and NHS (0.34 per 1,000). Coverage is lower for both the other public and other private sectors. The table also shows estimated figures for the number of full-time equivalent physicians. However, unlike the OH nurse data, we have no information on the average hours worked by the part-time physician. The table assumes two part-time doctors for one FTE, but this is likely to be an overestimate with some physicians working much less than half time for their client companies. Respondents rating of the occupational medicine competence to which they have access to is reported on p.121.
12
Performance indicators and benchmarking in OH nursing Results and analysis
FTE = full-time equivalent. Assumes that two part-time physicians = 1 FTE (likely to be an overestimate)
OH facilities
The vast majority (95%) of respondents report having a dedicated OH facility or clinic at their workplace. A majority (56%) describe this as being satisfactory, 22% excellent and 22% unsatisfactory (figure 9). A smaller proportion of NHS respondents (17%) and other public sector respondents (13%) describe their facility as excellent, compared with commercial OH providers (26%) and other private sector (28%). Nearly one-third (31%) of NHS respondents and one-quarter (25%) of other public sector respondents say that their OH facility is unsatisfactory, compared with just 16% of commercial OH providers and 20% of private sector respondents (figure 10).
60
50
40
Per cent 30
20
10
13
Performance indicators and benchmarking in OH nursing Results and analysis
Excellent
Satisfactory
Unsatisfactory
None
Out-of-hours cover
Across all sectors, 21% of organisations provide OH cover to employees outside standard working hours (8.00 am to 5.30 pm); 62% say that cover is not provided, while 16% say it is not required (1% did not answer the question). Figure 11 shows how this compares across the sectors. Surprisingly, only 11% of NHS employers provide OH cover outside standard hours, while only 8% of respondents say this is not necessary. Out-of-hours cover was much higher in the private sector (29%) and commercial OH providers (27%). Three self-employed practitioners provide out-of-hours cover. Onefifth of respondents (18%) say they have a lead role in providing out-of-hours cover.
Figure 11: Provision of OH cover outside standard daytime hours (8.00 am to 5.30 pm)
80 70 60 50 Per cent 40 30 20 10 0 Commercial OH provider Other private sector NHS Other public sector Self employed* All sectors
Yes
No
Not required
14
Performance indicators and benchmarking in OH nursing Results and analysis
Yes
* There were just 11 self-employed respondents
No
Not required
15
Performance indicators and benchmarking in OH nursing Results and analysis
50
40
Per cent 3 0
20
10
0 Commercial OH provider Other private sector NHS Other public sector Self employed All sectors
Basic
Comprehensive
Non-existent
Not stated
Respondents are much more likely to rate this as an essential function in the private sector and in commercial OH providers than they are in the NHS or other public sector (figure 14). Eight of the 11 self-employed practitioners describe this function as essential, suggesting that this is an important part of their business.
16
Performance indicators and benchmarking in OH nursing Results and analysis
80 70 60 50 Per cent 4 0 30 20 10 0 Commercial OH provider Other private sector NHS Other public sector Self employed All sectors
Essential
Desirable
Nil/negligible
Not stated
Respondents were asked to rate their role in delivering attendance monitoring (lead, support or negligible) (figure 15a) and to rate their level of competence (excellent, satisfactory or unsatisfactory) (figure 15b). Two-thirds of the respondents have either a lead (23%) or support (41%) role with one-third (33%) no or negligible role (3% did not answer). Nearly one-third (30%) describe their competence as excellent, 45% satisfactory and 12% unsatisfactory (12% not stated).
OHN role and competence in attendance monitoring Figure 15a: Role in delivery
17
Performance indicators and benchmarking in OH nursing Results and analysis
By cross-referencing the two factors we were able to estimate whether or not those in, for example, a lead role have, in their own opinion, the necessary competence. The cross-analysis yields interesting findings. Nearly two-thirds (62%) of those with a lead role in attendance monitoring describe their competence as excellent, with one-third (34%) describing it as satisfactory. Conversely, of those in a support role, one-third (35%) say they have excellent competence, and 60% satisfactory. Of the 156 respondents who described their role as none or negligible, there is an almost equal split between those stating that they have satisfactory (39%) and unsatisfactory (35%) competence (table 6). Only four per cent of those with no or negligible role believe that they have excellent skills in this area; conversely, of the 59 respondents who describe their skills as unsatisfactory, 93% of them have no or negligible role in attendance monitoring (table 7).
62 35 4
34 60 39
2 1 35
2 4 22
143 214 59
48 17 3
48 54 3
4 29 93
0 0 0
Return-to-work interviews
The majority (73%) of respondents in all sectors offer return-to-work interviews as part of their OH function, with around half of them describing the service as comprehensive (figure 16). Slightly fewer (38%) respondents from the public sector (excluding NHS) than in other sectors described their service in this area as comprehensive. Fifty-eight per cent of all respondents described such a service as essential, with nine of the 11 of self-employed respondents holding this view (figure 16).
18
Performance indicators and benchmarking in OH nursing Results and analysis
50
40
Per cent 3 0
20
10
0 Commercial OH provider Other private sector NHS Other public sector Self employed All sectors
Basic
Comprehensive
Non-existent
Not stated
More respondents in commercial OH providers (73%) and the private sector (71%) describe the provision of return-to-work interview as either essential or desirable, compared with those in the NHS (67%) or other public sector (64%) (figure 17). Six of the 11 self-employed respondents considered the service essential.
Essential
Desirable
Nil/negligible
Not stated
Nearly three-quarters of the respondents have either a lead (29%) or support (42%) role in returnto-work interviews, with one-quarter (26%) no or negligible role (3% did not answer) (figure 18a). More than one-third (37%) describe their competence as excellent, 46% satisfactory and 6% unsatisfactory (11% not stated) (figure 18b). Of the 138 respondents describing their role as a lead one, 58% believe they have excellent competence no one described their competence as
19
Performance indicators and benchmarking in OH nursing Results and analysis
unsatisfactory (table 8). Of those in a support role, more feel their competence is satisfactory (55%) than excellent (41%). Of the 27 respondents describing their competence as unsatisfactory, the vast majority (81%) have no or negligible role, only 15% have a support role and none has a lead role (4% did not answer the question on competence) (table 9).
OHN role and competence in return-to-work interviews Figure 18a: Role in delivery
58 41 10
39 55 43
0 2 18
3 2 29
175 218 27
46 25 0
47 51 15
7 24 81
0 0 4
20
Performance indicators and benchmarking in OH nursing Results and analysis
60
50
40
Per cent 30 20
10
0 Commercial OH provider Other private sector NHS Other public sector Self employed All sectors
Basic
Comprehensive
Non-existent
Not stated
60
50
40
Per cent 30 20
10
0 Commercial OH provider Other private sector NHS Other public sector Self employed All sectors
Essential
Desirable
Nil/negligible
Not stated
21
Performance indicators and benchmarking in OH nursing Results and analysis
Only half (50%) of respondents have either a lead (27%) or support role in this area (figure 20a). Two-thirds (68%) describe their competence as either excellent or satisfactory (figure 20b).
OHN role and competence in home/off-site visits to workers on sick leave Figure 20a: Role in delivery
Cross-analysis finds that virtually all those in a lead role have either excellent (60%) or satisfactory (36%) competence; 36% of those in a support role have excellent competence and 59% satisfactory (table 10). Of 62 respondents who describe their competence in this area as unsatisfactory, 93% have no or negligible role (though one individual has a lead role in this function).
Table 10: Competence against role in delivering home/off-site visits to workers on sick leave
Role/competence Lead Support None/negligible n Excellent % Satisfactory % Unsatisfactory % Not stated % Total %
60 36 12
36 59 33
1 3 27
3 2 28
22
Performance indicators and benchmarking in OH nursing Results and analysis
144 181 62
53 25 2
28 36 5
17 39 94
2 1 0
70 60 50 40 Per cent 30 20 10 0 Commercial OH provider Other private sector NHS Other public sector Self employed All sectors
Basic
Comprehensive
Non-existent
Not stated
23
Performance indicators and benchmarking in OH nursing Results and analysis
90 80 70 60 50 Per cent 40 30 20 10 0 Commercial OH provider Other private sector NHS Other public sector Self employed All sectors
Essential
Desirable
Nil/negligible
Not stated
Just under half (46%) of nurses have a lead role and 42% a support role in delivering disability assessments and adjustments (figure 22a). One-third (32%) of respondents describe their competence as excellent, half (51%) satisfactory and 11% unsatisfactory (figure 22b).
OHN role and competence in disability assessment Figure 22a: Role in delivery
24
Performance indicators and benchmarking in OH nursing Results and analysis
Of those in a lead role, there is an almost equal split between those who describe their competence as excellent (52%) and as satisfactory (45%), with just three individuals with a lead role (1%) describing their competence as unsatisfactory (table 12). Of those in support roles, 11% express concern about their level of competence in disability assessment and adjustment.
Table 12: Competence against role in delivering disability assessments and adjustments
Role/competence Lead Support None/negligible n Excellent % Satisfactory % Unsatisfactory % Not stated % Total %
216 199 46
52 17 9
45 67 13
1 11 54
2 5 24
150 239 50
75 41 6
23 56 44
3 3 50
0 1 0
Vocational rehabilitation
The majority (82%) of OH departments across all sectors offer vocational rehabilitation (figure 23a). However, just under half (47%) of respondents across all sectors describe the service as comprehensive other public sector employers (34% comprehensive) are the worst performers in this context. The vast majority of respondents (88% describe vocational rehabilitation as either essential or desirable, with only minor variation between sectors (figure 23b).
60 50 40 Per cent 30 20 10 0 Commercial Other private OH provider sector NHS Other public sector Self employed All sectors
Basic
Comprehensive
Non-existent
Not stated
25
Performance indicators and benchmarking in OH nursing Results and analysis
90 80 70 60 50 Per cent 40 30 20 10 0 Commercial OH provider Other private sector NHS Other public sector Self employed All sectors
Essential
Desirable
Nil/negligible
Not stated
More OH nurses describe their role in vocational rehabilitation as one of support (42%) than lead (34%) (figure 24a). Around one-fifth (19%) have no or negligible role. More nurses describe their competence in this area as satisfactory (45%) than excellent (28%) or unsatisfactory (15%) (figure 24b 12% did not answer the question).
OHN role and competence in vocational rehabilitation Figure 24a: Role in delivery
26
Performance indicators and benchmarking in OH nursing Results and analysis
Of those in a lead role, the majority (61%) describe their competence as excellent (table 14). Just 2% of those is a lead role describe their competence as unsatisfactory. Of those in a support role, just 14% say they have excellent competence, 71% satisfactory and 10% in need of improvement. Of the 69 respondents who believe their competence in this area is unsatisfactory, 29% are in a support role and 6% in a lead role.
162 198 90
61 14 4
35 71 18
2 10 50
2 5 28
133 213 69
74 26 6
21 66 29
3 8 65
2 0 0
27
Performance indicators and benchmarking in OH nursing Results and analysis
90 80 70 60 50 Per cent 40 30 20 10 0 Commercial OH provider Other private sector NHS Other public sector Self employed All sectors
Basic
Comprehensive
Non-existent
Not stated
90 80 70 60 50 Per cent 40 30 20 10 0 Commercial OH provider Other private sector NHS Other public sector Self employed All sectors
Essential
Desirable
Nil/negligible
Not stated
Three-quarters (73%) of OH nurses have a lead role in analysing pre-employment/pre-placement questionnaires, with just 5% having no or negligible role (figure 26a). Nearly three-quarters (72%) describe their competence in this area as excellent, with no respondents describing their competence as unsatisfactory (figure 26b).
28
Performance indicators and benchmarking in OH nursing Results and analysis
OHN role and competence in analysis of pre-employment/ pre-placement questionnaires Figure 26a: Role in delivery
100
Per cent
More respondents with a lead role described their competence as excellent (78%) compared with those in a support role (61%) (table 16).
345 95 23
78 61 61
20 38 26
0 0 0
2 1 13
341 113 0
79 62 -
17 32 -
4 5 -
0 1 -
29
Performance indicators and benchmarking in OH nursing Results and analysis
100 90 80 70 60 Per cent 5 0 40 30 20 10 0 Commercial OH provider Other private sector NHS Other public sector Self employed All sectors
Basic
Comprehensive
Non-existent
Not stated
100 90 80 70 60 Per cent 5 0 40 30 20 10 0 Commercial OH provider Other private sector NHS Other public sector Self employed All sectors
Essential
Desirable
Nil/negligible
Not stated
Seventy-one per cent of respondents have a lead role in assessing fitness for work, with 24% in a support role (figure 28a). The vast majority (95%) of respondents describe their competence as excellent (61%) or satisfactory (34%), with just 1% describing their competence in this area as unsatisfactory (figure 28b 4% did not answer the question).
30
Performance indicators and benchmarking in OH nursing Results and analysis
Those in a lead role were twice as likely to rate their performance as excellent (72%) as do those in a support role (35%) (table 18).
OHN role and competence in assessment of fitness for work Figure 28a: Role in delivery
100
Per cent
The vast majority (84%) of those who rate their competence as excellent are in lead roles in the assessment of fitness for work; this compares with just over half (53%) of those with satisfactory self-rated competence.
337 114 13
72 35 31
26 62 31
1 2 8
2 1 31
n = number of respondents in each category; 9 did not answer the question. Figures round up to more than 100%.
287 163 5
84 53 40
14 44 40
1 2 20
1 1 0
31
Performance indicators and benchmarking in OH nursing Results and analysis
60 50 40 Per cent 30 20 10 0 Commercial OH provider Other private sector NHS Other public sector Self employed All sectors
Basic
Comprehensive
Non-existent
Not stated
80 70 60 50 Per cent 40 30 20 10 0 Commercial OH provider Other private sector NHS Other public sector Self employed All sectors
Essential
Desirable
Nil/negligible
Not stated
Three-quarters (75%) of respondents have a role in developing fitness-for-work standards (figure 30a). Nearly half (48%) of respondents describe their competence as satisfactory, 29% excellent and 15% unsatisfactory (figure 30b 8% did not answer the question on competence).
32
Performance indicators and benchmarking in OH nursing Results and analysis
OHN role and competence in developing fitness-for-work standards Figure 30a: Role in delivery
40
More of those in a lead role describe their competence as excellent (57%) rather than satisfactory (38%) two per cent describe their competence as unsatisfactory (table 20). Of those in a support role, 13% describe their competence as excellent, 77% satisfactory and 7% unsatisfactory. Of the 71 respondents who believe their competence is unsatisfactory, only 21% have a role in developing fitness-for-work standards (table 21).
185 172 97
57 13 5
38 77 21
2 7 55
3 3 19
135 225 71
79 31 4
17 59 17
4 9 75
1 1 4
33
Performance indicators and benchmarking in OH nursing Results and analysis
Basic
Comprehensive
Non-existent
Not stated
Essential
Desirable
Nil/negligible
Not stated
34
Performance indicators and benchmarking in OH nursing Results and analysis
90 80 70 60 50 Per cent 40 30 20 10 0 Commercial OH provider Other private sector NHS Other public sector Self employed All sectors
Basic
Comprehensive
Non-existent
Not stated
90 80 70 60 50 Per cent 40 30 20 10 0 Commercial OH provider Other private sector NHS Other public sector Self employed All sectors
Essential
Desirable
Nil/negligible
Not stated
Most OH nurses have a role in delivering health surveillance (just 8% have a negligible or no role), with more (67%) having a lead than support role (23%) (figure 33a). Three-fifths (59%) rate their competence as excellent, 34% satisfactory and just 2% as unsatisfactory (figure 33b).
35
Performance indicators and benchmarking in OH nursing Results and analysis
OHN role and competence in health surveillance provision Figure 33a: Role in delivery
No practitioners in a lead role, and just 4% of those in a support role rate their competence in this area as unsatisfactory (table 22). Those rating themselves as excellent are more likely to be in a lead role (78% in lead role) compared with those rating their competence as satisfactory (53% in lead role) (table 23).
316 109 37
70 44 30
27 50 51
0 4 14
3 2 5
281 160 10
78 53 10
17 34 40
4 12 50
1 1 0
36
Performance indicators and benchmarking in OH nursing Results and analysis
The picture is slightly different for the role of OH nurses in the interpretation of health surveillance: 62% have a lead role and 29% a support role (figure 34a); 50% rating their competence as excellent, 43% satisfactory and 3% unsatisfactory (figure 34b).
OHN role and competence in interpretation of health surveillance Figure 34a: Role in delivery
100
Per cent
As with the provision of health surveillance, none of the practitioners in a lead role, and just 4% of those in a support role rate their competence in this area as unsatisfactory (table 24). Similarly, those rating themselves as excellent are more likely to be in a lead role (78% in lead role) compared with those rating their competence as satisfactory (50% in lead role) (table 25).
294 135 34
63 30 29
34 65 38
0 4 24
3 1 9
37
Performance indicators and benchmarking in OH nursing Results and analysis
236 202 14
78 50 0
17 44 43
4 6 57
1 0 0
70 60 50 40 Per cent 30 20 10 0 Commercial OH provider Other private sector NHS Other public sector Self employed All sectors
Basic
Comprehensive
Non-existent
Not stated
38
Performance indicators and benchmarking in OH nursing Results and analysis
80 70 60 50 Per cent 40 30 20 10 0 Commercial OH provider Other private sector NHS Other public sector Self employed All sectors
Essential
Desirable
Nil/negligible
Not stated
Three-fifths (60%) of respondents have a support role in health and safety risk assessment (figure 36a), and a similar proportion (59%) describe their competence as satisfactory (figure 36b).
OHN role and competence in health and safety risk assessment Figure 36a: Role in delivery
39
Performance indicators and benchmarking in OH nursing Results and analysis
Of 105 respondents in a lead role, 61% describe their competence as excellent; this contrasts with the 284 respondents in a support role of whom 22% describe their competence as excellent (table 26). The majority of those who describe their competence in this area as unsatisfactory (58%) have either no or a negligible role in this area. However, one practitioner in a lead role and 12 in a support role describe their competence as unsatisfactory.
Table 26: Competence against role in health and safety risk assessment
Role/competence Lead Support None/negligible n Excellent % Satisfactory % Unsatisfactory % Not stated % Total %
105 284 71
61 22 11
33 72 55
1 4 25
5 2 8
100 100 99
n = number of respondents in each category; 13 did not answer the question; figures round down to 99%
135 279 31
47 13 3
46 73 39
6 14 58
1 0 0
40
Performance indicators and benchmarking in OH nursing Results and analysis
60
50
40
Per cent 30 20
10
0 Commercial OH provider Other private sector NHS Other public sector Self employed All sectors
Basic
Comprehensive
Non-existent
Not stated
90 80 70 60 50 Per cent 40 30 20 10 0 Commercial OH provider Other private sector NHS Other public sector Self employed All sectors
Essential
Desirable
Nil/negligible
Not stated
The majority of respondents (84%) have either a lead (38%) or support (46%) role in assessing mental health risks (figure 38a). Similarly, 82% describe their competence as either excellent (29%) or satisfactory (53%) (figure 38b). More than half (53%) of those in a lead role describe their competence as excellent, with just 2% saying it is unsatisfactory (table 28). However, of those in a support role, just 16% say their competence is excellent, with 70% satisfactory and 12% unsatisfactory (table 29).
41
Performance indicators and benchmarking in OH nursing Results and analysis
OHN role and competence in assessing risks to mental health Figure 38a: Role in delivery
179 216 66
53 16 11
42 70 35
2 12 45
3 2 9
138 252 60
68 30 7
25 60 43
5 9 50
1 1 0
while 12% have no service provision in this area (2% did not respond) (figure 39a). Three-fifths (59%) said this service was essential, while one third (34%) said it was a desirable function. There was little variation between sectors, though slightly more public sector respondents (66%) said the service was essential (figure 39b).
80 70 60 50 Per cent 40 30 20 10 0 Commercial OH provider Other private sector NHS Other public sector Self employed All sectors
Basic
Comprehensive
Non-existent
Not stated
70 60 50 40 Per cent 30 20 10 0 Commercial OH provider Other private sector NHS Other public sector Self employed All sectors
Essential
Desirable
Nil/negligible
Not stated
43
Performance indicators and benchmarking in OH nursing Results and analysis
Just 21% of OH nurses have a lead role in advising on work organisation and design, with 55% having a support role (figure 40a). A similar percentage (21%) describe their competence as excellent and 57% satisfactory (figure 40b). Those in a lead role are much more likely to describe their competence as excellent compared with those in a support role (table 30).
OHN role and competence in advising on work organisation and design Figure 40a: Role in delivery
Table 30: Competence against role in advising on work organisation and design
Role/competence Lead Support None/negligible n Excellent % Satisfactory % Unsatisfactory % Not stated % Total %
100 260 94
58 13 5
33 75 38
4 9 49
5 3 7
100 100 99
n = number of respondents in each category; 19 did not answer the question; total figures round down to below 100
97 269 74
60 12 5
35 72 32
5 13 62
0 2 0
44
Performance indicators and benchmarking in OH nursing Results and analysis
45 40 35 30 25 Per cent 20 15 10 5 0 Commercial OH provider Other private sector NHS Other public sector Self employed All sectors
Basic
Comprehensive
Non-existent
Not stated
Essential
Desirable
Nil/negligible
Not stated
45
Performance indicators and benchmarking in OH nursing Results and analysis
Just 8% of OH nurses say they have a lead role in the provision of PPE the lowest ranked of any of the job functions (figure 42a). Half (49%) have a support role and 40% have a negligible or no role. The majority of respondents (77%) describe their competence in this area as satisfactory or better. Those in a lead role are far more likely to rate their competence as excellent compared with those in a support role or with no role (table 32).
OHN role and competence in provision of personal protective equipment Figure 42a: Role in delivery
40
Table 32: Competence against role in the provision of personal protective equipment
Role/competence Lead Support None/negligible n Excellent % Satisfactory % Unsatisfactory % Not stated % Total %
39 233 187
67 15 11
26 77 50
3 5 29
5 4 10
n = number of respondents in each category; 14 did not answer the question; some numbers round up to more than 100
81 284 66
32 4 2
42 63 17
26 33 82
0 1 0
46
Performance indicators and benchmarking in OH nursing Results and analysis
Monitoring work-related accident, injury and illness data Figure 43a: Level of provision
70 60 50 40 Per cent 30 20 10 0 Commercial OH provider Other private sector NHS Other public sector Self employed All sectors
Basic
Comprehensive
Non-existent
Not stated
70 60 50 40 Per cent 30 20 10 0 Commercial OH provider Other private sector NHS Other public sector Self employed All sectors
Essential
Desirable
Nil/negligible
Not stated
47
Performance indicators and benchmarking in OH nursing Results and analysis
Just 23% of respondents have a lead role in monitoring work-related accident, injury and illness data (figure 44a), with most (80%) describing their competence as satisfactory or excellent (figure 44b). Sixty respondents describe their competence in this area as unsatisfactory, but 83% of these said that they have either no role or only a negligible role in this area (table 35).
OHN role and competence in monitoring work-related accident, injury and illness data Figure 44a: Role in delivery
Table 34: Competence against role in monitoring work-related accident, injury and illness data
Role/competence Lead Support None/negligible n Excellent % Satisfactory % Unsatisfactory % Not stated % Total %
55 21 11
39 72 41
0 5 39
6 2 9
123 257 60
49 17 0
38 62 17
11 20 83
2 1 0
48
Performance indicators and benchmarking in OH nursing Results and analysis
50 45 40 35 30 Per cent 25 20 15 10 5 0 Commercial OH provider Other private sector NHS Other public sector Self employed All sectors
Basic
Comprehensive
Non-existent
Not stated
60 50 40 Per cent 30 20 10 0 Commercial OH provider Other private sector NHS Other public sector Self employed All sectors
Essential
Desirable
Nil/negligible
Not stated
49
Performance indicators and benchmarking in OH nursing Results and analysis
OHN role and competence in costbenefit analysis of OH interventions Figure 46a: Role in delivery
45 10 5
50 68 23
4 18 62
1 4 10
71 196 163
65 26 2
20 49 15
14 24 82
1 1 1
50
Performance indicators and benchmarking in OH nursing Results and analysis
80 70 60 50 Per cent 40 30 20 10 0 Commercial OH provider Other private sector NHS Other public sector Self employed All sectors
Basic
Comprehensive
Non-existent
Not stated
70 60 50 40 Per cent 30 20 10 0 Commercial OH provider Other private sector NHS Other public sector Self employed All sectors
Essential
Desirable
Nil/negligible
Not stated
51
Performance indicators and benchmarking in OH nursing Results and analysis
The majority of respondents have either a lead (44%) or support (39%) role in delivering DSE assessments (figure 48a), with most rating their competence as either satisfactory (33%) or excellent (56%) (figure 48b). Those rating their competence as excellent are more likely to be in a lead role than those with satisfactory self-rated competence (table 38).
OHN role and competence in display screen equipment assessments Figure 48a: Role in delivery
Table 38: Competence against role in carrying out display-screen equipment assessments
Role/competence Lead Support None/negligible n Excellent % Satisfactory % Unsatisfactory % Not stated % Total %
210 185 62
78 44 24
20 50 34
0 2 31
2 5 11
n = number of respondents in each category; 16 did not answer the question; some figures round up to more than 100
263 155 24
62 27 4
31 59 13
6 14 79
2 0 4
52
Performance indicators and benchmarking in OH nursing Results and analysis
80 70 60 50 Per cent 40 30 20 10 0 Commercial OH provider Other private sector NHS Other public sector Self employed All sectors
Basic
Comprehensive
Non-existent
Not stated
53
Performance indicators and benchmarking in OH nursing Results and analysis
Essential
Desirable
Nil/negligible
Not stated
Overall, 68% of respondents have some role in sharps/needlestick prevention and management (figure 50a); however, this clearly reflects the lower level of service outside the NHS. Two-fifths (41%) of respondents describe their competence in this area as excellent, and 43% satisfactory (figure 50b).
OHN role and competence in sharps/needlestick prevention and management Figure 50a: Role in delivery
40
54
Performance indicators and benchmarking in OH nursing Results and analysis
The majority (69%) of those in a lead role in this function describe their competence as excellent (table 40). And of the 39 respondents describing their competence in this area as unsatisfactory, 36 of them (92%) have no or negligible role (table 41).
69 36 13
29 60 49
0 1 26
3 2 13
101 99 101
n = number of respondents in each category; 13 did not answer the question; totals did not equal 100 as numbers rounded to nearest integer
194 203 39
65 26 0
25 40 5
9 33 92
0 1 3
Immunisation
A similar picture emerges with the provision of immunisation by OH departments (figure 51a). Provision is almost universal among NHS respondents (85% comprehensive, 9% basic). Provision is higher in other public sectors than both other private sector and commercial OH providers. As with sharps/needlestick prevention and management, with the exception of the NHS, more respondents tend to view the service as essential than are actually providing a comprehensive service (figure 51b). For example, more than half (53%) of public sector respondents consider the service as essential and 23% desirable, yet only 35% provide a comprehensive service and 35% no service at all.
55
Performance indicators and benchmarking in OH nursing Results and analysis
90 80 70 60 50 Per cent 40 30 20 10 0 Commercial OH provider Other private sector NHS Other public Self employed sector All sectors
Basic
Comprehensive
Non-existent
Not stated
90 80 70 60 50 Per cent 40 30 20 10 0 Commercial OH provider Other private sector NHS Other public sector Self employed All sectors
Essential
Desirable
Nil/negligible
Not stated
Two-thirds (64%) of respondents have either a lead (42%) or support role (22%) in delivering immunisation services (figure 52a), with competence described, in most cases, as satisfactory (33%) or excellent (44%) (figure 52b). Three-quarters (73%) of respondents in a lead role believe their competence to be excellent (table 42). Those with self-rated unsatisfactory competence are most likely (91%) to have no or negligible role in its delivery (table 43).
56
Performance indicators and benchmarking in OH nursing Results and analysis
73 37 13
24 55 31
1 4 44
2 4 12
206 154 75
71 31 3
19 38 5
10 31 91
0 1 1
50 45 40 35 30 Per cent 25 20 15 10 5 0 Commercial OH provider Other private sector NHS Other public sector Self employed All sectors
Basic
Comprehensive
Non-existent
Not stated
50 45 40 35 30 Per cent 25 20 15 10 5 0 Commercial OH provider Other private sector NHS Other public sector Self employed All sectors
Essential
Desirable
Nil/negligible
Not stated
Although only half of the OH nurses (52%) have either a support or lead role on this area (figure 55a), two-thirds (68%) rate their competence as at least satisfactory (figure 55b). The majority (85%) of those describing their competence as unsatisfactory have no or negligible role in travel health provision and advice (table 45).
58
Performance indicators and benchmarking in OH nursing Results and analysis
OHN role and competence in travel health advice Figure 55a: Role in delivery
60 40
Per cent
52 19 8
44 70 35
2 9 44
2 2 12
100 100 99
n = number of respondents in each category; 17 did not answer the question; some numbers round down to less than 100
63 27 3
21 38 10
16 34 85
1 1 2
59
Performance indicators and benchmarking in OH nursing Results and analysis
Provision of training and education (eg manual handling) excluding first aid
Just over two-thirds (68%) of all respondents organisations provide some level of occupational health training and education (such as manual handling); but only a minority (28% commercial OH provider, 37% other private sector, 30% NHS and 22% other private sector) offer a comprehensive service (figure 56a). This is in stark contrast to the 85% describing the service as either essential (53%) or desirable (32%) similar across all sectors (figure 56b).
Provision of training and education (eg manual handling) excluding first aid Figure 56a: Level of provision
45 40 35 30 25 Per cent 20 15 10 5 0 Commercial OH provider Other private sector NHS Other public sector Self employed All sectors
Basic
Comprehensive
Non-existent
Not stated
60
50 40
Per cent 30 20
10
0 Commercial OH provider Other private sector NHS Other public sector Self employed All sectors
Essential
Desirable
Nil/negligible
Not stated
60
Performance indicators and benchmarking in OH nursing Results and analysis
Two-thirds (64%) have either a lead (24%) or support (40%) role in training (figure 56a), with three-quarters describing their competence as excellent (29%) or satisfactory (46%) (figure 56b). Those with a greater role are more likely to rate their competence as excellent (table 45).
OHN role and competence in provision of training and education (eg manual handling) excluding first aid Figure 56a: Role in delivery
40
Table 45: Competence against role in delivering training and education (excluding first aid)
Role/competence Lead Support None/negligible n Excellent % Satisfactory % Unsatisfactory % Not stated % Total %
68 22 11
31 70 34
1 6 39
1 3 15
101 101 99
n = number of respondents in each category; 14 did not answer the question; numbers round up/down to above/below 100
137 219 74
56 16 1
31 60 15
13 24 82
0 0 1
61
Performance indicators and benchmarking in OH nursing Results and analysis
Organisation of first aid and first-aid training Figure 57a: Level of provision
70 60 50 40 Per cent 30 20 10 0 Commercial OH provider Other private sector NHS Other public sector Self employed All sectors
Basic
Comprehensive
Non-existent
Not stated
60
50
40
Per cent 30 20
10
0 Commercial OH provider Other private sector NHS Other public sector Self employed All sectors
Essential
Desirable
Nil/negligible
Not stated
62
Performance indicators and benchmarking in OH nursing Results and analysis
Nearly half of the respondents (48%) have no or negligible role in delivering first-aid training (figure 58a), though two-thirds describe their competence as either excellent (35%) or satisfactory (33%) (figure 58b). The vast majority (84%) of respondents in a lead role describe their competence as excellent (table 47), with 93% of those reporting unsatisfactory competence having no or negligible role in its delivery (table 48).
OHN role and competence in organisation of first aid and first-aid training Figure 58a: Role in delivery
Table 47: Competence against role in organisation of first aid and first aid-training
Role/competence Lead Support None/negligible n Excellent % Satisfactory % Unsatisfactory % Not stated % Total %
84 25 15
13 66 31
1 5 39
2 4 15
166 156 96
65 11 1
15 43 5
20 46 93
0 1 1
63
Performance indicators and benchmarking in OH nursing Results and analysis
70 60 50 40 Per cent 30 20 10 0 Commercial Other private OH provider sector NHS Other public sector Self employed All sectors
Basic
Comprehensive
Non-existent
Not stated
80 70 60 50 Per cent 40 30 20 10 0 Commercial OH provider Other private sector NHS Other public sector Self employed All sectors
Essential
Desirable
Nil/negligible
Not stated
64
Performance indicators and benchmarking in OH nursing Results and analysis
Most OH nurses have some role in confidential counselling: 38% lead; 46% support; 14% none/negligible; and 2% not stated (figure 60a). Similarly, most rate their competence as either excellent (34%) or satisfactory (52%) just 8% were unsatisfactory (6% not stated) (figure 60b). Twothirds of respondents with excellent self-rated competence in this area are in a lead role in its delivery (table 49).
OHN role and competence in the provision of confidential counselling Figure 60a: Role in delivery
181 217 67
60 21 6
37 71 36
1 6 39
2 2 19
160 246 39
68 27 3
29 63 31
3 10 67
1 0 0
65
Performance indicators and benchmarking in OH nursing Results and analysis
60
50
40
Per cent 30 20
10
0 Commercial OH provider Other private sector NHS Other public sector Self employed All sectors
Basic
Comprehensive
Non-existent
Not stated
60 50 40 Per cent 30 20 10 0 Commercial OH provider Other private sector NHS Other public sector Self employed All sectors
Essential
Desirable
Nil/negligible
Not stated
66
Performance indicators and benchmarking in OH nursing Results and analysis
Half of all respondents (50%) have a lead role in general health and wellness screening, with 27% in a support role and 21% having no or negligible role (2% not stated) (figure 62a). Most describe their competence as excellent (48%) or satisfactory (41%) (figure 62b). Nearly threequarters (71%) of those in a lead role describe their competence as excellent (table 51).
OHN role and competence in general health and wellness screening Figure 62a: Role in delivery
Table 51: Competence against role in delivering general health and wellness screening
Role/competence Lead Support None/negligible n Excellent % Satisfactory % Unsatisfactory % Not stated % Total %
71 29 19
26 67 49
0 2 18
3 2 14
226 195 21
75 31 5
16 44 10
8 25 86
1 0 0
67
Performance indicators and benchmarking in OH nursing Results and analysis
70 60 50 40 Per cent 30 20 10 0 Commercial OH provider Other private sector NHS Other public sector Self employed All sectors
Basic
Comprehensive
Non-existent
Not stated
90 80 70 60 50 Per cent 40 30 20 10 0 Commercial OH provider Other private sector NHS Other public sector Self employed All sectors
Essential
Desirable
Nil/negligible
Not stated
68
Performance indicators and benchmarking in OH nursing Results and analysis
An almost equal percentage of respondents have either a support (43%) or lead (44%) role in advising on OH law (figure 64a). However, fewer describe their competence as excellent (30%) than satisfactory (53%) (figure 64b). A minority (11%) describe their competence as unsatisfactory (6% did not respond to this question).
OHN role and competence in interpreting and advising on OH law Figure 64a: Role in delivery
Of those in a lead role, 56% describe their competence as excellent, with just 2% rating their competence as unsatisfactory (table 53).
206 203 53
56 13 2
40 77 21
2 8 58
1 2 19
99 100 100
n = number of respondents in each category; 11 did not answer the question; some numbers round down to less than 100
144 252 52
80 33 10
19 62 31
1 4 60
1 1 0
69
Performance indicators and benchmarking in OH nursing Results and analysis
Confidential handling of health and personal data Figure 64a: Level of provision
100 90 80 70 60 Per cent 50 40 30 20 10 0 Commercial OH provider Other private sector NHS Other public sector Self employed All sectors
Basic
Comprehensive
Non-existent
Not stated
Essential
Desirable
Nil/negligible
Not stated
70
Performance indicators and benchmarking in OH nursing Results and analysis
More than three-quarters (77%) describe their role as a lead one, with 21% in a support role and none with just one respondent describing their role as nil or negligible (2% not stated) (figure 65a). Three-quarters (75%) describe their competence as excellent and 21% satisfactory (4% did not respond) (figure 65b). The vast majority in a lead role describe their competence as excellent (table 55).
OHN role and competence in confidential handling of health and personal data Figure 65a: Role in delivery
80 60
Per cent 4 0
Table 55: Competence against role in confidential handling of health and personal data
Role/competence Lead Support None/negligible n Excellent % Satisfactory % Unsatisfactory % Not stated % Total %
362 99 1
83 53 0
15 43 100
0 2 0
2 2 0
354 99 2
85 56 0
15 43 100
0 1 0
1 0 0
71
Performance indicators and benchmarking in OH nursing Results and analysis
Figure 66: Do nurses in a lead role tend to have high levels of self-rated competence?
90
80
26 25
26
70
23 22
23 18
24 25
60
24
50 Per cent 40
11 10 17
21 22
21
18 19
20
13 14 12
14 13
15 16
16
17
30
5 6
11 10
8 7
8
12
15
19
20
20
1
4
4
10
1
0 0 5 10 15 20 25 30
Lead role
Excellent competence
Note: the x axis refers to the 26 skill areas, arranged in order of increasing numbers in lead roles. The Y axis shows the percentages of OH nurses in lead roles and the corresponding self-rated competence levels. Key:
1 PPE 6 Injury/illness data 11 Return to work 16 Sharps/needlestick 21 Health/wellness 26 Data handling 2 Work organisation 7 Training 12 Rehab 17 Immunisation 22 Health surveillance interpretation 3 H&S 8 Travel health 13 Mental health 18 DSE 23 Health surveillance 4 Cost-benefit 9 Home/off-site 14 Counselling 19 OH law 24 Assessing fitness for work 5 Attendance 10 First aid 15 Fitness for work standards 20 Disability 25 Pre-employment questionnaires
72
Performance indicators and benchmarking in OH nursing Results and analysis
More nurses have a lead role in confidential handling of health and personal data than any other skill area (table 57). Provision of personal protective equipment is the lowest ranked. In terms of self-rated competence ranking, nurses rate confidential handling of health and personal data as their most competent skill area, with costbenefit analysis of OH interventions the lowest (table 58).
1 2 3 4 5 6 7 8= 8= 10 11= 11= 13= 13= 15 16 17= 17= 17= 20 21= 21= 23= 23= 25 26
Confidential handling of health and personal data Analysing of pre-employment/pre-placement questionnaires Assessment of fitness for work Delivering health surveillance Interpretation of health surveillance General health and wellness screening Disability assessments and adjustments Display screen equipment assessments Interpreting and advising on OH law Immunisation Sharps/needlestick prevention and management Developing fitness-for-work standards Confidential counselling Assessing risks to mental health Vocational rehabilitation Delivering return-to-work interviews Travel health advice/provision Organisation of first aid and first-aid training Home/off-site visits to workers on sick leave Provision of training and education Monitoring work-related accident, injury and illness data Attendance monitoring Costbenefit analysis of OH interventions Health and safety risk assessment Advising on work organisation and design Provision of personal protective equipment
77 73 71 67 62 50 46 44 44 42 39 39 38 38 34 29 27 27 27 24 23 23 22 22 21 8
73
Performance indicators and benchmarking in OH nursing Results and analysis
Table 58: Competence area ranking by percentage rating their competence as excellent
Ranking Competence area % excellent
Confidential handling of health and personal data Analysing of pre-employment/pre-placement questionnaires Assessment of fitness for work Delivering health surveillance Display screen equipment assessments Interpretation of health surveillance General health and wellness screening Immunisation Sharps/needlestick prevention and management Delivering return-to-work interviews Organisation of first aid and first-aid training Confidential counselling Disability assessments and adjustments Interpreting and advising on OH law Home/off-site visits to workers on sick leave Attendance monitoring Assessing risks to mental health Developing fitness-for-work standards Provision of training and education Health and safety risk assessment Vocational rehabilitation Monitoring work-related accident, injury and illness data Travel health advice/provision Advising on work organisation and design Provision of personal protective equipment Costbenefit analysis of OH interventions
75 72 61 59 56 50 48 44 41 37 35 34 32 30 30 30 29 29 29 29 28 26 23 21 17 15
74
Performance indicators and benchmarking in OH nursing Results and analysis
90
25 23 24 25 26
80
19
20 21 20
22 24
23
70
17 16 14 15 17
18
22
60
10 8 9 11
13 12
Per cent 50
4 5 5
7 7 11 13 15 9 10 12 16 18
19
40
3 3
21
30
1 1 2 2 4 6
20
10
0 0 5 10 15 20 25 30
Essential service
Comprehensive provision
Note: the x axis refers to the 26 service areas, arranged in increasing order of perceived importance. The Y axis shows the percentages of OH nurses rating the service as essential, and the corresponding percentages where the service is rated as comprehensive. Key:
1 Home/off-site visits to workers on sick leave 6 Costbenefit analysis of OH interventions 11 Delivering return-towork interviews 16 Health and safety risk assessment 21 Assessing risks to mental health 26 Confidential handling of health and personal data 2 Travel health advice/provision 7 Immunisation 12 Advising on work organisation and design 17 Confidential counselling 22 Disability assessments and adjustments 3 General health and wellness screening 8 Provision of training and education 13 Vocational rehabilitation 18 Developing fitnessfor-work standards 23 Interpretation of health surveillance 4 Provision of personal protective equipment 9 Attendance monitoring 14 Display screen equipment assessments 19 Interpreting and advising on OH law 24 Delivering health surveillance 5 Organisation of first aid and first-aid training 10 Monitoring work-related accident, injury and illness data 15 Sharps/needlestick prevention and management 20 Analysing of preemployment/pre-placement questionnaires 25 Assessment of fitness for work
75
Performance indicators and benchmarking in OH nursing Results and analysis
The graph plots all 26 of the above nursing practice/service delivery areas in pairs, according to the percentage of nurses describing each as an essential function and the percentage describing their organisations provision as comprehensive. The x-axis refers to the 26 service areas, arranged in order of increasing percentages as essential functions the functions are described in the key. One might expect that the more a service is seen as essential (circles), the more organisations would be providing a comprehensive service (triangles). However, as can be seen, although there is a general upward trend in service provision the more a service is deemed essential, there is often a wide discrepancy between what practitioners see as essential and the organisation actually providing a full level of service. In all but four cases analysis of pre-employment/pre-placement questionnaires, DSE assessments, general health and wellness screening and home/off-site visits to workers on sick leave the percentage with a comprehensive service is lower than the percentage deemed as essential. The discrepancies are shown clearly in table 59 where the service areas are ranked according to how essential it is perceived by practitioners and the level of comprehensive provision. Assessing risks to mental health, for example, is seen as an essential service by 81% of respondents, yet only 42% are deemed to be providing a comprehensive service. Table 59 ranks the services according to whether or not respondents perceive them as essential. Handling confidential health and personal data is seen as most important, with home/off-site visits to workers on sick leave as least essential. Table 60 shows that handling confidential health and personal data is followed by the assessment of fitness to work and analysis of pre-employment/pre-placement questionnaires as the areas where organisations provide comprehensive services. Costbenefit analysis of OH interventions is the lowest ranked.
76
Performance indicators and benchmarking in OH nursing Results and analysis
Table 59: Service delivery ranking as essential with comparison figures for organisations provision as comprehensive (all sectors)
Ranking Competence area % essential % comprehensive
Confidential handling of health and personal data Assessment of fitness for work Delivering health surveillance Interpretation of health surveillance Disability assessments and adjustments Assessing risks to mental health Analysing of pre-employment/pre-placement questionnaires Interpreting and advising on OH law Developing fitness-for-work standards Confidential counselling Health and safety risk assessment Sharps/needlestick prevention and management Display screen equipment assessments Vocational rehabilitation Advising on work organisation and design Delivering return-to-work interviews Monitoring work-related accident, injury and illness data Attendance monitoring Provision of training and education Immunisation Costbenefit analysis of OH interventions Organisation of first aid and first-aid training Provision of personal protective equipment General health and wellness screening Travel health advice/provision Home/off-site visits to workers on sick leave
95 88 84 84 81 81 77 76 71 68 66 63 62 61 59 58 58 53 53 50 50 44 44 39 25 23
88 84 74 73 64 42 80 49 47 57 43 43 62 47 33 47 37 38 31 46 21 39 26 41 24 25
77
Performance indicators and benchmarking in OH nursing Results and analysis
Table 60: Service delivery ranking by percentage rating the organisations provision as comprehensive (all sectors)
Ranking Service % comprehensive
Confidential handling of health and personal data Assessment of fitness for work Analysing of pre-employment/pre-placement questionnaires Delivering health surveillance Interpretation of health surveillance Disability assessments and adjustments Display screen equipment assessments Confidential counselling Interpreting and advising on OH law Developing fitness-for-work standards Vocational rehabilitation Delivering return-to-work interviews Immunisation Health and safety risk assessment Sharps/needlestick prevention and management Assessing risks to mental health General health and wellness screening Organisation of first aid and first-aid training Attendance monitoring Monitoring work-related accident, injury and illness data Advising on work organisation and design Provision of training & education Provision of personal protective equipment Home/off-site visits to workers on sick leave Travel health advice/provision Costbenefit analysis of OH interventions
88 84 80 74 73 64 62 57 49 47 47 47 46 43 43 42 41 39 38 37 33 31 26 25 24 21
Tables 6164 give the sector rankings according to respondents views on whether or not the service is essential and the corresponding level of comprehensive provision. There are some notable differences, such as NHS respondents viewing the management of sharps/needlesticks as the fourth most important function, whereas commercial OH providers and other private sector respondents rank this in 20th and 21st place, respectively. Return-to-work interviews are ranked 10th by respondents from commercial OH providers, but 16th, 17th and 17th in the other private, NHS and other public sectors, respectively.
78
Performance indicators and benchmarking in OH nursing Results and analysis
Service delivery ranking as essential with comparison figures for organisations provision as comprehensive (by sector)
Table 61: Commercial OH provider
Ranking Competence area % essential % comprehensive
Confidential handling of health and personal data Assessment of fitness for work Delivering health surveillance Interpretation of health surveillance Assessing risks to mental health Analysing of pre-employment/pre-placement questionnaires Disability assessments and adjustments Interpreting and advising on OH law Developing fitness-for-work standards Confidential counselling Delivering return-to-work interviews Display screen equipment assessments Health and safety risk assessment Attendance monitoring Advising on work organisation and design Provision of training and education Vocational rehabilitation General health and wellness screening Costbenefit analysis of OH interventions Sharps/needlestick prevention and management Organisation of first aid and first-aid training Monitoring work-related accident, injury and illness data Immunisation Provision of personal protective equipment Travel health advice/provision Home/off-site visits to workers on sick leave
95 88 87 85 82 77 74 72 71 62 62 61 60 56 55 55 54 51 50 49 48 45 39 35 33 18
88 89 78 78 47 81 62 54 55 46 55 76 37 49 34 28 47 55 30 28 39 28 34 23 29 28
79
Performance indicators and benchmarking in OH nursing Results and analysis
Confidential handling of health and personal data Assessment of fitness for work Disability assessments and adjustments Delivering health surveillance Interpretation of health surveillance Assessing risks to mental health Interpreting and advising on OH law Analysing of pre-employment/pre-placement questionnaires Developing fitness-for-work standards Health and safety risk assessment Monitoring work-related accident, injury and illness data Display screen equipment assessments Attendance monitoring Confidential counselling Vocational rehabilitation Delivering return-to-work interviews Advising on work organisation and design Provision of training and education Organisation of first aid and first-aid training Sharps/needlestick prevention and management Costbenefit analysis of OH interventions Provision of personal protective equipment General health and wellness screening Immunisation Travel health advice/provision Home/off-site visits to workers on sick leave
97 88 84 81 81 79 76 74 74 71 70 66 63 62 62 61 58 58 58 52 51 47 38 33 29 24
88 81 66 72 70 33 48 76 47 49 51 59 46 52 51 49 33 37 52 30 24 27 40 31 29 26
80
Performance indicators and benchmarking in OH nursing Results and analysis
Confidential handling of health and personal data Assessment of fitness for work Delivering health surveillance Sharps/needlestick prevention and management Interpretation of health surveillance Immunisation Analysing of pre-employment/pre-placement questionnaires Assessing risks to mental health Confidential counselling Disability assessments and adjustments Interpreting and advising on OH law Developing fitness-for-work standards Health and safety risk assessment Advising on work organisation and design Vocational rehabilitation Display screen equipment assessments Delivering return-to-work interviews Monitoring work-related accident, injury and illness data Costbenefit analysis of OH interventions Provision of training and education Provision of personal protective equipment Attendance monitoring General health and wellness screening Organisation of first aid and first-aid training Home/off-site visits to workers on sick leave Travel health advice/provision
96 89 89 88 85 85 83 81 79 78 77 70 66 60 59 57 54 54 46 44 44 37 28 24 21 12
93 90 76 79 76 85 90 49 66 61 50 46 44 34 46 61 48 26 15 30 27 22 34 24 18 16
81
Performance indicators and benchmarking in OH nursing Results and analysis
Confidential handling of health and personal data Assessment of fitness for work Disability assessments and adjustments Assessing risks to mental health Interpretation of health surveillance Delivering health surveillance Interpreting and advising on OH law Confidential counselling Analysing of pre-employment/pre-placement questionnaires Sharps/needlestick prevention and management Developing fitness-for-work standards Advising on work organisation and design Vocational rehabilitation Health and safety risk assessment Display screen equipment assessments Monitoring work-related accident, injury and illness data Delivering return-to-work interviews Immunisation Costbenefit analysis of OH interventions General health and wellness screening Attendance monitoring Provision of training and education Provision of personal protective equipment Organisation of first aid and first-aid training Travel health advice/provision Home/off-site visits to workers on sick leave
96 92 86 86 85 82 81 77 72 68 66 66 64 62 61 57 55 53 51 51 50 50 47 36 23 23
81 82 65 47 72 70 43 69 76 31 34 31 34 32 58 31 35 35 15 42 31 22 18 31 19 28
82
Performance indicators and benchmarking in OH nursing Results and analysis
90
25 23 24
80
19 20
21
22 26
70
17 16 13 10 8 9 11 12 14 14 15
18
20
60
25 24
Per cent 50
3 4 5
7 7 15 11
23
40
3 5 17 22 1 1 2 2 4 6 8 9 10 12 13 16 18 19 21
30
20
10
0 0 5 10 15 20 25 30
Essential service
Excellent competence
Note: the x axis refers to the 26 service areas, arranged in increasing order of perceived importance. The Y axis shows the percentages of OH nurses rating the service as essential and the corresponding percentages where the OH nurses rate their own competence in delivering these functions. Key:
1 Home/off-site visits to workers on sick leave 6 Costbenefit analysis of OH interventions 11 Delivering return-towork interviews 16 Health and safety risk assessment 21 Assessing risks to mental health 26 Confidential handling of health and personal data 2 Travel health advice/provision 7 Immunisation 12 Advising on work organisation and design 17 Confidential counselling 22 Disability assessments and adjustments 3 General health and wellness screening 8 Provision of training and education 13 Vocational rehabilitation 18 Developing fitnessfor-work standards 23 Interpretation of health surveillance 4 Provision of personal protective equipment 9 Attendance monitoring 14 Display screen equipment assessments 19 Interpreting and advising on OH law 24 Delivering health surveillance 5 Organisation of first aid and first-aid training 10 Monitoring work-related accident, injury and illness data 15 Sharps/needlestick prevention and management 20 Analysing of pre-employment/ pre-placement questionnaires 25 Assessment of fitness for work
84
Performance indicators and benchmarking in OH nursing Results and analysis
OHN competence in research skills and awareness Figure 69a: Level of competence
Team working
OH nurses rate their competence in team working as either excellent (71%) or satisfactory (26%) (figure 70a). The vast majority (87%) believe this skill to be essential (9% desirable) (figure 70b).
85
Performance indicators and benchmarking in OH nursing Results and analysis
Per cent
Budget management
OH nurses are less confident of their competence in budget management (56% satisfactory, 17% excellent, 26% unsatisfactory, 2% not stated) (figure 71a). However, most view this function as either essential (44%) or desirable (42%) (figure 71b).
86
Performance indicators and benchmarking in OH nursing Results and analysis
Resource management
A slightly more positive picture emerges for OH nursing skills in resource management, with 57% rating their competence as satisfactory, 27% as excellent, and 15% unsatisfactory (figure 72a). Again, most OH nurses see this skill as either essential (54%) or desirable (37%) (figure 72b).
Leadership skills
Most nurses are confident of their leadership skills at an operational level (43% excellent, 48% satisfactory, 6% unsatisfactory, 3% not stated) (figure 73a). Two-thirds (66%) rate this skill as essential and 25% desirable (5% nil or negligible, 4% not stated) (figure 73b).
OHN competence in leadership sills at an operational level Figure 73a: Level of competence
87
Performance indicators and benchmarking in OH nursing Results and analysis
Fewer nurses believe their competence to be excellent at strategic-level leadership skills (25% excellent; 54% satisfactory and 19% unsatisfactory). Again, more than half (52%) rate this skill as essential and 36% desirable (9% nil/negligible and 3% not stated) (figure 74b).
OHN competence in leadership skills at a strategic level Figure 74a: Level of competence
88
Performance indicators and benchmarking in OH nursing Results and analysis
OHN competence in communication with clients and OH colleagues Figure 76a: Level of competence
Per cent
Per cent
89
Performance indicators and benchmarking in OH nursing Results and analysis
Conflict management
Nearly two-thirds (62%) of OH nurses rate their competence in conflict management as satisfactory, with 23% excellent and 13% unsatisfactory (2% not stated) (figure 77a). Three-fifths (58%) rate this as essential and 37% desirable (figure 77b).
Presentation skills
OH nurses are generally confident of their presentation skills (45% excellent, 48% satisfactory, 6% unsatisfactory, 1% not stated) (figure 78a). Two-thirds (65%) rate this skill as essential (figure 78b).
90
Performance indicators and benchmarking in OH nursing Results and analysis
Coaching/mentoring
Most OH nurses rate their competence in coaching and mentoring as either excellent (33%) or satisfactory (55%) (11% unsatisfactory, 1% not stated) (figure 79a). This function is generally seen as essential (55%) or desirable (36%) (figure 79b).
Clinical supervision
A similar picture is seen regarding OH nurses skills in clinical supervision, with 31% describing their competence as excellent and 51% satisfactory (figure 80a). However, a significant minority (15%) say their competence in this area is unsatisfactory (2% not stated). More than half (55%) rate this skill as essential and 35% desirable (7% nil/negligible; 3% not stated) (figure 80b).
91
Performance indicators and benchmarking in OH nursing Results and analysis
92
Performance indicators and benchmarking in OH nursing Results and analysis
90
11
80
12
70
8 9
10
11
60
7 4 5 6
Per cent 50
1
40
6 10
30
4 3 2
20
1
10
0 0 2 4 6 8 10 12 14
Essential rating
Excellent competence
Key:
1 Budget management 7 Conflict management 2 Research skills 3 Leadership skills strategic level 9 Leadership skills operational level 4 Resource management 1 0 Interpreting developments in OH practice 5 Clinical supervision 6 Coaching/ mentoring 1 2 Communication with clients and OH colleagues
8 Presentation skills
1 1 Teamwork
Communication with clients and OH colleagues, and teamwork are viewed as the most essential of the 12 skill areas in this section of the research (table 65). These two skill areas are also the two where more nurses rate their competence as excellent (table 66). Of interest is that these are the only two of the 12 skill areas where more than half of the nurses rate their competence as excellent. Just 17% of OH nurses rate their skills in budget management as excellent the lowest-ranked skill area despite the fact that 44% see this skill as essential.
93
Performance indicators and benchmarking in OH nursing Results and analysis
1 2 3 4 5 6 7= 7= 9 10 11 12
Communication with clients and OH colleagues Teamwork Interpreting developments in OH practice Leadership skills operational level Presentation skills Conflict management Coaching/mentoring Clinical management Resource management Leadership skills strategic level Research skills Budget management
94 87 71 66 65 58 55 55 54 52 51 44
1 2 3 4 5= 5= 7 8 9 10 11 12
Communication with clients and OH colleagues Teamwork Presentation skills Leadership skills operational level Interpreting developments in OH practice Coaching/mentoring Clinical supervision Resource management Leadership skills strategic level Conflict management Research skills Budget management
81 71 45 44 33 33 31 27 25 23 23 17
94
Performance indicators and benchmarking in OH nursing Results and analysis
Table 67: Average referral time (days) between management referral and being seen by OH professional
Sector Mean Standard deviation Commercial OH provider Other private sector NHS Other public sector Self-employed All sectors
5.43 4.26
4.51 4.23
8.23 4.61
6.90 5.43
4.15 4.18
6.05 4.78
The spread of responses shown in figures 82 and 83 is also interesting. Nearly one-quarter (22%) of commercial OH providers claim that the average managementOH referral time is one to two working days; with the majority (59%) reporting that average referral times are no more than five days. The other private sector fares even better, with 73% of respondents reporting that average referral times are no more than five days. By contrast, just 6% of NHS referrals are achieved in one to two working days, and only 29% are seen within five days. The other public sector respondents report that 16% are seen within two days and 57% within five days.
Figure 82: Average referral time (days) between management referral and being seen by OH professional (all sectors)
95
Performance indicators and benchmarking in OH nursing Results and analysis
Figure 83: Average referral time (days) between management referral and being seen by OH professional (by sector)
45 40 35 30 25 Per cent 20 15 10 5 0 Commercial OH provider Other private sector NHS Other public sector Self employed*
1 to 2 days
3 to 5 days
6 to 10 days
11 to 20
21+
Don't know
Fitness-for-work reports
Respondents were asked to estimate the length of time in days it takes to deliver a fitness-forwork report after the employee has been seen by the OH professional. The average (mean) response time across all sectors was 2.63 days (sd = 2.18); with the commercial OH providers (2.63 days) and other private sector (2.83 days) outperforming the NHS (3.53 days) and other public sector (2.99 days) (table 68). However, there is considerable variation within sectors, as indicated by the relatively large standard deviations. Figure 84 shows that most respondents report fairly rapid delivery of fitness-for-work reports (90% within five days). Although 88% of NHS respondents estimate that reports are generally delivered within five working days, figure 85 shows a shift towards slightly longer delivery times when compared with the other sectors. For example, 47% of NHS respondents say that reports take at least three days to be delivered. This compares with 30% in the commercial OH providers, 31% in other private sector, and 41% in the other public sector respondents.
2.63 2.18
2.83 2.74
3.53 3.61
2.99 2.65
3.45 4.16
3.00 2.91
96
Performance indicators and benchmarking in OH nursing Results and analysis
Figure 84: Average time (days) to deliver a fitness-for-work report (all sectors)
70
60 50 40 Per cent 30 20 10
Figure 85: Average time (days) to deliver a fitness-for-work report (by sector)
70 60 50 40 Per cent 30 20 10 0 Commercial OH provider Other private sector NHS Other public sector Self employed*
1 to 2 days
3 to 5 days
6 to 10 days
11 to 20
21+
Don't know
97
Performance indicators and benchmarking in OH nursing Results and analysis
11.20 5.94
12.52 6.23
15.47 6.47
14.87 5.96
16.50 4.15
13.44 6.32
Figure 86 presents the spread of response times across all sectors. Figure 87 shows a shift towards longer referral times in the other public sector (49% of respondents say average referral times are 11 days or longer), other private sector (40% 11 days or longer) and NHS (37% 11 days or longer), compared with the commercial OH providers (29% 11 days or longer).
Figure 86: Average time (days) to be seen by external specialist (all sectors)
35 30 25 20
Per cent
Figure 87: Average time (days) to be seen by external specialist (by sector)
45 40 35 30 25
Per cent
20 15 10 5 0
Commercial OH provider
NHS
Self employed*
1 to 2 days
3 to 5 days
6 to 10 days
11 to 20
21+
Don't know
98
Performance indicators and benchmarking in OH nursing Results and analysis
Respondents were also asked to state the main factors that can delay referral for a specialist health or medical assessment. They were asked to select any of the following possible factors: I signing off by occupational physician I signing off by line manager I lack of cooperation from employee I time taken by employees GP I NHS waiting list I time taken by private health consultant. As figure 88 shows, the three main factors were the time taken by the employees GP, NHS waiting lists and time taken by a private health consultant. Respondents from the NHS were particularly frustrated by the delay caused by NHS waiting lists (81% of NHS respondents selected this option) (figure 89).
Figure 88: Main factors delaying referral for specialist health/medical assessment (all sectors)
70
60
50
40 Per cent 30
20
10
0 Occ physician Line manager Employee Employees GP NHS waiting list Private health consultant
99
Performance indicators and benchmarking in OH nursing Results and analysis
Figure 89: Main factors delaying referral for specialist health/medical assessment (by sector)
90 80 70 60 50 Per cent 40 30 20 10 0 Commercial OH provider Other private sector NHS Other public sector Self employed
Occ physician
Line manager
Employee
GP
NHS list
Private consultant
Figures 90 and 91 also include responses from the other sectors. Although some respondents from the other private sector will be working in healthcare, the comparatively large number of responses from the sector suggests that some practitioners were answering this question from beyond the target healthcare or emergency services. Of the 22 responses from the other public sector (which would include emergency services), 27% state that PEP is available through the OH department, 68% through A&E and 14% have no provision. More than two-thirds (68%) say that PEP is available out of hours unsurprising given that this matches the number saying that provision was via A&E departments.
Figure 90: Provision of post-exposure prophylaxis (respondents working with the NHS and emergency services only)
80 70 60 50 Per cent 40 30 20 10 0 NHS Other public sector Commercial OH provider Other private sector
Through OH dept
No provision
Note: respondents could select more than one option n = 113 NHS; 22 other public sector; 20 OH provider; 46 other private sector
100 90 80 70 60 Per cent 50 40 30 20 10 0 NHS Other public sector Commercial OH provider Other private sector
Yes
No
Don't know
101
Performance indicators and benchmarking in OH nursing Results and analysis
Figure 92: Time taken between needlestick injury and worker being seen by OH professional (NHS only)
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Performance indicators and benchmarking in OH nursing Results and analysis
Medical confidentiality
Just 6% of respondents report that their organisation does not have a policy on medical confidentiality and health data security (figure 93). Nearly half (43%) of practitioners have a lead role in developing and/or delivering this policy and 36% a support role.
Attendance
Most organisations have a sickness absence policy (just 2% do not). However, OH nurses are more likely to have a support role (64%) in this area than lead role (19%) (figure 94).
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Performance indicators and benchmarking in OH nursing Results and analysis
70
60
50
40 Per cent 30
20
10
n = 473
Disability
There is a very similar situation concerning OH nurses role in the organisations disability policy, with 63% having a support role and 17% a lead role (figure 95).
70
60
50
40 Per cent 30
20
10
n = 473
104
Performance indicators and benchmarking in OH nursing Results and analysis
n = 473
Stress
A larger proportion of OH nurses (29%) have a lead role in developing and/or delivering a stress policy; half (50%) have a support role and just 14% no or negligible role (figure 97). Just 6% of organisations do not have a stress policy.
n = 473
105
Performance indicators and benchmarking in OH nursing Results and analysis
Manual handling
More than half (54%) of OH nurses have a support role in developing/delivering the manual handling policy. However, more than one-quarter (26%) have no or negligible role and just 15% a lead role.
60
50
40
Per cent 30 20
10
n = 473
Health and safety and the reporting of injury and illness data
Two-thirds (67%) of respondents have a support role in the development and/or delivery of the health and safety policy 19% have no or negligible role and 11% a lead role (figure 99). A similar picture emerges for the development/delivery of the policy on the reportable injuries, diseases and dangerous occurrences (RIDDOR), with 58% having a support role, 12% a lead role and 27% no or negligible role (figure 100).
n = 473
106
Performance indicators and benchmarking in OH nursing Results and analysis
60
50
40
Per cent 30
20
10
n = 473
Bloodborne viruses
Most organisations have a policy on bloodborne viruses (12% do not). More OH nurses have a lead role (37%) than have a support role (30%) in developing and/or delivering the policy (figure 101).
n = 473
107
Performance indicators and benchmarking in OH nursing Results and analysis
Substance misuse
Most organisations have a policy on substance abuse (8% do not). Half (50%) of OH nurses have a support role in this area, with 22% having a lead role and 18% no role.
n = 473
108
Performance indicators and benchmarking in OH nursing Results and analysis
Working across more than one workplace had no significant impact on the level of clinical supervision (table 80), access to occupational physician (table 81), peer support/mentoring (table 82). The data was analysed according to whether or not the respondent was working alone or as part of an OH team (tables 8392). There are surprisingly few differences in the overall responses on clinical governance. The largest difference of note concerns opportunities for trainee OH nurses and interns. Of the 107 lone practitioners answering the question, 57% say that opportunities are unsatisfactory, compared with 34% of responses from those working as part of a team. A higher percentage of lone worker respondents (33%) report that peer support and mentoring is unsatisfactory compared with those working as part of an OH team (23% unsatisfactory); however, around half (47%) of both groups report being satisfied in this context. Even when looking at lower opportunities for professional development, the scores are only marginally lower for lone workers (35% v 40% excellent; 46% v 39% satisfactory), but not statistically significant. Lone workers record slightly lower scores for service delivery auditing (19% v 18% excellent; 35% v 48% satisfactory; 46% v 33% unsatisfactory), but again not significantly different.
56 34 9 1 0.48 0.65
64 27 9 1 0.56 0.65
57 35 7 1 0.51 0.62
50 36 11 2 0.40 0.69
59 32 8 0 0.51 0.65
27 45 18 9 0.10 0.74
* Note: positive mean scores indicate relatively good performance overall; negative scores indicate poor performance overall
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Performance indicators and benchmarking in OH nursing Results and analysis
41 50 7 2 0.34 0.62
44 43 12 2 0.33 0.68
43 50 6 1 0.38 0.59
38 52 6 4 0.33 0.59
36 57 5 1 0.32 0.57
45 36 9 9 0.40 0.70
35 53 10 1 0.25 0.63
41 43 14 2 0.28 0.70
34 58 6 1 0.28 0.57
35 52 11 2 0.24 0.65
32 53 15 0 0.18 0.67
45 36 9 9 0.40 0.70
Table 73: Opportunities for professional development (% responses and mean ratings)
Sector Excellent (+1) Satisfactory (0) Unsatisfactory (-1) Not stated Mean rating Standard deviation All sectors Commercial OH provider Other private sector NHS Other public sector Self-employed
38 41 20 1 0.18 0.75
33 45 21 1 0.12 0.73
42 40 16 2 0.26 0.72
34 40 24 2 0.10 0.76
41 38 22 0 0.19 0.77
45 27 18 9 0.30 0.82
25 45 27 3 -0.02 0.73
29 43 27 2 0.02 0.76
24 47 28 2 -0.04 0.72
29 45 24 2 0.05 0.74
20 43 35 1 -0.15 0.74
18 45 18 18 0 0.71
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Performance indicators and benchmarking in OH nursing Results and analysis
20 51 27 2 -0.08 0.69
19 51 29 1 -0.10 0.69
23 53 21 2 0.02 0.68
15 50 31 4 -0.17 0.67
22 42 36 0 -0.15 0.75
27 45 18 9 0.10 0.74
18 48 32 3 -0.14 0.70
18 47 33 2 -0.15 0.71
19 49 27 4 -0.08 0.69
18 44 36 2 -0.18 0.73
11 49 38 3 -0.28 0.65
45 36 0 18 -0.56 0.53
16 50 32 2 -0.17 0.68
18 46 35 1 -0.17 0.72
17 55 25 3 -0.18 0.66
14 47 37 2 -0.24 0.68
12 49 39 0 -0.27 0.67
27 55 9 9 0.20 0.63
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Performance indicators and benchmarking in OH nursing Results and analysis
18 44 36 1 -0.18 0.72
21 46 32 1 -0.11 0.73
19 49 31 1 -0.12 0.70
18 43 37 2 -0.20 0.72
15 34 50 1 -0.36 0.73
27 27 36 9 -0.10 0.88
Table 79: Opportunities for trainee OH nurses (% responses and mean ratings)
Sector Excellent (+1) Satisfactory (0) Unsatisfactory (-1) Not stated Mean rating Standard deviation All sectors Commercial OH provider Other private sector NHS Other public sector Self-employed
20 35 42 4 -0.23 0.77
18 32 45 5 -0.28 0.77
15 34 48 4 -0.35 0.73
27 44 26 3 0.01 0.74
22 27 49 3 -0.28 0.81
9 36 36 18 -0.33 0.71
Rating of clinical governance impact of working across more than one workplace
Table 80: Clinical supervision effect of working across more than one workplace
Responsible for more than one workplace % Excellent (+1) Satisfactory (0) Unsatisfactory (-1) Not stated Mean rating* Standard deviation Responsible for one workplace %
18 48 31 3 -0.13 0.70
17 48 32 3 -0.16 0.70
* Note: positive mean scores indicate relatively good performance overall; negative scores indicate poor performance overall
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Performance indicators and benchmarking in OH nursing Results and analysis
Table 81: Access to occupational physician effect of working across more than one workplace
Responsible for more than one workplace % Excellent (+1) Satisfactory (0) Unsatisfactory (-1) Not stated Mean rating Standard deviation Responsible for one workplace %
58 34 8 1 0.50 0.64
54 34 11 1 0.43 0.69
Table 82: Peer support/mentoring effect of working across more than one workplace
Responsible for more than one workplace % Excellent (+1) Satisfactory (0) Unsatisfactory (-1) Not stated Mean rating Standard deviation Responsible for one workplace %
27 45 26 2 0.02 0.74
21 46 29 3 -0.09 0.72
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Performance indicators and benchmarking in OH nursing Results and analysis
40 54 5 1 0.36 0.57
34 53 12 1 0.22 0.64
* Note: positive mean scores indicate relatively good performance overall; negative scores indicate poor performance overall
15 50 31 5 -0.17 0.68
18 49 31 2 -0.13 0.70
15 50 34 1 -0.19 0.68
16 50 32 1 -0.16 0.68
* Note: positive mean scores indicate relatively good performance overall; negative scores indicate poor performance overall
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Performance indicators and benchmarking in OH nursing Results and analysis
45 48 7 0 0.37 0.62
41 50 7 2 0.35 0.61
60 31 9 0 0.50 0.66
59 32 8 1 0.52 0.64
35 46 20 0 0.15 0.72
40 39 21 1 0.19 0.76
19 35 46 1 -0.27 0.76
18 48 33 1 -0.15 0.70
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Performance indicators and benchmarking in OH nursing Results and analysis
17 47 33 4 -0.17 0.70
29 47 23 1 0.07 0.72
22 49 29 0 -0.07 0.72
20 51 27 2 -0.07 0.69
6 30 57 7 -0.56 0.61
27 38 34 2 0.08 0.78
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Performance indicators and benchmarking in OH nursing Results and analysis
60
50
40
Per cent 30
20
10
Excellent
Satisfactory
Unsatisfactory
60 50 40
Per cent 30 20
Excellent
Satisfactory
Unsatisfactory
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Performance indicators and benchmarking in OH nursing Results and analysis
50 45 40 35 30 Per cent 25 20 15 10 5 0 Strategic planning Service auditing Opportunities for trainee nurses
Excellent
Satisfactory
Unsatisfactory
No provision
In-house
Independent provider
50 45 40 35 30 Per cent 25 20 15 10 5 0 Commercial OH provider Other private sector NHS Other public sector Self employed
In-house
Independent provider
No provision
Not stated
n = 473
Of the 107 sole OH practitioners answering the question, 46% said that they did not have access to OH support for themselves. This compares with just 21% of practitioners working as part of an OH team. (Care must be taken when interpreting data that could be confounded by other factors, such as the sector that the practitioner works in.)
In-house
Independent provider
No provision
Not stated
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Performance indicators and benchmarking in OH nursing Results and analysis
50 45 40 35 30 Per cent 25 20 15 10 5 0 Commercial OH provider Other private sector NHS Other public sector Self employed
Excellent
Satisfactory
Unsatisfactory
Non existent
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Performance indicators and benchmarking in OH nursing Results and analysis
46 41 9 3 1 0.38 0.65
47 43 7 3 0 0.41 0.63
50 37 10 2 1 0.42 0.67
44 44 11 0 2 0.33 0.67
45 43 7 5 0 0.40 0.62
45 36 9 9 0 0.40 0.70
* Note: positive mean scores indicate relatively good performance overall; negative scores indicate poor performance overall
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Performance indicators and benchmarking in OH nursing Results and analysis
123
Performance indicators and benchmarking in OH nursing Results and analysis
Table 94. OH nurses perception of the single most important OH nurse competency (unprompted responses)
Communication and listening Interpersonal skills Knowledge and education Confidentiality Flexibility and adaptability Legislation awareness Leadership, self-motivation and proactive working Knowing own limitations Teamwork Evidence-based practice n = 394 129 47 41 40 38 21 21 18 13 9
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Performance indicators and benchmarking in OH nursing Results and analysis
Others, however, were concerned that there was nothing to stop a registered nurse working in occupational health, with no specific OH qualifications, and that this portrayed the profession in a bad light. If I want to be a midwife I have to train to be a midwife. If I want to be a health visitor I have to train to be a health visitor. But without any qualifications I can go and work in occupational health and call myself an occupational health adviser and that sends out a very weak message, said one delegate. The survey findings highlight the limited number of training posts currently available in OH nursing. This point was taken up by a number of delegates. One urged employers to create more training posts, while another called for greater commitment to training from the big OH service providers. I actually think it is unfair that service providers dont offer more training posts, she said. However, a delegate from one of the national OH providers disagreed: At any one time we have a lot of people training and will continue to do so, she said. Even though there was a range of opinions on whether or not OH nurses needed to have special OH qualifications, there was near unanimous agreement that all physicians working in an OH capacity should be OH-qualified or at least in training. It was pointed out, however, that there simply are not enough OH physicians to meet demand and one delegate said that nonOH physicians could continue to fill certain functions. There is a role for the non-OH qualified doctor, depending on what it is you are expecting them to do. They shouldnt be working outside their competence but there are things that you can have a non-OH qualified doctor doing. We do a lot of driver medicals; we dont need an OH physician to be doing driver medicals, she said.
Manpower: is there an ideal ratio between the number of OH nurses and the number of employees in an organisation?
While there was some agreement that broad recommendations could be made on manpower, any recommendation on service provision needed to reflect more than total employee numbers. It would, for example, also need to take account of the risk levels within particular industries and the types of OH interventions appropriate for that industry. One delegate commented: We might be able to come up with something on an industry basis but it is not necessarily about risk. It may reflect what our interventions are in those particular industries. Coming from the NHS we do a lot of benchmarking in terms of vaccination, which is very labour-intensive, whereas other organisations may be equally risky, but in a different way, where there are some interventions which are not so time-consuming. Another delegate suggested that you could not stipulate how many OH nurses were required in a given size of organisation because so much OH work was done by multidisciplinary teams. An OH service needs to look at what levels of service are required, but these may be deliverable by different professionals, she said. You have to look very carefully at what the whole service is
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Performance indicators and benchmarking in OH nursing Results and analysis
required to deliver, because people will work in multi-disciplinary ways and they might at times work outwith a traditional occupational health nurse definition. If indeed that is the right definition. OH nurses need to be careful not to be over-territorial about their work. The discussion also raised wider issues of OH service provision in general. Even if it were possible to say how many nurses were required to deliver quality services, would there be enough competent nurses to meet demand? According to one delegate: There is not enough resource in Scotland to meet minimum numbers and thats an issue for OH education, and also for the [professional] organisations. Theres just not enough people trained to the right level.
The balance between what customers expect from the OH service and what OH practitioners perceive as essential
In completing the questionnaires, respondents were asked to assess aspects of service delivery and OH nursing competences using subjective terms such as satisfactory or excellent, and essential or desirable. Although delegates were confident that they had an inherent understanding of such terms in respect of their own work and skills, perceptions may differ depending on ones perspective as an OH professional or as a customer or employer. Most felt that the subjective terminology was helpful in setting goals for improving service delivery. But did others outside the profession agree? According to one delegate: If we aim for excellent and our customers expectations are only for satisfactory we are going to be delivering beyond the needs of our customers. We are going to end up being perceived as not cost-effective in terms of service provision. But more could be done to bridge this gap. What we havent done is marketing occupational health services and measuring their impact, he said.
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Performance indicators and benchmarking in OH nursing Results and analysis
DISCUSSION
Occupational health nurses practice in a wide range of situations, from single practitioners working in isolation for medium-sized private sector businesses, to members of large multidisciplinary teams in the NHS, major companies and commercial OH providers. Others are self-employed and contract their services to several client organisations. The experiences of OH nurses are inevitably diverse and this research has shed light on the different situations and challenges faced by nurses. It also provides a comprehensive insight, for the first time, of the levels of OH services provided by organisations across all employment sectors, the value placed on those services by the OH nurses themselves, the different roles OH nurses have in delivering those services and nurses own perception of their competence in performing the functions required of them. The research is based on responses to a mailed questionnaire with no telephone follow-up and no account has been taken for self-selection bias; however, with nearly 500 replies across all employment sectors, and a 24% response rate, the data represents a valuable cross-section of opinion. Although good data were revealed on the number of nurses working in more than one place of work, it must be acknowledged that this phenomenon creates some uncertainty in the findings where respondents were asked to quantify or rate the available OH nursing services in their particular area of work. The questionnaire did not accommodate nurses who may have wished to comment differently for different organisations. It must also be borne in mind that many of the findings represent the subjective views of respondents. However, taken en masse the data provide a strong body of evidence as to the gaps in provision, variable referral-response times and areas where the general level of OH nurse competences might be improved. The research identifies other wider issues, such as the inconsistent level of OH provision for OH nurses themselves, the perceived lack of training opportunities for nurses new to the field. The focus group discussion raised issues concerning the need for OH nurses and physicians to be appropriately qualified and how best to deliver OH nurse education. Overall, the research provides a detailed picture of the work of OH nurses in the UK, how their practice differs between sectors, and evidence that OH providers, educators and policymakers can consider when deciding how to address gaps in OH nursing provision.
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Performance indicators and benchmarking in OH nursing Discussion
LITERATURE REVIEW
Aims and objectives
The literature review aims to support the research project being undertaken by the At Work Partnership for the RCN covering the development of core and specialist competences for occupational health nurses. It seeks to review material published by accredited researchers, academics and official bodies in three main areas: I the role and competences of occupational health professionals: published research and multi-government and agency policy papers covering the competences and learning outcomes for OH physicians and nurses; I the provision and delivery of occupational health (OH) services: published research and policy papers covering employees access to the range of OH support services; including assessment and monitoring; physical intervention services; absence, disability and rehabilitation management; preventative measures; psychosocial services and OH clinical governance; and I customer needs and priorities: studies examining the service priorities of the main stakeholders in an OH service, focusing on employers and employees, including the development of a quality framework for occupational health.
nursing diagnosis: this is a holistic concept that considers the whole person and their healthcare needs in the broadest sense. It is a health-based model rather than one based on disease, and nurses have the skills to apply the approach in the population they serve. For example, they can assess the needs of individuals and groups and can analyse, interpret, plan and implement strategies to achieve specific goals; individual and group care plans: for example, in a return-to-work plan, the OH nurse can (with the patients consent) liase with primary healthcare providers to ensure a comprehensive approach is maintained; general health advice and health assessment: OH nurses can give advice on a wide range of health issues and on their relationship to working ability. They can offer advice on a range of issues not directly caused by work, but which can affect performance at work. They are also in a good position to provide health information to hard-to-reach groups, including young men and ethnic workers; and research: OH nurses will be able to use research to support their work in fostering the general health of the working population. Specialist: OH policy and practice development, implementation and evaluation: the OH nurse is in a good position to advise management on the development of policy, but the potential to perform this role will depend on the level of OH nurse education, skills and experience; OH assessment: fitness for work, pre-employment or pre-placement examinations, and individual health assessments for lifestyle risk factors. Collaboration with physicians may be necessary depending on law and accepted practice; health surveillance: where there is residual risk and surveillance is legally required, the OH nurse will be involved in undertaking and evaluating the results of screening, but this does require a high degree of clinical skill. The OH nurse should know when to refer to an OH physician or other specialist, and is in a good position to monitor return to work, and to coordinate the examination of working practices in order to protect others potentially exposed to similar risks; sickness absence management: training line managers and supervisors, developing referral procedures, ensuring that medical confidentiality is protected, advising managers on preventing absence; rehabilitation: the OH nurse is often the key person in a return-to-work plan, and can complete a risk assessment, devise the rehabilitation programme, monitor progress and communicate with the parties involved (for example, the employee, the OH doctor and line manager). OH nurses can
131
Performance indicators and benchmarking in OH nursing Literature review
also develop proactive rehabilitation programmes to detect early changes in health before the onset of long-term absence; maintenance of work ability: health advice or planned programmes of work hardening to maintain or restore ability to work. Increasingly, these will involve psychosocial issues, and OH nurses are in a good position to advise management on mental health at work strategies; health and safety: the OH nurses experience in risk assessment, surveillance and environmental health management can be used by health and safety specialists in developing an organisations health and safety practices; hazard identification: new hazards may emerge out of new processes or working practices, and OH nurses are likely to become quickly aware of these because they have close contact with workers. OH nurses need to undertake regular workplace visits in order to maintain an up-todate knowledge and awareness of working processes; risk assessment: this technique underpins much health and safety legislation in the UK, and OH nurses can play a part in this process; advice on control strategies: OH nurses can provide advice and information on controlling the risks identified in risk assessments; research: OH nurses use findings from a wide range of disciplines and need to have the skills to read and critically assess research findings from these different disciplines and to incorporate findings into an evidence-based approach to their practice. OH nurses may also be involved in producing management reports for employers on accident and absence trends, and in evaluating the delivery of OH services, for which they need research skills; and ethics: OH nurses are trusted professionals, and this enables them to practice more effectively. Protecting the confidentiality of workers health data and the privacy of workers is key. Manager: management: an OH nurse may manage an OH unit, coordinating the work of other health professionals and acting as the budget holder for the department. S/he needs to have the skills to sit alongside other line managers within the organisation; administration: maintaining medical and nursing records, monitoring expenditure, staffing levels and skills mix; budget planning: OH nurses may be involved in securing resources and managing the financial assets of the department;
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Performance indicators and benchmarking in OH nursing Literature review
marketing: even in units that do not sell services externally, OH nurses will still need to sell the benefits of OH internally to line managers and senior level people, and to show them how best to use the service; service level agreements: OH nurses may be involved in setting up these within an organisation, for use with internal and external clients, and in monitoring the delivery of services against predetermined levels; quality assurance: OH nurses can contribute to continuous quality improvements; professional audit: OH nurses will be involved in auditing the nursing practices within the department, or in wider clinical auditing where all the clinical team participate in multidisciplinary audit; and continuing professional development: the nurse manager is in a good position to identify their own and the teams professional development needs and to ensure that these are met to maintain the competences of professional staff. Coordinator: OH team: in many cases, the OH nurse is the only permanent member of the team and is in a unique position to shape and direct the OH programme, using communication, planning, involvement, management and organisational skills; worker education and training: the OH nurse should be involved in informing and educating workers in how to protect themselves from occupational hazards and to raise awareness of nonoccupational but preventable diseases; and environmental health management: OH nurses can advise management on basic environmental policy, particularly in the absence of other specialists. Adviser: to management and staff on workplace health management: for example, making presentations to health and safety committees; and as a conduit to other external health or social agencies: for example, encouraging workers to seek help from GPs and specialist support services. Health educator: OH nurses can assess needs for health promotion, consult with management and workers, develop and plan programmes, and deliver health promotion strategies.
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Performance indicators and benchmarking in OH nursing Literature review
Counsellor: the OH nurse may be the only healthcare professional around, and may be the first point of contact for many people experiencing stress or other mental ill health; counselling and listening skills: providing these with the support of additional professional services; and problem solving skills: OH nurses are often approached for advice on personal issues, and need problem-solving skills developed through nurse education and training. Researcher: health needs assessment: this can be used as the basis for individual case management or OH programme planning; research skills: simple survey techniques, semi-structured interviews, and descriptive statistical techniques to present data; evidence-based practice: skills in literature searching, reviewing available evidence (including guidelines and protocols), and applying these in a practical way. OH nurses should also be skilled in identifying gaps in current knowledge; and epidemiology: OH nurses need to be familiar with the principles and basic methods used.
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I OH nurses must be able to work as a full member of a multidisciplinary team in the work setting, and in close collaboration with nurses and other health professionals in hospitals, health centres and other health services; and I OH nurses need to be aware of how an individual workers occupation may affect family life and vice versa. Learning outcomes: The WHO recommends that, on completion of a course in OH nursing, students should be able to: I contribute positively and effectively to the development, delivery, management and evaluation of all aspects of OH nursing, including: occupation-related health and safety promotion and health education; surveillance and screening; risk assessment and accident prevention; first aid for injuries and treatment of minor ailments; advice and nursing care for workers with specific work-related injuries or illnesses; and the rehabilitation of ill or injured workers; I maintain accurate and punctual completion of nursing documentation; I maintain an accurate and up-to-date database of all national legislation and policies of specific relevance to the work setting in which s/he is employed; I recognise and support the rights of all those employed in the work setting to work in a healthy and safe environment; and I provide leadership which is appropriate to the setting and which is underpinned by knowledge and understanding of the OH and safety risks present in the sector, industry or enterprise in which they work. OH nursing curriculum: The WHO curriculum presents seven training modules covering the role of the OH nurse, four of which are common to the entire specialist nursing curricula it has developed as part of a continuing development programme. These could usefully be used in drawing up a UK framework for performance: introductory module: competences and learning outcomes include: understanding how previous learning and experience can inform and enrich the new knowledge and skills necessary for the practice of OH nursing, and an understanding of competence and its relevance in nursing practice and in the team approach to care; OH nursing I: competences and learning outcomes include: demonstrating knowledge of national legislation affecting OH and safety and its impact on work practices; an ability to
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describe the principles of health promotion, health education and health surveillance in work settings; and to recognise confidentiality, ethical and legal issues which have implications for OH nursing practice and be able to take appropriate action; information management and research: competences include: the ability to analyse different sources of information and apply them; set measurable outcomes for nursing practice; and define possible research questions from day-to-day practice; OH nursing II: competences include: the ability to describe social and psychological factors that influence employers and employees behaviour at work, and their capacity for work; to conduct health promotion, health education and health clinic activities which meet the needs of the workforce, including immunisation and vaccination where necessary; and to provide referral to other members of the OH team or to external health services as appropriate; decision-making: competences include: demonstrating an understanding of the complexities of clinical decision making; an ability to describe the exercise of accountability and responsibility in relation to the care of workers in the OH setting; and to differentiate between strategic and clinical/ethical decision making in nursing; leadership and managing resources: competences include: demonstrating an understanding of management principles and processes and their application to the organisation and management of the OH nursing service; use OH nursing staffing protocols to schedule adequate staffing cover, reporting when safe levels cannot be achieved; and to play a part in maintaining standards and to contribute to quality assurance monitoring; and OH nursing III: competences include: applying and evaluating a risk assessment and management approach with a triple focus on the worker, the workplace and the work processes; the ability to plan and conduct physical examinations, such as pre-employment health assessment and hearing, sight and lung function tests; and to prepare protocols in conjunction with others on the safe use of new technology, chemical and other work processes.
measurement of workplace hazards and the monitoring of health trends, in addition to the above three elements included in the broad definition (Pilkington et al, 2002). This study by the HSE, which was conducted to form a baseline against which to assess performance towards the target of improving access to OH provision by 2003, examines the provision of different levels of OH service by organisation size, segregating employers into micro, small, medium and large enterprises. Table 95 shows the percentage of respondents in each of the size categories providing different OH services, according to whether they offer services in line with the HSEs broad or stringent definition of occupational health:
Hazard identification Formal risk management Information on health related issues Modifying work activities Training on health related issues Measuring workplace hazards Monitoring trends in health Health surveillance Rehabilitation programmes Promoting general health OH service by doctor or nurse Employee counselling
100/100 100/100 100/100 69/100 68/100 46/100 44/100 36/63 29/53 34/53 13/23 13/30
100/100 100/100 100/100 75/100 77/100 53/100 50/100 52/78 41/49 38/51 21/34 17/27
100/100 100/100 100/100 81/100 81/100 72/100 63/100 62/79 50/57 51/67 33/45 30/37
100/100 100/100 100/100 88/100 85/100 88/100 82/100 83/93 71/80 70/79 70/80 64/72
Micro employers: those employers with fewer than 10 employees rely on external sources of OH support. Owners and managers have direct and sole responsibility for health and safety. They often feel that many health and safety initiatives are not directly relevant to them. In general, no money is specifically allocated for OH support and in-house provision is mostly limited to a health and safety poster and a first aid box. The nature of the risks in the employers sector is the most important factor determining the existence of specific OH initiatives, such as health surveillance. Most micro employers surveyed by the HSE did not expect the level of provision in their business to change significantly and felt that HSE initiatives need to be simplified and the anticipated outcomes clearly explained. Small companies: OH provision tends to reflect the hazards present, and those enterprises with a statutory requirement to undertake surveillance tend to buy in these services as required. Safety
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is seen as a more important priority and to have more immediate benefits OH is often a second priority within health and safety, and has no distinct identity. No formal evaluation of the cost/benefits of providing OH is conducted. Most small companies are satisfied with the level of OH provided. Some acknowledge that they are limited by a lack of knowledge and time or resources. They feel that paperwork should be reduced and that information from the HSE and others should be more concise and concentrate on what is required to comply with legislation. Medium companies: seven of the 12 medium companies participating in the follow-up interviews for the HSE used external OH providers, one had an in house service and four had no formal provision. As with micro and small companies, safety had a higher profile than health in determining policy and resources in medium-sized companies. This group is more likely to have formal structures for involving employees in the area. The nature of the industry or sector, and its hazards, determines how much is spent on OH for example, the need for ongoing health surveillance. This group felt that more structured surveillance programmes are required and that changes in customer/client expectations from an OH service will prompt shifts in future service provision. None of the micro, small or medium-sized companies in the HSEs 2002 study had inhouse occupational health nursing support. Large companies: Nine of the 18 large employers in the follow-up interviews had in-house provision and the services had often been established for more than 10 years. This group is also more likely to have specialist OH personnel providing the service. But few large companies report using other specialists, such as ergonomists or occupational psychologists on a regular basis. Insurance companies are driving the development of OH in large companies, particularly in relation to health surveillance. Auditing and benchmarking is growing, yet OH is still often perceived as a cost without clear benefits by boards and senior managers. Most wished to develop more proactive approaches to OH, and believe that psychosocial issues like stress and bullying will shape provision in future. The stratification of OH provision by enterprise size described in the UK-wide study by the HSE, and in particular, the findings on access to specialist OH professionals, is supported by an EEFsponsored study of employers OH priorities (Reetoo et al, 2004). This concludes that 48% of small employers have no access to occupational physicians, compared with the 23% of large companies having full-time physician support. Medium-sized companies use occupational physicians on an as required basis.
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1998 99.6% of trusts claimed to provide access to OH in 1998, but virtually no service was provided to primary care staff. There was also wide variability in the quality and range of OH available, and only a third of employers had access to a specialist occupational physician. There was substantial inequality of access to OH services and the NHS had not met its 1994 target of providing access to specialist OH services to all staff (Hughes et al, 1999): I 70% of trust employees in the late 1990s had access to a service based with their employer; 27% were provided with OH from another trust; and 3% from the private sector. It was clear that provision of an OH service from within the NHS was, and is, the preferred option for NHS employers; I Only 38% of OH departments in 1998 employed a doctor full time and almost two-thirds employed one for half time or less. It was estimate that only 27% of the total NHS workforce received specialist medical OH services; I at least half of in-house OH departments employed three or fewer nurses; 61% of these nurses held a recognised OH qualification and a further 15% were in OH training positions. More than two-thirds (69%) of departments had at least one nurse with a degree in OH or an OH nursing diploma. More than two-thirds (69%) of nurses worked full time and 96% of departments had at least one full-time nurse; I the number of potential clients per OH nurse varied, but not as widely as the doctors lists, with an average of 1,838 clients per nurse. There was no suggestion in 1998 that inadequate doctor cover was supplemented by additional nurse cover; and I OH in primary care was virtually non-existent: 79 out of 90 health authorities had no formal arrangements to provide OH services to GPs or their staff. 2001 The amount of doctor time available for the occupational health of NHS employees increased between 1998 and 2001, as did the proportion of doctors holding professionals qualifications (Hughes et al, 2002). However, big variations in service levels continued to exist and government policy that all NHS staff should have access to a consultant led service had not yet been implemented. However, more doctors were working more sessions for their trusts and were better qualified in OH and many also undertook the OH function in settings other than their NHS trust environment. No real rise in the number of doctors in training in the specialty took place between 1998 and 2001. It is also possible that an increase in the medical staffing in NHS OH services may not have been matched by improvements in other crucial OH staffing provision, for example nurses:
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I the number of consultant staff rose by 50% between 1998 and 2001, and there was a small increase in the proportion of specialist registrar grades in OH; I the proportion of doctors holding an FOM qualification rose to 60%; I the proportion of doctors working in OH departments without an OH qualification fell from 33% to 22%; and I there was a 50% rise in the number of full-time doctor posts and a rise in the number of sessions worked by doctors in OH departments amongst the remainder between 1998 and 2001. 2002/03 All NHS trusts provided some OH but this was largely reactive and the quality and accessibility varied (National Audit Office, 2003). The number of trusts signing up to NHS Plus had levelled off and some noted that the resources generated by this scheme to sell OH services to non-trust employers were not being invested in improving the provision of services: I all trusts provided OH in 2002/03, but this was usually only available during normal office hours, and only 50% had arrangements for staff who required out-of-hours cover; I 82% of acute trusts had dedicated in-house staff, compared with only 30% of mental health trusts and 17% of ambulance trusts. Of the rest, 35% contracted OH from another trust; 3% from a non-NHS provider; and 5% used a combination of provision; I constraints on provision included difficulties recruiting suitable staff (just under half cited this as a barrier); lack of resources for investing in OH (72% of ambulance trusts; 41% of acute trusts); and problems with accommodation/geographic location (around a third of all trusts cited this as a barrier); I staffing varies widely; I sickness absence in trusts falls as OH spending per employee increases (but this finding is based on only 13% of trusts); I the services provided are largely reactive (for example, rehabilitation and post exposure screening) rather than proactive (for example, health surveillance, promotion and education). Part of the reason for the reactive nature of OH in the NHS is that the allocation of resources is dictated by legal requirement to provide OH checks on staff, especially when they move to another trust. This means fewer resources are available for proactive services; and
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I 68% provided fast track treatment programmes for particular conditions (for example, physiotherapy for MSDs). Access to OH in primary care Practice managers in primary care identify some improvement in OH provision in recent years (Reetoo et al, 2004). However, awareness of the available provision is variable and some managers regard their services to be understaffed and difficult to access due to location. Practice nurses also feel that provision has improved, citing protocols for needlestick injuries, and checking of immunisations. Knowledge of available OH provision amongst GPs was quite limited. Mental health problems were the greatest concern for this group, and GPs would like to see quick access to services where concerns over confidentiality are minimised.
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I managers do not consider that employees are reluctant to use the OH service out of fear of losing their job, although health records are sometimes kept by mangers in SMEs, raising issues of confidentiality; and I only one SME employer had carried out an audit of their OH service. Perceptions of OH amongst SME employers: I 71.4% agree that OH is an important part of running the company, primarily from the point of view of lost-productivity due to sickness absence (if someone is ill then that is 25% of our workforce down); and I 82.1% thought they had a responsibility for their workers; although 100% also thought that workers should take responsibility for their own health.
The majority of SMEs in a 2004 HSE-sponsored study (Reetoo et al, 2004) report little or no access to occupational physicians, and awareness of this group as a source of advice is low amongst managers in SMEs. However, occupational health nurses are used more widely. Barriers to the greater use of specialist physicians included perceived bias (either towards the employer or employee, depending on the respondent) and the likely costs of employing specialist doctors.
Multi-national organisations
Considerable differences exist between the OH activities of different sites within multi-national organisations (Bratveit et al, 2001). These differences reflect the type of OH set-up in each part of the organisation, resulting in wide variations and possibly inequalities in access to OH for employees in different parts of the same organisation. The OH professionals operating in sites with multidisciplinary OH teams spend most of their time on surveillance and preventative activities and relatively little on curative, more reactive, services for individual workers. Those sites relying on external doctors backed up by internal or external OH nurses spend more time on curative services for non-occupational diseases and, consequently, less time on activities related to the working environment. This latter group of OH services are also less likely to be involved in the planning and follow-up of surveillance in the
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working environment, an activity which tends to be conducted by external consultants at such sites. These stand-alone services are less likely to use doctors with a specialist qualification in occupational medicine. OH professional input: I two out of the eight distribution centres in the 2001 study of a multi-national, including one in the UK, had no provision for OH; I eight out of the 20 sites studied drew on the services of an inter-enterprise, multidisciplinary OH service, employing at least three of the following professions doctor, nurse, occupational hygienist, ergonomist, social worker, psychologist. All the doctors in these services, except one, had specialised in occupational medicine for at least one year; and I other locations had stand-alone services, using external or internal doctors in combination with external or internal nurses. Of the doctors, only one in 10 had at least one years specialisation in occupational medicine. External doctors and nurses were individual practitioners working part-time for the enterprise. OH provision in the past three years at one multi-national: I those sites with access to a multidisciplinary service spent less than 10% of time on curative services for non-work conditions, including vaccinations; I curative services for occupational diseases were provided at most locations in the multinational; I pre-employment health examinations were carried out at most locations, as were health examinations after workers returned to work after more than three weeks sick leave; I activities related to the working environment accounted for a considerable fraction (25%50%) of the multidisciplinary teams work. Standalone services using external doctors spent less time on these topics (in some locations, this work was carried out by external consultants and the in-house OH service was not briefed on the results). The standalone services were rarely involved in the development of strategies for OH programmes or in planning new workstations/work organisation; and I up to 20% of time in all OH departments at the multi-national was spent on health promotion activities like smoking cessation and healthy diet.
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Advice on the control of hazards at work: Health education and health promotion:
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Overall, more than 80% of managers and employees in the Irish civil service view the OH unit as important or very important. There are no differences by age, sex, grade or occupation, suggesting that a uniform service can be provided to all workers, regardless of these differences. The ranking of the eight most important functions of an OH unit vary slightly between employees and managers as follows, showing that HR managers view pre-employment and promotional screening as significantly more important than do employees. Screening and medical surveillance of workers with specific OH health risks, together with research, are not considered central to the role by employees (table 98):
1 2 3 4 5 6 7 8
7 2 3 6 8 4 1 5
The major sponsors and users of OH services employers and workers agree that the training of OH physicians reflects their priorities for an occupational health service. Research conducted for the HSE (Reetoo et al, 2004) concludes that employers and employees agree that all the competency areas covered in occupational physician training are important. However, when asked to rank these, advice on law and ethics is a top priority for employers, followed by assessments of occupational hazards and fitness for work. Employers rank the required competences of OH physicians in decreasing order as follows: I advice on law and ethics I assessment of occupational hazards to health I assessment of disability and fitness for work I communication I assessment of environmental exposures to health
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Although employers believe that the core competences for physicians set out above cover most aspects of occupational medicine as set out in the ILO convention, they do express a need for further training on the provision of advice on stress-related issues. Also, providers and purchasers of OH both agree that OH training needs to focus on equipping doctors to deal with situations where they are between medicine and management, where pure patient-to-doctor relationships can be confused with managerial issues (for example, advice on ill-health retirement or fitness for work). Research suggests there are no significant differences in the competences that employers require occupational physicians to possess by company size or sector, although public sector organisations rate the assessment of fitness for work higher than employers in other sectors. The quality and effectiveness of OH is influenced by the extent to which services meet the perceived demands of users. Identifying these demands and needs should enable the quality of OH to be enhanced by focusing on those most valued. Although differences exist in the priorities of HR managers and employees, there are overlaps, notably in areas of occupational and general health education.
Benchmarking OH performance
As different stakeholders have different needs and demands from an OH service, so the various actors and client groups will have different perceptions of quality and performance. These different perceptions will influence attempts to benchmark and measure the performance of OH at the micro level: I Quality to the OH professional means: outcomes whether the service meets the professionally assessed needs of its clients; process whether the service correctly selects and carries out the techniques and procedures which all the health professionals in the unit believe to meet the needs of clients; I Quality to the manager of the OH service means: the selection and deployment of resources in the most efficient way to meet client needs, within limits and according to legislative requirements; and
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I Quality to the clients and users of the service means: whether the direct beneficiaries perceive the service as giving them what they expect. OH is complex at the level of the workplace, OH is usually the responsibility of the employer acting with the commitment of the employee (through partnership working; joint committees and works councils). Needs are also determined by external legal requirements, which reflect wider society. Despite this complex matrix, client satisfaction is still widely accepted as one of the main aims and criteria of the OH service.
Professional performance Communication; information Referrals; prescriptions; tests Adaptability; flexibility; speed
OHS managers
Employers
Good working environment and culture; increase in productivity and quality; reduced personnel costs related to ill health; conforming to legal requirements. Effectiveness; working culture conductive to health and safety
Society
Developing competences in OH
The development of accepted standards in occupational health encompasses the roles and required competences of the different professionals working in the area, in particular, occupational physicians and nurses. The WHO prepared guidelines on the scope of, and competences required in, occupational medicine in 2000 to assist member states to harmonise a training curriculum for occupational physicians. The training and core competences of occupational physicians have evolved in Europe in response to continuous changes in working life and to the needs of society. The document reflects developments and trends in occupational medicine as a science and in practice. It reflects the core competency requirements for the physician and the work profiles of physicians in different countries. It is designed for medical schools and national regulators to give them a common understanding of the scope and core functions of occupational medicine. Describing the scope of OH is seen as important by the WHO, particularly in countries where GPs or other nonspecialists carry out some of the functions of OH physicians (for example, fitness assessments and examinations).
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The WHO sets out in detail the role and functions of occupational physicians under the following headings: ethics and the occupational physician the role of the occupational physician: including his or her role as an agent of change, acting as a counsellor, a source of knowledge, and as an adviser; competences: sets out the core competences for occupational physicians, including identifying and assessing risks; legal surveillance; advising on OH, safety and hygiene, and on protective equipment; organising first aid and treatment; advising on work organisation; formulating OH policy; promoting work ability; advising on the protection of vulnerable groups (for example, pregnant workers); providing information and training; contributing to scientific knowledge; advising on implementing OH and safety legislation; recognising and advising on hazardous exposure; participating in workplace health promotion programmes; managing the OH service; and working as part of a multidisciplinary team; areas of knowledge: including a description of the general clinical knowledge and skills required (from haematology to mental health); and knowledge areas and skills in occupational medicine: uses the 1997 Glasgow Conference on Core Competences, which range from formulating health and safety policy with due attention to occupational health law and ethics, to developing a multidisciplinary OHS. A section of the WHO guidelines deals with the relationship between occupational physicians and others working in a multidisciplinary service, but has little to say on the nurse-doctor professional relationship. The most frequent members of interdisciplinary OH teams include nurses, safety engineers, occupational hygienists, ergonomists, physiotherapists, occupational therapists, laboratory technicians and occupational psychologists the use of each of these varies throughout Europe. Although the use of a multidisciplinary approach is compulsory in many EU countries, in most, the different disciplines are not organised into formal teams, but are drawn on when required. The relationship between the OH doctor and other members of the team will depend on legislative and organisational factors, including: I whether the use of a multidisciplinary approach is compulsory; I whether the OH practitioner is full or part-time; I whether the service is nurse-led or led by another specialist; and
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I whether the service is provided by an institute offering comprehensive advice or is a service provided by an individual occupational physician.
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Summary of sources
Reid A, Malone J. A cross-sectional study of employer and employee occupational health needs and priorities within the Irish Civil Service. Occupational Medicine 2003; 53: 4145. Methods: postal surveys of employees and HR managers were conducted in which participants were asked to rank eight functions of an OH unit for the Irish civil service. Sample sizes: employees = 524; HR managers = 25. Summary: More HR managers than employees perceive OH as important or very important. HR managers prioritise those functions of an OH unit connected with assessing fitness for work (for example, pre-employment health assessments), whereas employees view the preventative role of OH as more important (for example, medical screening, health education and medical surveillance).
Hughes A, Philipp R, Harling K. Provision and staffing of NHS occupational health services in England and Wales. Occupational and Environmental Medicine 1999; 56: 714717. Method: two postal surveys of purchasers and providers in the NHS in England and Wales were conducted in 1998/99 to inform discussions on the formation of NHS Plus. Summary: 99.6% of trusts claimed to provide access to OH, but virtually no service was provided to primary care staff. There was also wide variability in the quality and range of OH support. Only a third of trusts have access to a specialist occupational physician. The study concludes that there is substantial inequality of access to OH services in the NHS but offers no real explanation. It shows that the NHS had not implemented its 1994 target of providing access to specialist OH services to all staff by 1998/99.
Hughes A, Philipp R, Harling K. NHS occupational health services in England and Wales: a changing picture. Occupational Medicine 2002; 53: 4751. Method: a postal questionnaire of OH medical staff working in the NHS in England and Wales. Summary: this is a follow-up study to the 1998/99 one described above. It finds that the amount of doctor time per NHS employee increased between 1998 and 2001, and that the proportion of doctors holding professional OH qualifications also rose. However, big variations in service continued to exist and government policy for all NHS staff to have access to consultant led service had not yet been met. However, more doctors were working more sessions for their trusts and were better qualified in OH. Many doctors also undertake an OH function in settings other than their NHS trust environment. The authors conclude it is slightly disconcerting that no real rise in the number of doctors in training in the specialty had taken place between 1998 and 2001. The study only examines the role of doctors and recognises that gains in the medical input from this profession may not have been matched by progress in other crucial OH staffing provision.
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Bradshaw LM, Curran AD, Eskin F, Fishwick D. Provision and perception of occupational health in small and medium-sized enterprises in Sheffield, UK. Occupational Medicine 2001; 51: 3944. Method: face-to-face interviews with 28 managers in small to medium sized enterprises in Sheffield, exploring the provision and perception of OH in their organisations. Summary: 14.4% of the employers used the services of a part-time OH physician; 7.2% employed a health and safety adviser; 10.8% used a part-time OH nurse. 25% had nominated a person to take responsibility for OH. 67% believed that a doctor or nurse is the best person to provide an OH service. 28% carried out pre-employment screening and 14.2% carried out health promotion. 53.5% collected health related absence data. There is confusion in SMEs as to the degree to which employers should be responsible for workers health, particularly in the case of non-work related issues. SMEs tend to use accident rates as the only marker for evaluating OH input, and are oriented towards safety issues, rather than health ones. The researchers encountered great difficulties in securing sufficient involvement of SMEs in the research.
Bratveit M, McCormack D, Moen BE. Activity profiles of the occupational health services in a multinational company. Occupational Medicine 2001; 51: 168173. Method: a baseline assessment of the services provided by each of the OH services in a multinationals European production and distribution sites was conducted using the ILO OH convention and recommendation to define the range of OH services. This was followed by up site visits and structured interviews with representatives from the local OH units. Summary: considerable differences in the OH activities of different sites were revealed interenterprise, multidisciplinary OH services spent most of their time on surveillance and preventative activities, and relatively little time on curative, more reactive, services for individual workers. The authors conclude that these services are more in line with ILO recommendations on accepted levels of service. Those sites relying on external doctors backed up by internal or external nurses spend more time on curative services for non-occupational diseases, and less time on activities related to the working environment. This group was also less likely to be involved in the planning and follow-up of surveillance in the working environment, which tended to be conducted by external consultants in these stand alone OH services. The study raises issues of causality it could be that differences in the activities undertaken by different parts of the multinational reflect the levels of training in occupational medicine of the staff concerned, rather than the structure or strategy of the service in that part of the enterprise. It is likely that doctors with specialist training gravitate towards the more multidisciplinary/preventative units, rather than stand alone services.
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National Audit Office. A safer place to work: improving the management of health and safety risks to staff in NHS trusts. Report by the Comptroller and Auditor General. London: NAO, 2003 HC 623. Method: a survey of NHS trusts in the context of a 2001 Department of Health statement on the range of OH services that should be available for all staff in the NHS. Summary: all NHS trusts provide some OH but this is largely reactive and the quality and accessibility varies. The number of trusts signing up to NHS Plus had levelled off and some note that the resources generated by NHS Plus were not being invested in improving the provision of services. This report follows up a similar NAO study in 1996.
Whitaker S, Baranski B (editors). The role of the occupational health nurse in workplace health management. WHO regional office for Europe, 2001, www.who.dk/document/e73312.pdf Method: research study looking at the role and required competences of OH nurses. Summary: OH nurses fulfil several, related and complimentary roles in workplace health management, including those of clinician, specialist, manager, coordinator, adviser, health educator, counsellor and researcher. The OH nurse is a unique front liner and tends to get approached about a range of issues beyond the traditional work health and safety ones (for example, questions on the health of workers spouses). These are issues beyond the immediate responsibility of the employer, but ones that could affect the workers ability to concentrate, attend or be productive. OH nurses are usually onsite and accessible providing opportunities for early intervention. Although the role differs between EU countries, the broad thrust of developments in recent years is the same namely, a move away from OH nurses acting as a doctors assistant towards a position where they work as an independent, autonomous professional, responsible and accountable for their own professional practice. However, this does not mean there is no teamwork all health and safety professionals are interdependent.
World Health Organisation. WHO Europe occupational health nursing curriculum, WHO Europe, 2003, www.euro.who.int/document/e81556.pdf Summary: the WHO prepared a curriculum for OH nurses in 2003 as part of its work on developing several post-qualification curricula for nursing and midwifery in Europe. This could form a valuable model for a framework in the UK. Key principles: I OH nurses must be equipped with the expertise to make sound clinical judgements within the work setting, where they may be the sole health professional responsible for workers health and education; I OH nurses require a well-developed knowledge base, together with specialist skills in risk assessment and health promotion related to the particular type of work conducted in their setting;
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I They must be able to work as a full member of a multidisciplinary team in the work setting, and in close collaboration with nurses and other health professionals in hospitals, health centres and other parts of healthcare; and I OH nurse needs to be aware of how an individual workers occupation may affect family life and vice versa.
MacDonald E, Baranski B, Wilford J (editors). Occupational medicine in Europe: scope and competences. WHO European Centre for Environment and Health, Bilthoven, 2000, www.who.dk/document/e68883.pdf Summary: The WHO prepared this document in 2000 to assist member states in harmonising a training curriculum for occupational physicians. The training and core competences of occupational physicians have evolved in Europe in response to continuous changes in working life and to the needs of society. The document reflects developments and trends in occupational medicine as a science and in practice. It reflects the core competency requirements for the physician and the work profiles of physicians in different countries. It is designed for medical schools and national regulators to give them a common understanding of the scope and core functions of occupational medicine. The provision of a description of the scope of the discipline was seen as important by the WHO, particularly in countries where GPs or other non-specialists more commonly carry out some of the functions of OH physicians (for example, fitness assessments and examinations).
Westerholm P, Baranski B (editors). Guidelines on quality management in multidisciplinary occupational health services. WHO European centre for environment and health, Bilthoven. 1999, www.who.dk/document/E68239.pdf. Summary: these guidelines were produced in 1999 and include a section on identifying demands and needs in OH, on the basis that quality or the success of an OH unit depends on meeting the expectations and needs of the customers (usually the employer and employees). However, in some cases the demands of the different stakeholders will be different, or hidden until revealed and explained by OH professionals. It is therefore the job of OH professionals to identify, assess and satisfy these hidden or disguised needs (for example, exposure to carcinogenic chemicals and other factors affecting fertility; or the case of MSDs, where employees request physiotherapy, but what they really need is improvements in work organisation or ergonomics).
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Reetoo KN, MacDonald EB, Harrington JM. Competencies of occupational health physicians: the customers perspective. HSE research report 247, 2004, www.hse.gov.uk/research Method: questionnaire of EEF member companies and other employers examining their use of OH services, and organisational priorities for such a service. Followed up by focus groups. Summary: this research study looks at whether the users of OH physicians (employers and employees) consider that the curriculum for this group accurately reflects the priorities of clients. It finds that all the established competency areas for OH are seen as important, but that advice on law and ethics is the top priority, followed by assessments of occupational hazards, fitness for work, with health promotion and management low down the list. The majority of SMEs reported little or no access to occupational physicians, so that awareness of this group of professionals as a source of advice was low. OH nurses were used more widely. Barriers to the greater use of occupational physicians included the fact that they were perceived as biased (either towards the employee or employer, depending on the respondent) and the likely costs of using them. The study confirms the low level of OH provision in most of British industry, the authors conclude.
OHara R, Elms J et al. The profile of patients occupational health in primary care. HSE research report 254, 2004, www.hse.gov.uk/research Methods: focus groups of GPs, practice nurses and practice managers in Sheffield and Manchester, exploring why this group of primary care professionals does not get more involved in offering OH advice and support and therefore in widening access to this provision, especially amongst SMEs. Summary: a lack of training and knowledge of the world of work and occupational hazards is the main barrier to the provision or signposting of OH in primary care. GPs, practice nurses and managers expressed concern that clarification was needed surrounding the respective responsibilities of employers, primary care and the NHS in the area of OH. Concludes that practice nurses and practice managers are best placed to respond to the OH agenda given support, training and resources.
Pilkington A, Graham MK et al. Survey of use of occupational health support. HSE research report 445, 2002, www.hse.gov.uk/research Method: structured telephone interviews with 4950 companies followed by 50 face-to-face interviews with a representative sample of employers. Summary: examines the proportions of employers who use different levels of OH support and looks at variations by size, sector and region. This is the most comprehensive study of UK access to OH, but the additional studies above provide a more detailed picture of provision in the key areas of the NHS and SMEs. The study was designed as a baseline to assess progress against the
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HSEs target of increasing the proportion of employers using OH support by 10% by 2003. Concludes that, when a stringent definition of OH support is used, only 19% of the organisations in the study provide it. This proportion extrapolates into only 3% of all UK companies once adjustments for the UK-wide distribution of companies by size and sector are taken into account.
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REFERENCES
Bradshaw LM, Curran AD, Eskin F, Fishwick D. Provision and perception of occupational health in small and medium-sized enterprises in Sheffield, UK. Occupational Medicine 2001; 51: 3944. Bratveit M, McCormack D, Moen BE. Activity profiles of the occupational health services in a multinational company. Occupational Medicine 2001; 51: 168173. Hughes A, Philipp R, Harling K. Provision and staffing of NHS occupational health services in England and Wales. Occupational and Environmental Medicine 1999; 56: 714717. Hughes A, Philipp R, Harling K. NHS occupational health services in England and Wales: a changing picture. Occupational Medicine 2002; 53: 4751. International Labour Organization. Occupational health services convention and recommendation. 1995. MacDonald E, Baranski B, Wilford J (editors). Occupational medicine in Europe: scope and competences. WHO European Centre for Environment and Health, Bilthoven, 2000, www.who.dk/document/e68883.pdf National Audit Office. A safer place to work: improving the management of health and safety risks to staff in NHS trusts. Report by the Comptroller and Auditor General. London: NAO, 2003 HC 623. OHara R, Elms J et al. The profile of patients occupational health in primary care. HSE research report 254, 2004, www.hse.gov.uk/research Pilkington A, Graham MK et al. Survey of use of occupational health support. HSE research report 445, 2002, www.hse.gov.uk/research Reetoo KN, MacDonald EB, Harrington JM. Competencies of occupational health physicians: the customers perspective. HSE research report 247, 2004, www.hse.gov.uk/research Reid A, Malone J. A cross-sectional study of employer and employee occupational health needs and priorities within the Irish Civil Service. Occupational Medicine 2003; 53: 4145. Westerholm P, Baranski B (editors). Guidelines on quality management in multidisciplinary occupational health services. WHO European centre for environment and health, Bilthoven. 1999, www.who.dk/document/E68239.pdf Whitaker S, Baranski B (editors). The role of the occupational health nurse in workplace health management. WHO regional office for Europe, 2001, www.who.dk/document/e73312.pdf World Health Organisation. WHO Europe occupational health nursing curriculum, WHO Europe, 2003, www.euro.who.int/document/e81556.pdf
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APPENDIX 1
The performance indicators questionnaire
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