What Is a Nursing Model and How Does It Apply To Occupational Health?

It is important to clarify what is meant by a ‘model’ as there are many different definitions. One of the most useful definitions is

“A way for nurses to organise their thinking about nursing and then to transfer that thinking into practice with order and effectiveness” McBain (2006)

Chang’s (1994) critical work on OH models states:

They all provide a framework or conceptual model of OH nursing. But there are common weaknesses in that they lack clarity in the scope of OH nursing practice; lack a clear definition of the OH nurse role; and lack empirical evidence”

More recent models are the Centre for Nurse Practice Research and Development’s (CeNPRaD) model which emerged from a national survey funded by the National Board for Nursing and Midwifery in Scotland (NBS) and was revised and updated as CeNPRaD’s OH model 2005( McBain 2006). Also the Hanasaari model developed to allow for flexibility in occupational health nursing practice. It was devised during a workshop at Hanasaari, Finland (1989) and has been used as a framework to develop the Occupational Health Nursing Syllabus. It combines three fundamental concepts: total environment; human, work and health; and occupational health nursing interaction (HSE 2005). This model was largely attributed to Ruth Alston a major contributor to the published model in 2001.

A great deal of writings concerned the governments introduction of NHS Plus OH service in 2001 along with initiatives such as Workplace Health Connection in 2006 (Paton 2007 p 21). This was an attempt by the then health secretary Alan Millburn to extend and develop current NHS occupational health departments to reach out to employers in their communities, to address the lack of OH provision identified by the HSE in 2000, which estimated that only 3% of UK employers have access to occupational health services (O’Reilly 2006). The other 97% not currently accessing OH services come from the small and medium-sized businesses (less than 50 employees and less than 250 employees) this being the market to be addressed (Paton 2007).

O’Reilly (2006) identifies three broad groups of OH providers

1. NHS consultancies, which employ OH physicians and their team.

2. In-house OH departments normally nurse lead with links to a multi-disciplinary teams.

3. Private independent sector.

The last group ranges from independent specialist firms like myself, to major operators such as Capita, Bupa, Atos Origin and Aviva.

A structured approach is essential when setting up a new service or changing the focus of an existing service. Therefore the nursing process of assessment, planning, implementation and evaluation is a good tool to achieve success (Kennaugh 1997,p 49)

A structured needs assessment should be conducted to identify the actual as opposed to perceived needs of the company (Harrington p336). This will act as a guide in planning how to implement the service.

Things to consider:

  • Company profile i.e. manufacturing, blue-collar, public sector, construction. What hazards
  • How many employees, type of management structure. Who are the key stakeholders/decision makers?
  • Internal/external forces, who do they employ? Permanent/seasonal staff?
  • Existing services. What provision have they had in the past? Is it a new venture?
  • What is their understanding of OH? What are past absence rate? Litigation costs?
  • Where does the company want OH department to be in 5 years time?

This is by no means conclusive, but will give an idea of which form of delivery would be appropriate and to what service level can be agreed. This could range from an in-house multi-staffed, purpose-built department servicing thousands of employees, to one day a week/month absence management or a one-off screening programme. There are a multitude of variations between these extremes. This should be tailored to the company’s individual needs.

I would now like to look at the strengths, weakness, opportunities and threats (swot analysis) of differing delivery models, namely in-house and bought in models.

In house service is run within the company and is somewhat self-managed, made up of OH professionals and contracted specialties.

Strengths

  • On site to monitor ongoing issues daily if needed.
  • Greater continuity of care, relationship building with employees
  • Better understanding of how the company runs and their priorities.
  • Better sharing of information within company.
  • Greater OH presence

Weakness

  • Could be high department running cost if not used efficiently
  • Could be isolated from evidence-based practice.

Opportunities

  • Ability to develop a varied multi-disciplinary team within the OH department.
  • Greater ability to build stronger links with the wider management team.
  • Easier to plan long-term goals and strategies.

Threats

  • If not performing could be outsourced.

Ad-hoc service as and when needed though an occupational health agency, which could be once a week or a month or short or long-term full-time.

Strengths

  • Cost affective, better for small to medium companies
  • Greater autonomy for the OH nurse.
  • More flexible to meet companies needs

Weakness

  • Isolating from shared knowledge within a OH team.
  • Reduced continuity of care if not seen regular.
  • Hard to plan rehabilitation programs for individuals
  • Unable to monitor issues or implement changes quickly

Opportunities

  • To build a well-managed evidence based service.
  • Build relations with local GP’s, physiotherapists, etc.

Threats

  • Could lack presence in the company
  • Hard to express the larger role of OH
  • May loose commitment from company if not seen to meet needs
  • OH may just be seen as covering H & S legislation. Quick fix.

By no means does this exercise demonstrate the full scope of issues highlighted although differing models do need to be address first for the success of the occupational health intervention.

Referances.

McBain M (2006) This Years Model? Occupational Health. 58(3) p16-19

Chang P.J.(1994) Factors Influencing Occupational Health Nursing Practice. Occupational Health 58 (3) p17

HSE(2005) Applyomh Health Models to 21st Century Occupational Needs. Buxton.HSL

Paton, N (2007) A Picture Of Health? Occupational Health. Vol 58; No 6. page 21

O’Reilly (2006) Access for all. Occupational Health. Vol 58;No 8 page 20

Kennaugh A (1997) Setting up occupational health services.’ In Oakley. K. Occupational Health Nursing. London. Whurr. P49

Harrington J.M.(1998) Occupational Health. 4th edn. London: Blackwell

Determining the Function of an Occupational Health Advisor and How to Evaluate Success

Those responsible for the management of health, environment and safety matters should consider the following guidance when determining what function the occupational health nurse specialist will fulfill within the company. There may well be variation in the function of an occupational health nurse between different organizations depending on the needs and priorities of the working population and the health care system in which they are operating. Some useful questions to consider are:

  • Has a comprehensive health needs assessment been performed recently to identify the needs of the organization and to help with setting priorities for action?
  • Has the workplace health management policy been reviewed and agreed in light of the needs assessment, taking into account both legislative demands and voluntary agreements?
  • Have the goals of the occupational health service been defined clearly and communicated throughout the organization?
  • Does the occupational health service have adequate resources to achieve these goals, including staff, expertise, facilities and management support?
  • Is it clear how the performance of the occupational health service or of individual professionals within that service, is to be evaluated and are there clear, objective criteria agreed?

The answers to each of these questions will help to shape the discussion about the role and function of the occupational health nursing specialist within a specific organization.

Workplace health management is most effective when there is:

  • Commitment from senior management
  • Active participation of employees and trade unions
  • Integration of company policies and clear targets for HES (health, environment and safety management)
  • Effective management processes and procedures
  • Adequate resources
  • A high level of management competence, and
  • Rigorous monitoring of company performance using the principles of continuous quality improvement.

Policy making should be based on legislation and on a voluntary agreement between social partners at work, covering the total concept of health, safety and wellbeing at work.

Evaluation of Performance

Evaluation can take place on three levels:

  1. Company performance in the area of workplace health management
  2. Contribution of the occupational health and safety service
  3. Contribution of the individual occupational health nurse

All review procedures should be based on the principles of continuous quality improvement or audit. The criteria and indicators against which performance is to be measured should be defined clearly as a part of the initial planning and contracting process so that everyone is clear about what performance indicators are being used. Some caution is required if health measures are to be used as performance indicators for the occupational health service as much of the work of an occupational health service is orientated primarily towards the prevention of disease or injury or the reduction of risk. The success or failure of preventative strategies can be difficult to measure using health data on its own as it is sometimes uncertain to what extent a single intervention or programme of interventions can claim responsibility for preventing the effect. Furthermore, many health effects only become apparent a long time after initial exposure and sometimes only become apparent in particularly vulnerable individuals. Where prevention is dependent upon the employee, the line manager or the organization following the advice of the occupational health professional, where this is not followed the adverse event may not necessarily indicate a failure on the part of the occupational health service, but rather a failure of the individual, manager or organization to respond appropriately to the advice they were given.

Evaluation can be based on the structure, input, process, output and outcome indicators, and both direct and indirect effects, positive or negative, can be taken into account when judging the relative success or failure of the service. It is often useful to consider two inter-related aspects of occupational health practice in the evaluation process, the professional standards that underpin professional practice and the delivery or services within the organization. Professional practice can be evaluated by, for example, evidence of participating in continuing professional development and adapting practices to take account of new knowledge, self-assessment of compliance with current best practice guidelines, regular internal and external peer review, or systematic audit of compliance with standards. The criteria used to evaluate professional practice should also take account of ethical standards, codes of practice and guidance from the professional bodies. Evaluating service delivery can be done by, for example, comparing the delivery of services against predetermined service level agreements or contracts, including meeting agreed quality standards for services, through customer or client satisfaction surveys, or by assessing the adequacy of access to and level of uptake of services.

Occupational Health – What Is the BIG Picture of OH?

The rapid development of workplace health protective and preventive services has been driven by government strategies and recommendations, as well as by the European Union legislation in the areas of health and safety at work and by the European Commission programme in public health. This was also largely due to the new demands and expectations from employers, employees and their representative bodies as they recognize the economic, social and health benefits achieved by providing these services at the workplace, thus providing the available knowledge and evidence necessary for the continuous improvement of workplace health management. Comprehensive workplace health management is a process involving all stakeholders inside and outside any business. It aims at empowering them to take control over their own health and their family’s health considering environmental, lifestyle, occupational and social health determinants and quality of health care. It is based on health promotion principles and it creates a great challenge to health, environment and safety professionals providing services, advice, information and education to social partners at work. It involves also taking care of considerable socioeconomic interest of all involved stakeholders. It has been shown in several instances that the business utilizing a well managed research based occupational health service can gain a competitive advantage by:

  • Protecting human health against health and safety hazards occurring in the work environment.
  • Promoting human health workplaces for all ages and healthy aging by appropriate work culture, work organization and support to social cohesion.
  • Promoting mental health, healthy lifestyle and preventing major non-communicable diseases using specific workplace health policies and management tools.
  • Maintaining work ability thus also employability throughout working life.
  • Reducing health care costs caused by employees’ and employers’ injuries, diseases, illnesses and premature retirement resulting from or influenced by occupational, environmental, life style and social health determinants
  • Using resources effectively, protecting the natural environment and creating a health supportive environment.
  • Improving social communication and literacy on health, environment and ethics.

This article series describes the author’s observations of various roles undertaken by the occupational health nurse. Whilst recognizing the wide variation that exists in occupational health nursing practice between different industrial and blue collar environments this series reflects the standards that have already been achieved where occupational health nursing is at its most advanced. However it has to be recognized that the level of education, professional skills and the exiting national legislation determines what role can be actually undertaken by occupational health nurses. Even more important is to remember that no one professional out of the exiting workplace health professions is now capable to meeting all health needs of the working population. A multi-disciplinary approach is needed to effectively manage the growing workplace health and safety demands in business today.

The workplace health services use the skills of many professionals such as specialist occupational physicians, safety engineers, occupational hygienists, occupational health nurses, ergonomists, physiotherapists, occupational therapists, laboratory technicians, psychologists and other specialists. The role and tasks actually performed for the companies by representatives of different health and safety professions vary greatly depending upon legislative needs, scope of the workplace health concept perceived by directors, enforcement practice, the level of their education, position in the occupational health infrastructure, actions undertaken by insurance institutions and many other factors. Occupational health nurses are the largest single group of health professionals involved in delivering health services at the workplace and have the most important role to play in the workplace health management. They are at the frontline in helping to protect and promote the health of the nations working population.

The role of the occupational health nurse in workplace health management is a new and exciting concept that is designed to improve the management of health and health related problems in the workplace. Specialist occupational health nurses can play a major role in protecting and improving the health of the working population as part of this strategy. Occupational health nurses can also make a major contribution to the sustainable development, improved competitiveness, job security and increased profitability of businesses and communities by addressing those factors which are related to the health of the working population. By helping to reduce ill health occupational health nurses can contribute to the increased profitability and performance of organizations and reduce health care costs. Occupational health nurses can also help to reduce the externalization of costs onto the taxpayer, by preventing disability and social exclusion, and by improving rehabilitation services at work. By protecting and promoting the health of the working population, and by promoting social inclusion, occupational health nurses can also make a significant contribution towards building a caring social ethos within the UK. This article provides guidance to employers and employees on establishing workplace health management systems within their own organizations. On how to determine and develop the role and functions of the occupational health nursing specialist within each enterprise and where to go for additional help and advice in relation to occupational health nursing.

Changing nature of working life and the new challenges

The world of work has undergone enormous change in the last hundred years. To a large extent the very heavy, dirty and dangerous industries have gone, and the burden of disease, which came with them, in most European countries, has declined. However, the new working environments and conditions of work that have replaced them have given rise to new and different concerns about the health of the working population. Exposure to physical, chemical, biological and psychosocial risk factors at work are now much more clearly linked to health outcomes in the mind of the general public. Expectations of society in regard to health at work have also changed, with increasing demands for better standards of protection at work and for the improvement of the quality of working life. Employers are also recognizing that health-related issues, such as sickness absence, litigation and compensation costs, increasing insurance premiums, are expensive; ignoring them can lead to serious economic consequences. The best employers’ emphasize the important message that good health is good business, and that much can be achieved in this field simply by introducing good management practices (HSE 1998).

The Need for Workplace Management

There are approximately 400 million people who work in the EU Member States. The majority of whom spend more than one half of their waking life at work. However, fatal accidents at work are still common. The standardized incident rates per 100,000 workers in the European Union (Eurostat 1997) show that the fatal accident rate varies between 1.6 in the UK to 13.9 in Spain, with Austria, Greece, France, Italy and Portugal all above 5.0%. In the entire European region there are approximately 200 to 7500 non-fatal accidents per 100,000 employees per year, of which around 10% are severe leading to over 60 days absence from work, and up to 5%, per year, lead to permanent disability (WHO 1995). It has been estimated that the total cost to society of work related injuries and ill health in the European Union is between 185 billion and 270 billion ECU per year, which represents between 2.6% to 3.8% of Gross National Product (GNP) in member states. The cost of workplace accidents and ill health, in both financial and human terms, remains an enormous, largely unrecognized burden in UK. The majority of those accidents and diseases could have been prevented if appropriate action had been taken at the workplace. Many responsible employers have consistently demonstrated that by paying attention to these issues this type of harm and the subsequent costs can be avoided, to the benefit of everyone concerned. Increasing concern is the growing awareness of occupational stress. Up to 42% of workers in a recent survey complained about the high pace of work. Job insecurity, fear of unemployment, lack of a regular salary and the potential loss of work ability are all additional sources of stress, even for those in employment.

The wide ranging social and health effects of occupational stress on the health of the working population are well documented, for example 23% of workers surveyed claimed that they had been absent from work for work related health reasons in the previous twelve months. The resulting cost of sickness absence in United Kingdom is considered to be substantial. In the UK 177 million working days were lost in 1994 as a result of sickness absence; this has been assessed at over 11 billion in lost productivity. HSE statistics are encouraging given in 2009; only 29.3 million days were lost overall, 24.6 million due to work-related ill health and 4.7 million due to workplace injury. Much of this burden of ill health and the resulting sickness absence is caused, or is made worse by working conditions. Even where ill health is not directly caused by work, but by other non-occupational factors such as smoking, lifestyle, diet etc. Interventions designed to improve the health of the working population, delivered at the workplace, may help to reduce still further the burden of ill health. At present the socioeconomic impact of environmental pollution caused by industrial processes on the working population is uncertain, but it is likely to contribute further to the burden of ill health in some communities.