The following case studies aim to give a flavour of the role of the occu- pational health nurse in a range of employment settings. The majority of occupational health nurses work in the independent sector (RCN verbal communication July 2007). The first case study relates to an independent OH service provider. This is followed by case studies on an NHS OH
and safety service, a group OH service, an occupational health project and finally a self-employed OH nurse. Some general background on the type of service/organisation is given along with examples of work carried out in the specific case chosen.
Case Study 1: Independent Occupational Health Service Provider
The head of nursing services at AXA PPP healthcare OHS Ltd says that ‘For nurses working within the private sector there are unlimited opportunities to develop and increase their portfolio of skills and com- petencies. The benefit of being able to experience such a wide variety of industry sectors, and have exposure to different client, employee, leg- islative and health and safety requirements is a great advantage to their professional development and progression.’
AXA PPP healthcare OHS Ltd is the second-largest medical insurer in the UK and is part of the UK business of AXA Group, one of the top four insurers in the world. AXA bought MIS, an occupational health service provider, in the late 1990s, and following this acquisition is now trading as AXA PPP healthcare OHS Ltd. Its staff includes over 85 occupational health workers, including nurses, physicians, health and safety staff and occupational health technicians. They all work closely with specialised teams of administrative and operational support workers.
A senior management team made up of the leads from finance, oper- ations, medical, nursing and business development operationally and clinically manages the company. The SMT meets monthly to develop and implement business strategy.
The nursing team is managed by the head of nursing services, sup- ported by the regional clinical managers in the north and south. Regional clinical team leaders, again in the north and south of the UK, support and assist them.
The clinical leadership team has ownership of clinical governance, with responsibility for review, development, implementation and main- tenance of clinical standards and policies and procedures. The heads of nursing services and medical services – with appropriate input and sup- port from in-house and external clinicians with the specialist skills and knowledge for the specific projects ongoing at any one time – lead the clinical leadership team.
The nurses can be home-based, work from client sites or AXA of- fices, or have a mix of locations. There is no particular service delivery model that AXA implements as its aim is to provide clients with a flex- ible approach to occupational health service provision, ensuring their needs are continually met. The skill sets and abilities of the nursing team include, but are not limited to, health surveillance, travel health, vocational rehabilitation, nurse case management, stress management,
workplace risk assessment and audit, health education and promotion, sickness absence management, fitness for work assessment and training both in-house personnel and external clients.
Case Study 2: An NHS Occupational Health Service
Many NHS trusts now provide occupational health programmes for commercial enterprises and businesses in their locality, targeting small and medium-sized companies. The occupational health department in this case study is a self-funding business unit within an NHS primary care trust based in south-east England. The head of occupational health services (a nurse) says, ‘working within an NHS setting, occupational health is driven by a business philosophy. This is further endorsed by the advice and standards set by the NHS Plus initiative which is an arm of the Department of Health.’ The government’s NHS Plus network aims to strengthen partnerships between the public and private sectors of the community (www.nhsplus.nhs.uk).
As part of the health service business culture, income is generated by providing a service to non-NHS employees employed by outside agencies, ranging from charities to funeral directors. It is of utmost im- portance, however, that the service to trust employees is a priority.
The philosophy of the department is captured in its mission state- ment: ‘We are a market leader in the provision of a professional quality and dynamic service tailored to the needs of the working environment.’
The aim of the department is ‘the promotion of positive health and fitness’.
The service employs qualified and experienced occupational health nurses and doctors, who each have areas of responsibility in relation to all contracts within and outside the NHS. Other staff includes clerical/
administrative grades, a health and fitness adviser, a ‘moving and han- dling trainer’ and a psychologist who acts as a staff counsellor. Core occupational health activities are offered as part of a customer-focused service, plus a wide range of health programmes, which include work- place health surveillance, assessments and employment health screen- ing. A gymnasium facility with supporting programmes is available for staff, as well as a comprehensive travel service. Members of staff are made aware of specific health topics on national awareness days.
Both qualitative and quantitative auditing is carried out by the occu- pational health service, based on statistical returns, activity analyses and evaluations, following training courses and health-related programmes (including stress-management sessions).
Innovations include developing specific projects, for example mental health services for staff; working with bullying and harassment advisers;
and back care and rehabilitation programmes, which include a fast- track referral system, clinical exercise programmes and a management case conference as part of return-to-work policies. Extensive work with
three call centres is another development. Another separate unit based in a satellite hospital has a travel clinic, fitness suite, equipment for disabled users, stress-relaxing chairs and a steam room. There is a strong emphasis on rehabilitation.
Case Study 3: A Group Occupational Health Service
The Gregson Report (1984) recognised the important contribution of group services, tracing their development and status and stating that
‘much depends on the zeal and proselytizing abilities of the staff’. The report recommended the extension of group services ‘especially in areas of primarily industrial development’.
Group health services employ a skill mix of professionals, who usu- ally operate from a central base but also provide on-site activities. Close liaison is maintained between the services and the regulatory bodies, including EMAS. Most services belong to an association of group oc- cupational health services and have a common identity in that they all provide services that are ‘employer-led’, non-profit-making (having charitable status) and accountable to member companies.
This case study is an example of a group service managed by an occupational health nurse and based on an industrial estate. Other oc- cupational health nurses are employed, together with two qualified occupational health physicians and two other medical officers who work on a sessional basis. The medical officers carry out executive med- ical examinations for member and non-member companies. Ancillary staff includes a first aid supplies officer and a physiotherapist. Admin- istrative support is provided by the company secretary/administrator, accounts clerk, two secretaries and two receptionists/clerks. First aid training is provided by a self-employed contract instructor.
Around 100 small and medium-sized enterprises (SMEs) belong to the service. Subscription charges are invoiced on a per capita basis, and additional charges are made for specific services (at a subsidised rate), such as health surveillance (health and safety legislation), health promotion activities, lifestyle screening, first aid and health and safety training, manual handling training and vision screening. In addition, some 80 companies use the service on an ad hoc basis.
Case Study 4: An Occupational Health Project
Occupational health projects (OHPs) have been in existence since 1978 and work with GPs and other health care staff to provide an independent occupational health advisory service to workers in a defined geograph- ical area. Jackson (2004) provides an interesting and detailed summary of the work of two projects in his report of an evaluation research study conducted for the HSE.
A national association has been established and project members meet regularly. The aims of the association include providing:
mutual aid and benefit to member organisations (staff and commit- tee members); pursuing a joint programme of exchange and activities;
attempting to develop new methods of identifying emerging patterns of occupational disease; providing a national voice; developing awareness of occupational health . . . in primary and secondary health care and fur- thering the development and integration of occupational health services into primary health care in England, Scotland and Wales; emphasising the special value and strength of collective action to resolve health and safety problems; developing skills and capacities of workers and patients to solve problems for themselves.
Other activities include creating models for the future develop- ment of occupational health services; establishing closer links with Europe; developing resources for public use; and identifying training programmes. Each OHP produces an annual report, and the projects are all at different stages of development. Funding for the projects comes from different sources, for example the Department of Health, health authorities and local authorities. Staff members are drawn from different backgrounds and include academics, scientists and nurses.
A nurse working in a long-established project says:
OHPs are ideally placed to plug a gap in occupational health service pro- vision, with a particular remit to provide health and safety advice and information to small and medium-sized enterprises, particularly where no on-site occupational health provision is available, and where health inequalities need to be addressed. They appear to provide impartial help, whereas with on-site services conflicts of interest may arise, for exam- ple among managers, staff representatives and the work of occupational health practitioners.
This particular project conducts research projects, e.g. on stress in taxi drivers and on health in self-employed ‘home-workers’. Several leaflets, available in different languages, are produced by the project – for example, on mothers at work.
As part of expansion of their services, OHPs see themselves continu- ing to provide workplace health and safety advice, establishing new working partnerships with providers of community health services, as well as continuing to strengthen existing relationships with health purchasers.
Case Study 5: A Self-Employed Occupational Health Nurse
Some self-employed occupational health nurses specialise in key areas such as stress management and the management of back pain. Others may work through nursing agencies, providing relief cover on a tem- porary basis. Some nurses have developed a consultancy role, which might include, for example, combining teaching with practice and pro- viding professional advice and support to organisations in other coun- tries. Numerous opportunities exist for the self-motivated, multi-skilled and experienced occupational health nurse to provide a wide range of services (see Chapter 5 for a detailed discussion).
An experienced and qualified occupational health nurse was prompted to become self-employed following redundancy. She has since used her knowledge, skills and abilities in a creative way and has de- veloped a portfolio of skills that has wide appeal and involves both on-site and off-site activities. Such activities include lifestyle screening, workplace risk assessment and environmental survey, vision screening and first aid examining. This occupational health nurse is also actively engaged in health education on behalf of a women’s cancer charity organisation and is developing male health education programmes.
Another important consideration for this nurse is the financial aspect of being self-employed. She has many expenses associated with, for ex- ample, ensuring adequate professional indemnity insurance, subscrib- ing to professional journals and organisations, purchasing equipment and supplies (including those required to maintain a home office base) and marketing. As one should when setting up any business, she sought advice on writing business proposals and engaged an accountant.
Changes in personal circumstances and a desire for freedom and more control over workloads may motivate nurses to become self-employed practitioners. The role of the occupational health nurse cited in this case study highlights the importance of practitioners keeping up to date clinically, in order to maintain competence and professional standards.