would be more important to their practice and that they would need to devote more time to them, but they sensed that their education needed to be updated before they could fulfil these new roles (Mellor & St John 2007).
Japan
Nursing in Japan is well established and nurses have worked in occu- pational health services for a long time, although their roles and com- petencies are not clearly described in national legislation (Muto 2007).
Ishihara et al. (2004) reported that OHNs’ roles include direct care to employees, education/advice and management. They compared these roles to those reported from other countries and found both similarities and differences between OHNs in Japan and the USA. These findings indicate that the needs of the working population are similar regardless of the country or the part of the world where they are employed.
Japan, however, has a unique organisation of occupational health ed- ucation, with a specialised University of Occupational and Environmen- tal Health. Within this university is the Department of Public Health and Occupational Health Nursing, in the School of Health Sciences, where nurses are educated for this specific role. OHNs study for four years and, along with other OH specialists, are seen as the supporting staff for OH physicians.
Japanese OHNs also have a leading role in the wider East Asian environment, collaborating with OHNs in other countries in the region and organising scientific and educational events.
Occupational Health Nursing within
The always-expanding EU increases in terms of workforce size, but also in the range of working conditions. In 2007 there are 27 full-member countries and more are applying. The situation in the more developed old member states is so different to that in the new ones that not only the politicians but the EU citizens themselves feel that there is a danger that all the benefits that they formerly expected to be granted will be waived.
Proposals for increases in retirement age – a result not only of the longer life expectancy in almost all EU countries, as well as the ever- decreasing birth rate, but also of the challenging state of the social secu- rity sector – will affect the provision of occupational health services in the future. Working stability and security, wage agreements and unions will make way for an increased retirement age, work flexibility or ‘flex- icurity’,2 individual contracts and competition. This new environment will create new challenges not only for the working population but also for occupational health service providers.
European Union Legislation
Each EU country has its own legal system, history and practices, which are unique to it. Much has been done, however, to harmonise the legal obligations of employers in relation to working conditions and occupa- tional health and safety. The Single European Act (1986) is one of the most important pieces of legislation to have come into force, in terms of health and safety. Article 118A of the Single European Act states:
‘Member states shall pay particular attention to encouraging improve- ments, especially in the working environment, as regards the health and safety of workers, and shall set as their objective the harmonisation of conditions in this area, while maintaining the improvements made.’
The Single European Act establishes that European Commission pro- posals for new health and safety directives must be accepted or not by
‘qualified majority voting’. Therefore there is a need for dialogue be- tween all countries before proposals are adopted through the Council of Ministers. Then all member states can harmonise their legislation ac- cording to the adopted directive, although interpretation, application and enforcement still vary between the different countries.
In terms of occupational health services in general, the EU organisa- tions that have a decision-making position are the European Commis- sion, the European Parliament, the Council of Ministers, the European Agency for Safety and Health at Work and the European Foundation for the Improvement of Living and Working Conditions.
2A term recently introduced by the Danish prime minister, while presiding the EU, to reflect ‘flexibility’ and ‘security’ as the right combination for the employability of the workforce – a policy that has been in place in Denmark since the 1990s and has reduced unemployment considerably – which however, in practice will endanger worker stability and development as they are known to member states today.
The European Commission, based in Luxembourg, is reorganised from time to time to reflect the current policies of the member states. Its main role is to manage the Community, and it ensures that member states fulfil their obligations under the Treaty. The directorates general that are of most interest to health and safety practitioners are the Employment, Social Affairs and Equal Opportunities and the Health and Consumer Protection, but there are others that have an impact on occupational health (europa.eu.int).
The Commission makes proposals on Community policy, including policies on health and safety; these then are proposed to the EU Parlia- ment, which considers and comments on them and can reject them or suggest amendments. Members of the European Parliament are elected by their individual member states; each country has a number of seats according to the size of its population.
The Council of Ministers is the most important decision-making body, composed of national government ministers. The council exam- ines and agrees, or refers back, directives that have been proposed by the Commission or the country that has the presidency (undertaken in six-month turns). In addition to the council, the heads of each member state meet twice a year to discuss broad areas of EU policy.
The European Agency for Safety and Health at Work seeks to im- prove standards of safety and combat problems of work-related ill health in Europe by collecting and disseminating information to assist govern- ments, employers, trade unions, workers and other stakeholders. The agency was established in 1994 and is based in Bilbao. It is governed by representatives from each member state and its work is in collaboration with health and safety work carried out by the European Commission and the European Foundation for the Improvement of Living and Work- ing Conditions.
According to the European Agency for Safety and Health at Work, the main research priorities for occupational health and safety to- day are the psychosocial work environment, ergonomic risk factors/
musculoskeletal disorders, dangerous substances and occupational health and safety management (European Agency for Safety and Health at Work 2005a, 2005b). The 2007 campaign focuses on mus- culoskeletal disorders and aims to inform employers, employees and OH practitioners at EU and country level. In addition, it publishes a newsletter, available electronically to anyone interested, and has var- ious publications of interest to both the working world and the OH practitioner.
The European Foundation for the Improvement of Living and Working Conditions is a European Union body that was established to work in specialised areas of EU policy by the European Council in 1975 (Council Regulation (EEC) No. 1365/75). Its role is to provide in- formation, advice and expertise on living and working conditions by using comparative information and research.
It is clear from the above that great importance is placed on health and safety by the EU governing bodies and it is certain that all member states try to place an equal importance in workers’ health and safety in their respective countries. It is not only EU institutions that influence OHN however, but also the EU-wide nursing organisations, which are presented below.
The European Federation of Nurses Associations (EFN), formerly the Standing Committee of Nurses of the EU (PCN), was established in 1971 to represent the nursing profession and its interests to the European Institutions, and is the independent voice of the nursing pro- fession, representing more than one million nurses within the EU. The changes that were proposed and adopted by the EU on nursing educa- tion and the free-movement directives were the result of this professional representation.
Members of the EFN are the National Nurses Associations – which are members of the International Council of Nurses (ICN) and the Council of Europe – of the 27 EU member states as well as Croatia, Norway, Iceland and Switzerland. Associated members are three man- dated representatives of the European Nursing Specialists Organisa- tions. The International Council of Nurses (ICN), the World Health Organisation (WHO) and the European Nursing Students Association (ENSA) also hold observer status within the EFN General Assembly.
EFN members meet twice a year, when important issues are discussed and decisions taken. The EFN Executive Committee also meets twice a year. Furthermore, some working groups are regularly constituted to al- low more detailed work on issues discussed by the General Assembly, the Executive Committee and/or linked to EU-level discussions. The EFN plays an important role in safeguarding the health and safety of all nurses.
FEPI is a new Federation of Nursing Regulating Bodies, formed as more and more countries succeed in giving the nursing profession more autonomy and self-regulation. It was established in 2004. FEPI’s primary aim is to protect European citizens by securing excellence in nursing competences and practice, professional standards, continuous education and training, as well as codes of conduct.
The goal of the European Specialist Nurses Organisations (ESNO) is to facilitate and provide an effective framework for communication, cooperation and coordination between the European specialist nurses organisations and the European specialist nurses’ interest groups, in or- der to represent the mutual interests and benefits of these organisations in relation to and within the European Federation of Nurses (EFN).
The Federation of Occupational Health Nurses within the EU (FOHNEU) is one of the specialist nurses organisations. It was estab- lished in 1993 in Windsor in the UK when the Royal College of Nursing’s European Working Group obtained a grant from the European Commis- sion to help fund a symposium for EU OHNs. Representatives from
Belgium, Denmark, France, Germany, Greece, Italy, the Republic of Ireland, Luxembourg, the Netherlands, Portugal, Spain, Finland, Norway and the UK met and decided that they wanted to understand and learn from each other (McK Graham 2002).
Members of FOHNEU are national occupational health nursing as- sociations or groups within each national nurses’ association. Observer status is granted to the national OHN associations of countries that are not members of the EU. FOHNEU represents 45 000 occupational health nurses working within the EU, is recognised by the European Commis- sion and is represented in the EFN through ESNO. FOHNEU has been active in all European institutions that relate both to nursing and OH, trying to present the unique role of OHNs within the OH team. In re- lation to education, FOHNEU has developed a core curriculum, which has been proposed as a model for developing specialist OHN education and includes the following five modules (FOHNEU 1997):
r The Work of an OHN and Interaction (see www.fohneu.org/
CoreCurrFinalforWebsite.doc) r Planning an OH Service
r Administration and Organisation r Health Promotion
r Evaluation and Development of OH Services.
OHN Education and Practice
Although the EU regulates occupational health and safety legislation, organisation of occupational health practice varies greatly among EU countries, especially those that have recently joined. In agreement with the 89/391/EEC directive on OH services provided by competent prac- titioners, which has been adopted by all EU countries, OHNs are best placed within an occupational health service (OHS) to provide appro- priate services to all employees. Implementation, however, differs from country to country, as does the role that OH professionals are expected to perform.
Information on current education and practice of OHNs throughout EU countries is based mainly on three studies, which found large dis- crepancies between as well as within countries (Rossi 1987, Sourtzi 1993, Sourtzi et al. 2006). None of these studies included all 27 EU counties as they were performed at different times and well before the EU reached its current size. All three studies investigated the existence or otherwise of specialised education for OHNs, its duration and content, as well as the extent of OHN practice.
Specialisation in occupational health is a requirement for employ- ment in relevant positions in countries that have well-established occu- pational health services and a recognised role for OHNs (Naumanen- Tuomela 2001, Whitaker and Baranski 2001). Although there is no
accepted international standard of education of OHNs, recommenda- tions do exist on the content and the level and duration of such spe- cialised education (WHO 1988, FOHNEU 1997).
Sourtzi (1993) found that 5 countries out of 11 had specialisation pro- grammes, although these courses differed both in content and duration.
Higher degree level (MSc) study was only found in the UK, and that was multi-disciplinary. In the most recent study (Sourtzi et al. 2006), 10 countries were found to have specialisation programmes, of variable du- ration but generally at postgraduate level. Of the existing programmes, most were established in the second half of the 1990s, but Finland, Ger- many, Sweden and the UK established theirs before 1980. Out of the 10 countries, 2 offered courses at certificate level, 5 at diploma, 2 at de- gree, and the UK offered both diploma and degree programmes. In the French community of Belgium, and in Cyprus, Greece and Portugal, occupational health is included in postgraduate courses in community or public health nursing, either as a specialisation or in master’s pro- grammes of at least one year’s duration. In this study it was reported that only registered nurses could apply for specialisation in OHN, but in some countries there were additional requirements, such as relevant experience. The content of the programmes had both similarities and differences. Subjects that were included in all or most of the specialisa- tion programmes were:
r health promotion and health education r prevention policies at the workplace r occupational epidemiology
r environmental surveillance and health protection r health assessment and surveillance
r organisation and administration of OH services.
OHNs were found to work in all countries for which data were available in all three studies. The only country that was found to have discontin- ued OHN as a nursing specialisation was Italy, where this role today is studied and practised as a separate profession (Sourtzi et al. 2006).
The role of OHNs today seems more uniform regardless of education and this was reported in all three studies, although there was an evo- lution in the range of activities performed by OHNs from that reported by Rossi (1987) to the most recent study (Sourtzi et al. 2006), in which the most common activities that were reported were:
r health education/promotion r disease and injury prevention r first aid services
r administrative duties in the service r health assessment and surveillance
r risk assessment and safety/environmental surveys/controls.
In conclusion, OHN practice is widespread in the EU, but education in some countries is not yet developed to meet the contemporary demands of OHN practice. The development of postgraduate specialisation pro- grammes based on well-developed educational models such as the Core Curriculum developed by FOHNEU (1997) could help advance the level of education and also practice of OHNs.
Further to the above comparative data I shall refer to a few EU countries with well-established OHN. There have unfortunately been changes for the worse in two of them, suggesting that the future may not be as bright as hoped unless efforts are made to safeguard the vested interests of the OH profession and thereby the health of the working population.
United Kingdom
The UK has the best-developed education for occupational health nurses in Europe, offering courses at diploma or degree level, as well as post- graduate studies. As a result of NMC registration changes in the UK in 2004, newly qualified OHNs must hold a minimum of a first degree in OH to be registered as specialists. This makes UK OHNs the best pre- pared to provide competent OH services, and although there are no legal requirements for the employment of OHNs, there are around 5000 work- ing in the field, either within company-run OH services, external OH services or as freelance OH consultants (Education Group of FOHNEU 2005). The OHN competencies published by the Royal College of Nurses (Bannister & Maw 2005) are a good practice guide, not only for UK nurses but for OHNs throughout the EU.
OHNs are organised in specialised groups, either within the Royal College of Nursing or in independent bodies, and there are many events and professional/scientific journals that provide the opportunity for OHNs to get information or publish their work.
The Netherlands
McK Graham (2002) reported OHS changes in the Netherlands and the very positive impact these had for OHNs. Both company and private OHS in the Netherlands expanded during the 1990s, and this was one of the very few countries in the EU where the vast majority of the work- ing population was covered. However, the focus that was placed on sickness-absence management, as well as on cost-effectiveness, resulted after some time in the extreme specialisation of private-owned OHS and in cuts in company-run services. Although there are still changes going on, it seems that most of the traditional OH professionals will either have to adapt to the new situation or cease to exist (Weel et al.
2007).
Specialist occupational health nursing education was and still is available for Dutch nurses, although some programmes have ceased to exist because there are fewer nurses looking for such an education. Al- though company OH services have kept their nurses, external OH ser- vices have reduced the number of OHNs by hundreds because they were unable to provide services such as risk assessments and health checks. OHNs are still organised as a profession, although separate from the national nurses’ association, but their position has been weak- ened to such a degree that if they do not find a way to respond to the changing environment of OH in their country they may lose the game (www.arboverpleegkunde.nl).
Finland
Finland has well-established OHN education and although the choice is not as wide as that in the UK, it is comparable. The Finnish Associa- tion of Occupational Health Nurses has 2500 members and OHNs are considered one of the two professions – alongside OH physicians – that are the core of OH services, both company run and external. Accord- ing to the previous and current Finnish Occupational Health Care Acts, all employers are obliged to organise primary preventive occupational health services which aim at minimising harmful work environment risk factors to employees’ health, and preventing occupational diseases and accidents (Lamberg et al. 2007).
The Finnish Occupational Health Care legislation and Good Occupa- tional Health Practice guidebook also describe the role of OHNs, who make up the largest group of health care professionals involved in de- livering health care at the workplace. Finnish OHNs have responded to future challenges, raised the standards of their professional education and training, modernised and expanded their role at the workplace, and for the most part work as members of larger multi-professional teams.
They are often at the frontline in helping to protect and promote the health of working populations (Naumanen-Tuomela 2001).
Sweden
Sweden has much in common with its neighbour Finland as OH ser- vices are well established and OHNs are members of the wider OH team (Bohlin et al. 2007). There is strong co-operation between OHNs from all the Nordic countries through the NORDSAM network. Although specialist education for OHNs still exists and the number of OHNs is considerable, changes that are taking place just now could influence the future of OHNs in either a positive or a negative way. The Swedish Insti- tute of Working Life, the organisation that was responsible for providing specialist OHN education, among other things, ceased to exist on 1 July 2007 (www.arbetslivsinstitutet.se/en). The OHNs Association is trying