Performance Indicators

PERFORMANCE INDICATORS AND BENCHMARKING IN OH NURSING
A report conducted by the At Work Partnership for the Royal College of Nursing Society of Occupational Health Nursing
November 2005
Performance indicators and benchmarking in occupational health nursing
A report by the At Work Partnership for the Royal College of Nursing Society of Occupational Health Nursing
John Ballard Sarah Silcox Paul Suff
The At Work Partnership Ltd 2005 The At Work Partnership Ltd 19 Bishops Avenue Elstree Hertfordshire WD6 3LZ info@atworkpartnership.co.uk
The At Work Partnership

The At Work Partnership (AWP) is an independent publisher, research and conferences organisation that focuses on occupational health and disability at work issues. It is committed to researching, evaluating and disseminating high quality, reliable and evidence-based information for the improvement of working lives. It publishes the bi-monthly professional journal Occupational Health [at Work] and organises seminars on all aspects of occupational health and disability at work. The At Work Partnership has worked jointly with the Institute for Employment Studies on a research project funded by the Health and Safety Executive (HSE) to examine the impact of the HSEs guidance on risk assessment, and on a second project on accident reporting for the Learning and Skills Council. It has also been commissioned by the Department for Transport, the Home Office and the Metropolitan Police. Private sector joint initiatives have included research sponsored by the healthcare group AXA PPP. For further information, email 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
Introduction and background Methods

Questionnaire Survey analysis SOHN conference and performance indicators workshop
3 4 4
Results and analysis

Results 1: General information
Physicians in the workplace OH facilities Out-of-hours cover OH support for off-site and home workers 5 11 13 14 15 16 16 18 21 23 25 27 30 32 34 38 40 42 45 47 49 51 53 55 57 60 62 64 66 68 70 70 75 83
Results 2: OH functions and competences

Attendance monitoring Return-to-work interviews Home/off-site visits to workers on sick leave Disability assessments and adjustments Vocational rehabilitation Analysis of pre-employment/pre-placement questionnaires Assessment of fitness for work Developing fitness-for-work standards Health surveillance provision and interpretation of health surveillance Health and safety risk assessment Assessment of risks to mental health (including stress) Advising on work organisation and design Provision of personal protective equipment Monitoring work-related accident, injury and illness data Costbenefit analysis of OH interventions Display screen equipment assessments Sharps/needlestick prevention and management Immunisation Travel health advice Provision of training and education (eg manual handling) excluding first aid Organisation of first aid and first-aid training Provision of confidential counselling General health and wellness screening Interpreting and advising on OH law Confidential handling of health and personal data
Results 3: Role and competence

Essential services and level of provision Essential services and OH nursing competence
i
Performance indicators and benchmarking in OH nursing Contents
Results 4: Generic OH nursing skills

Research skills and awareness Team working Budget management Resource management Leadership skills Interpreting developments in OH practice Communication with clients and OH colleagues Conflict management Presentation skills Coaching/mentoring Clinical supervision Importance rating and competence
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
Results 5: OH performance indicators

ManagementOH referral times Fitness-for-work reports Time taken to be seen by external specialist Provision of post-exposure prophylaxis
Results 6: Role in OH policies and policy development

Medical confidentiality Attendance Disability Bullying and harassment Stress Manual handling Health and safety and the reporting of injury and illness data Bloodborne viruses Substance misuse
Results 7: Clinical governance

Occupational health support for the OH team Competence of occupational medicine
Results 8: Core competences Results 9: Focus group

OH education and qualifications Manpower: is there an ideal ratio between the number of OH nurses and the number of employees in an organisation? The balance between what customers expect from the OH service and what OH practitioners perceive as essential
Discussion Literature review

Aims and objectives
The role and required competences of OH nurses
Role of the OHN Competences of the OHN
128
129 129 130 134 136 136 138 141 142 144 144 144 146 147 150
Provision and delivery of occupational health

UK-wide provision OH provision in the NHS Small and medium-sized employers Multi-national organisations
Accepted standards and performance measures for OH

Definitions of OH activities Employer and employee OH priorities Benchmarking OH performance Developing competences in OH
Summary of sources
References Appendix
The performance indicators questionnaire
ii
156
157
Performance indicators and benchmarking in OH nursing Contents
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.
Box 1: Essential OH nursing functions (all sectors)

1 Confidential handling of health and personal data (95%) 5 Disability assessments and adjustments (81%) 9 Developing fitness-for-work standards (71%) 13 Display screen equipment assessments (62%) 17 Monitoring work-related accident, injury and illness data (58%) 21 Costbenefit analysis of OH interventions (50%) 25 Travel health advice/provision (25%) 2 Assessment of fitness for work (88%) 6 Assessing risks to mental health (81%) 10 Confidential counselling (68%) 14 Vocational rehabilitation (61%) 18 Attendance monitoring (53%) 22 Organisation of first aid and first-aid training (44%) 26 Home/off-site visits to workers on sick leave (23%) 3 Delivering health surveillance (84%) 7 Analysing of pre-employment/preplacement questionnaires (77%) 11 Health and safety risk assessment (66%) 15 Advising on work organisation and design (59%) 19 Provision of training and education (53%) 23 Provision of personal protective equipment (44%) 4 Interpretation of health surveillance (84%) 8 Interpreting and advising on OH law (76%) 12 Sharps/needlestick prevention and management (63%) 16 Delivering return-to-work interviews (58%) 20 Immunisation (50%) 24 General health and wellness screening (39%)
Note: the figures show the percentages of OH nurses who rate each function as essential
Box 2: Comprehensive provision of OH services (all sectors)

1 Confidential handling of health and personal data (88%) 5 Interpretation of health surveillance (73%) 9 Interpreting and advising on OH law (49%) 13 Immunisation (46%) 17 General health and wellness screening (41%) 21 Advising on work organisation and design (33%) 25 Travel health advice/provision (24%) 2 Assessment of fitness for work (84%) 6 Disability assessments and adjustments (64%) 10 Developing fitness-forwork standards (47%) 14 Health and safety risk assessment (43%) 18 Organisation of first aid and first-aid training (39%) 22 Provision of training and education (31%) 26 Costbenefit analysis of OH interventions (21%) 3 Analysing of pre-employment/preplacement questionnaires (80%) 7 Display screen equipment assessments (62%) 11 Vocational rehabilitation (47%) 15 Sharps/needlestick prevention and management (43%) 19 Attendance monitoring (38%) 23 Provision of personal protective equipment (26%) 4 Delivering health surveillance (74%) 8 Confidential counselling (57%) 12 Delivering return-to-work interviews (47%) 16 Assessing risks to mental health (42%) 20 Monitoring work-related accident, injury and illness data (37%) 24 Home/off-site visits to workers on sick leave (25%)
Note: the figures show the percentages of OH nurses who rate each service as comprehensive
Role and competence

Respondents were asked to rate their level of competence in each service area as excellent, satisfactory or unsatisfactory. They were also asked to describe their role in the delivery of each service: lead, support or nil/negligible. Self-rated competence varies considerably: just 15% of OH nurses rate their skills in costbenefit analysis of OH interventions as excellent; whereas 75% consider that they excel in the confidential handling of health and personal data. The full list of assessed skills is grouped below: I at least 70% excellent confidential handling of health and personal data; analysis of preemployment/pre-placement questionnaires
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.
OH policies and policy development

Medical confidentiality Nearly all respondents (94%) report that their OH service has a policy on medical confidentiality and health data security; 43% of OH nurses have a lead role in developing and/or delivering the policy, with 36% having a support role. Attendance and disability Ninety-eight per cent of respondents organisations have a sckness absence policy, and 97% a disability policy. However, OH nurses are more likely to have a support role than a lead role in developing and/or delivering these policies: sickness absence 64% support, 19% lead; disability 63% support, 17% lead. Bullying and harassment Nearly all (96%) of organisations have a policy on bullying and harassment. The OH nurse is most likely to play a support role in its development and/or delivery. Two-thirds of nurses have a support role, 5% have a lead role and 28% no or negligible role. Stress Most respondents organisations have a stress policy (93%). Half of OH nurses have a support role in its development and/or delivery; 29% have a lead role and 14% have no or negligible role (7% of respondents either have no policy or did not answer the question). Bloodborne viruses Slightly more nurses (37%) have a lead rather than a support role (30% support) in developing and/or delivering policies on bloodborne viruses. Seventeen per cent report no or negligible role (16% either had no policy or did not state it). Other policy areas Nurses are more likely to have a support role than a lead role in developing and/or delivering policies on manual handling (54% support role, 15% lead, 26% nil/negligible 5% unstated/no policy), health and safety (67% support, 11% lead, 19% nil/negligible), RIDDOR (58% support, 12% lead, 27% nil/negligible), and substance misuse (50% support, 22% lead, 18% no role).
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.
INTRODUCTION AND BACKGROUND

This report presents the findings of research carried out by The At Work Partnership for the Royal College of Nursing (RCN). The research aimed to establish the current scope and standards of performance in delivering occupational health nursing services throughout the United Kingdom, and the competences of OH nurses to deliver those services. There are three elements to the research: I a literature search to set the findings in context I a questionnaire-based survey of 2,000 practising occupational health nurses, stratified by sector, region and size of service, to establish service delivery benchmarks and draft performance indicators I a workshop at the RCN Society of Occupational Health Nursing annual conference in November 2004, to refine the draft performance indicators. The RCN is developing national competency standards for all nursing disciplines. The standards will form part of an integrated career and competency framework across the nursing profession. The current research will help inform the development of core and specialist competences for OH nurses. Occupational health within organisations is being delivered increasingly by OH nurses. However, there have been no comprehensive studies to date on the extent and range of performance delivery in occupational health nursing in the UK. According to the National Audit Offices (NAO) 2003 report on the management of health and safety risks to NHS staff: Occupational health services fulfil a number of important roles, from health surveillance and screening, health education and counselling, assessments of individual employees fitness for work, and the rehabilitation of staff into work following an injury or illness, to planning and implementing health improvement measures in the workplace (National Audit Office, 2003). However, the NAO also concluded that, even in the NHS which markets its own OH services to other employers All NHS trusts provide some occupational health services but this is largely reactive and the quality and accessibility varies. The NAO report found variable access to OH services, particularly to out-of-hours provision, and that a lack of resources to invest in OH is frequently cited as a constraint on the level of services provided. A study by the Institute of Occupational Medicine (IOM) found that very few employers (3% of UK companies) provided access to wide-ranging occupational health support, though a higher
1
Performance indicator and benchmarking in OH nursing Introduction and background
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.
SOHN conference and performance indicators workshop

The main survey findings were presented at the RCN/SOHN conference in November 2004. The headline findings were then discussed at a specially convened workshop where practising OH nurses were able to comment on the relevance of the results for their work.
4
Performance indicators and benchmarking in OH nursing Methods
RESULTS AND ANALYSIS

Results 1: General information
Of the 2,000 questionnaires mailed in October 2004, 473 were returned (24% response). Fifty-eight per cent of respondents are from the private sector, 44% from the public sector (28% NHS), with 2% describing themselves as self-employed (figure 1). Twenty-one respondents say they work in more than one sector (the totals thus add up to more than 100%). Of the private sector respondents, around one-third (34%) are from commercial OH providers. A small minority (4%) work in more than one sector.
Figure 1: Employers business
40% 35% 30% 25% 20% 15% 10% 5% 0%
Commercial OH provider Other private sector NHS Other public sector Self-employed
20% 38% 28% 16% 2%
Note: some respondents work in more than one sector
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
Figure 2: Job title
45 40 35 30 25 Per cent 20 15 10 5 0 OH adviser/nurse adviser OH manager OH nurse OH sister Other/unstated
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.
Figure 3: Working alone or part of an OH team
80 70 60 50 Per cent 40 30 20 10 0 Sole OH practitioner Part of OH team
Note: figures based on 412 respondents answering the question
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
Figure 4: Full time or part time
70 60 50 40
Per cent
30 20 10 0
Full-time Part-time Not stated
Figure 5: Contracted working hours
80 70 60 50
Per cent 40 30 20 10 0 less than 20 hours 21 to 30 hours more than 31 hours
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
Figure 6: Respondents OH qualifications

35 30 25 20 Per cent 15 10 5 0 OHN cert OHN Dip OHN deg PGDip MSc/PhD No formal qualification
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.
Figure 7: Responsibility for more than one 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
Don't know/not stated
8
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.
Table 1: OH provision by sector: full-time and part-time nurses

Sector n Mean no. nurses (all levels) Non-OH qualified Currently training Certificate Diploma Degree PGDip MSc or PhD Total OHqualified nurses
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
6.14 2.94 4.55*
2.24 1.01 1.60*
0.73 0.25 0.42
0.65 0.43 0.53
0.98 0.5 0.79
1.24 0.63 1.00
0.19 0.06 0.10
0.11 0.06 0.10
3.17 1.68 2.53
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)
Table 2: OH provision by sector: full-time equivalents

Sector n Mean no. nurses per organisation (all levels) Non-OH qualified Currently training Certificate Diploma Degree PGDip MSc or PhD Total OHqualified nurses
Commercial OH provider Other private sector NHS Other public sector All sectors
75 146 127 68 416
4.79* 2.96 4.83 2.26 3.66*
1.43* 0.90 1.63 0.68 1.18*
0.42 0.20 0.61 0.22 0.36
0.41 0.39 0.51 0.37 0.42
1.19 0.49 0.76 0.41 0.64
1.02 0.84 1.08 0.51 0.88
0.13 0.05 0.16 0.06 0.09
0.16 0.10 0.10 0.04 0.09
2.92 1.86 2.61 1.40 2.12
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
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
Table 3: Ratio of nurses working in OH capacity per 1,000 employees

Sector Total employees No. organisations
All sectors
Commercial OH provider*
Other private sector
NHS
Other public sector
2,155,222 431 5,000 0.88 0.70 0.49 0.41
374,689 75 4,996 1.15 0.95 0.68 0.58
791,236 146 5,419 0.66 0.55 0.39 0.34
607,772 127 4,786 1.28 1.01 0.66 0.54
381,344 68 5,608 0.52 0.40 0.30 0.25
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
Physicians in the workplace

A total of 104 respondents (22%) report that a full-time FOM-qualified OH physician operates at their place or places at work, with 327 (69%) saying that a part-time FOM-qualified OH physician operates at their place of work (figure 8). Thirty-two respondents (7%) say a full-time non-FOM qualified physician operates at their place or places of work, with 134 (28%) reporting that a parttime non-FOM qualified physician operates there.
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
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.
Table 4: Physicians in the workplace (OH and non-OH qualified)

Sector n Mean no. FOMqualified OH physicians (fulland part-time) Mean number FOM-qualified OH physicians (FTE) % of organisations with no access to FOM-qualified OH physicians Mean number nonOH qualified physicians/GP (fulland part-time) Mean number nonOH qualified physicians/GP (FTE)
Commercial OH provider Other private sector NHS Other public sector Self-employed All sectors
94 178 131 74 11 473
2.03 1.11 1.57 1.38 0.82 1.45
1.48 0.66 1.0 0.82 0.45 0.92
12% 22% 12% 16% 45% 17.3%
2.90 0.34 0.85 0.53 0.27 1.02
1.54 0.18 0.52 0.29 0.14 0.56
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
Table 5: Ratio of physicians working in OH capacity per 1,000 employees

Sector Total employees Total physicians per 1,000 employees (full- and part-time) Total physicians per 1,000 employees (FTEs) Total FOM-qualified physicians per 1,000 employees Total FOM-qualified physicians per 1,000 employees (FTEs) All sectors Commercial OH provider Other private sector NHS Other public sector
2,155,222 0.54 0.32 0.32 0.20
374,689 1.24 0.76 0.51 0.37
791,236 0.32 0.19 0.25 0.15
607,772 0.52 0.33 0.34 0.22
381,344 0.37 0.22 0.27 0.16
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).
Figure 9: Dedicated OH facility or clinic (all sectors)
60
50
40
Per cent 30
20
10
0 Excellent Satisfactory Unsatisfactory None
13
Figure 10: Dedicated OH facility or clinic (by sector)

70 60 50 40 Per cent 30 20 10 0 Commercial OH provider Other private sector NHS Other public sector Self employed*
Excellent
Satisfactory
Unsatisfactory
None
* There were just 11 self-employed respondents
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
n = 473 * There were just 11 self-employed respondents
14
OH support for off-site and home workers

More than half (53%) of organisations provide OH cover for off-site and home workers (figure 12). One-fifth (20%) of respondents say off-site cover is not necessary in their workplace, around onequarter (26%) say they do not provide cover (1% did not respond). This pattern of responses is broadly similar across all sectors, though fewer self-employed respondents provide off-site cover (just 11 self-employed practitioners responded to the survey, so care should be taken in drawing conclusions from this finding). The role of OH nurses in delivering off-site support is discussed below.
Figure 12: Provision of OH cover for off-site and/or home workers

60 50 40 Per cent 3 0 20 10 0 Commercial Other private OH provider sector NHS Other public sector Self employed* All sectors
Yes
* There were just 11 self-employed respondents
No
Not required
15
Results 2: OH functions and competences

Attendance monitoring
Almost two-thirds (64%) of all respondents report that the OH department offers an attendance monitoring services (figure 13). Across all sectors, 38% say that they offer a comprehensive attendance monitoring service, with 26% describing it as basic and 29% non-existent. The private sector (49% of commercial OH providers and 46% in the rest of the private sector) is much more likely to offer a comprehensive attendance monitoring service than the public sector (22% of NHS and 31% in the rest of the public sector) (figure 13). Thirty-seven per cent of NHS employers and 39% of other public sector organisations do not offer attendance monitoring at all within their OH function. This compares with 32% of commercial OH providers and 23% of other private sector employers.
Figure 13: Attendance monitoring level of provision (all sectors)

60
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
Figure 14: Rating of importance
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
50 40 30 Per cent 20 10 0 Lead Support Negligible
Figure 15b: Level of competence
50 40 30 Per cent 20 10 0 Excellent Satisfactory Unsatisfactory
17
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).
Table 6: Competence against role in delivering attendance monitoring

Role/competence Lead Support None/negligible n Excellent % Satisfactory % Unsatisfactory % Not stated % Total %
109 192 156
62 35 4
34 60 39
2 1 35
2 4 22
100 100 100
n = number of respondents in each category; 16 did not answer the question
Table 7: Job function against competence

Competence/role Excellent Satisfactory Unsatisfactory n Lead % Support % None/negligible % Not stated %
143 214 59
48 17 3
48 54 3
4 29 93
0 0 0
n = number of respondents in each category
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
Figure 16: Return-to-work interviews level of provision

60
50
40
Per cent 3 0
20
10
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.
Figure 17: Rating of importance

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
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
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
Table 8: Competence against role in delivering return-to-work interviews

138 201 122
58 41 10
39 55 43
0 2 18
3 2 29
100 100 100

175 218 27
46 25 0
47 51 15
7 24 81
0 0 4
20
Home/off-site visits to workers on sick leave

Three-fifths (61%) of all respondents say that their OH service offers some level of provision for home or off-site visits to workers on sick leave. The provision of off-site/home visits is slightly lower in the NHS and other public sector respondents (54% in both sectors) compared with commercial OH providers (60%) and other private sector respondents (68%). Nine of the 11 self-employed respondents say they offer this service, with six of them describing the provision as comprehensive.
Home/off-site visits to workers on sick leave Figure 19a: Level of provision
60
50
40
Per cent 30 20
10
Basic
Comprehensive
Non-existent
Not stated
Figure 19b: Rating of importance
60
50
40
Per cent 30 20
10
Essential
Desirable
Nil/negligible
Not stated
21
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
40 30 Per cent 20 10 0 Excellent Satisfactory Unsatisfactory
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
126 111 215
60 36 12
36 59 33
1 3 27
3 2 28
100 100 100
22

144 181 62
53 25 2
28 36 5
17 39 94
2 1 0
Disability assessments and adjustments

Nearly all OH services (94%) offer some form of disability assessment and advice on adjustments. Around two-thirds (64%) describe this service as comprehensive, with very little variation across the sectors (figure 21a). Four-fifths (81%) of respondents describe the service as essential, 14% desirable, and no respondents said the service was of nil or negligible importance (6% of respondents did not answer the question) (figure 21b).
Disability assessments Figure 21a: 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
23
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
60 40 Per cent 20 0 Lead Support Negligible
60 40 Per cent 20 0 Excellent Satisfactory Unsatisfactory
24
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
216 199 46
52 17 9
45 67 13
1 11 54
2 5 24
100 100 100

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).
Vocational rehabilitation Figure 23a: Level of provision
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
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
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.
Table 14: Competence against role in delivering vocational rehabilitation

162 198 90
61 14 4
35 71 18
2 10 50
2 5 28
100 100 100

133 213 69
74 26 6
21 66 29
3 8 65
2 0 0
Analysis of pre-employment/pre-placement questionnaires

Virtually all respondents (95%) say their organisation offers some level of analysis of preemployment or pre-placement health questionnaires, with 80% describing the provision as comprehensive. There was little variation between sectors (figure 25a). Around three-quarters (77%) describe this service as essential, with most others saying it is a desirable function of the OH department (figure 25b).
27
Analysis of pre-employment/pre-placement questionnaires Figure 25a: Level of provision
Basic
Comprehensive
Non-existent
Not stated
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
OHN role and competence in analysis of pre-employment/ pre-placement questionnaires Figure 26a: Role in delivery
100
Per cent
50 0 Lead Support Negligible
More respondents with a lead role described their competence as excellent (78%) compared with those in a support role (61%) (table 16).
Table 16: Competence against role in analysis of pre-employment/pre-placement questionnaires

345 95 23
78 61 61
20 38 26
0 0 0
2 1 13
100 100 100

341 113 0
79 62 -
17 32 -
4 5 -
0 1 -
29
Assessment of fitness for work

The vast majority (84%) of respondents report that their OH department provides a comprehensive service in the assessment of fitness to work; only four respondents (1%) from the whole sample say that this service was not provided (figure 27a). Between 88% and 92% of respondents across the various sectors describe this function as essential (figure 27b).
Assessment of fitness for work Figure 27a: Level of provision
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
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.
Table 18: Competence against role in assessing fitness for work

337 114 13
72 35 31
26 62 31
1 2 8
2 1 31
101 100 101
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
Developing fitness-for-work standards

Most OH departments (85%) have a role in developing fitness-for-work standards, with around half (47%) describing the service as comprehensive (figure 29a). Other public sector respondents were the poorest performers in this context, with only one-third (34%) describing their service as comprehensive and 22% describing it as non-existent (compared with 13% across the whole sample). Virtually all respondents across all sectors described the service as either desirable (23% of all respondents) or essential (71%) (figure 29b).
Developing fitness-for-work standards Figure 29a: Level of provision
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
OHN role and competence in developing fitness-for-work standards Figure 30a: Role in delivery
40
Per cent 20 0 Lead Support Negligible
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).
Table 20: Competence against role in developing fitness-for-work standards

185 172 97
57 13 5
38 77 21
2 7 55
3 3 19
100 100 100

135 225 71
79 31 4
17 59 17
4 9 75
1 1 4
33
Health surveillance provision and interpretation of health surveillance

The vast majority (93%94%) of OH departments offer health surveillance (such as audiometry, spirometry and urinalysis) and the interpretation of health surveillance, three-quarters (73%74%) of which are described as comprehensive (figures 31a and 32a). Around 85% of respondents across all sectors view these services as essential (figures 31b and 32b).
Health surveillance provision Figure 31a: Level of provision

Basic
Comprehensive
Non-existent
Not stated

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
Essential
Desirable
Nil/negligible
Not stated
34
Interpretation of health surveillance Figure 32a: Level of provision
Basic
Comprehensive
Non-existent
Not stated
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
OHN role and competence in health surveillance provision Figure 33a: Role in delivery
80 60 Per cent 4 0 20 0 Lead Support Negligible
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).
Table 22: Competence against role in delivering health surveillance

316 109 37
70 44 30
27 50 51
0 4 14
3 2 5
100 100 100

281 160 10
78 53 10
17 34 40
4 12 50
1 1 0
36
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).
Table 24: Competence against role in interpreting health surveillance

294 135 34
63 30 29
34 65 38
0 4 24
3 1 9
100 100 100
37

Competence/role Excellent Satisfactory Unsatisfactory n Lead % Support % None/negligible % Not stated
236 202 14
78 50 0
17 44 43
4 6 57
1 0 0
Health and safety risk assessment

Although most respondents (86%) report that the OH department provides health and safety risk assessment about half of these say that the service is basic rather than comprehensive (figure 35a). Seven out of 11 self-employed respondents claim to offer a comprehensive service. Around twothirds of respondents across all sectors describe the service as essential; most of the others describe it as desirable (figure 35b).
Health and safety risk assessment Figure 35a: Level of provision
Basic
Comprehensive
Non-existent
Not stated
38
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
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
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
Assessment of risks to mental health (including stress)

Around 90% of all respondents say they offer some level of assessment of risks to mental health and stress; however, only around half of these offer a comprehensive service (figure 37a) other private sector employers were the worst performers in this respect with 33% describing their provision as comprehensive. Most respondents (81%) describe such provision as essential, with virtually all other respondents describing it as desirable (figure 37b).
40
Assessing risks to mental health Figure 37a: Level of provision
60
50
40
Per cent 30 20
10
Basic
Comprehensive
Non-existent
Not stated
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
OHN role and competence in assessing risks to mental health Figure 38a: Role in delivery
Table 28: Competence against role in assessing risks to mental health

179 216 66
53 16 11
42 70 35
2 12 45
3 2 9
100 100 100

138 252 60
68 30 7
25 60 43
5 9 50
1 1 0
Advising on work organisation and design

Around half (53%) of all respondents say their OH department offers a basic level of service in advising on work organisation and design; a further third (33%) offer a comprehensive service,
42
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).
Advising on work organisation and design Figure 39a: Level of provision
Basic
Comprehensive
Non-existent
Not stated
Essential
Desirable
Nil/negligible
Not stated
43
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
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
Provision of personal protective equipment

Just under two-thirds (62%) of OH departments provide personal protective equipment (PPE), though more than half of these describe the provision as basic (figure 41a). Just 18% of other public sector employers offer a comprehensive service in the provision of PPE, even though 47% of respondents from that sector describe such provision as essential (figure 41b). Across all sectors, the proportion of respondents describing the provision of PPE as an essential function of the OH department is greater than the proportion who say that a comprehensive service is provided (figures 41a and 41b).
Provision of personal protective equipment Figure 41a: Level of provision
Basic
Comprehensive
Non-existent
Not stated

Essential
Desirable
Nil/negligible
Not stated
45
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
39 233 187
67 15 11
26 77 50
3 5 29
5 4 10
101 101 100
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
Monitoring work-related accident, injury and illness data

Three-quarters of OH departments monitor work-related accident, injury and illness data, with 23% not offering this service. There is some variation between sectors, with 66% of commercial OH providers offering such a service, compared with 83% of other private sector organisations (figure 43a). Private sector OH departments are also more likely than those from other sectors to offer a comprehensive service. Perhaps unsurprisingly, 70% of other private sector respondents say that such a service is essential compared with 45% of respondents from OH providers, 54% of NHS respondents and 57% of other public sector respondents (figure 43b).
Monitoring work-related accident, injury and illness data Figure 43a: Level of provision
Basic
Comprehensive
Non-existent
Not stated
Essential
Desirable
Nil/negligible
Not stated
47
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
110 220 128
55 21 11
39 72 41
0 5 39
6 2 9
100 100 100

123 257 60
49 17 0
38 62 17
11 20 83
2 1 0
48
Costbenefit analysis of OH interventions

Just 57% of respondents OH departments carry out costbenefit analysis of OH interventions (figure 45a), despite the fact that around half of respondents across all sectors rate this function as essential and 40% desirable (figure 45b). Only 50% of other public sector OH departments offer some provision in this area, with non-provision between 36% and 40% in the other sectors. In keeping with the overall finding, 45% of respondents have no or negligible role in costbenefit analysis (figure 46a), with just 15% describing their competence as excellent the lowest-ranked of all the competences. Of the 71 respondents describing their competence as excellent two-thirds (65%) have a lead role in this function (table 46b).
Costbenefit analysis of OH interventions Figure 45a: Level of provision
Basic
Comprehensive
Non-existent
Not stated
Essential
Desirable
Nil/negligible
Not stated
49
OHN role and competence in costbenefit analysis of OH interventions Figure 46a: Role in delivery
Table 36: Competence against role in analysis of costbenefit of OH interventions

102 141 213
45 10 5
50 68 23
4 18 62
1 4 10
100 100 100

71 196 163
65 26 2
20 49 15
14 24 82
1 1 1
50
Display screen equipment assessments

The vast majority of respondents report that their OH departments offer assessments in compliance with the Health and Safety (Display Screen Equipment) Regulations 1992, with just under two-thirds describing this provision as comprehensive (figure 47a). Commercial OH providers are most likely to offer a comprehensive service (76%, according to respondents from this sector). Just under two-thirds agree that this function is essential, with just under one-third saying it is desirable very few feel it is of nil or negligible value (figure 47b).
Display screen equipment assessments Figure 47a: Level of provision
Basic
Comprehensive
Non-existent
Not stated
Essential
Desirable
Nil/negligible
Not stated
51
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
210 185 62
78 44 24
20 50 34
0 2 31
2 5 11
100 101 100
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
Sharps/needlestick prevention and management

As expected, the provision of OH services to prevent and manage sharps and needlestick injuries is much higher in the NHS than in any other sector (figure 49a). Four-fifths (79%) of all NHS OH departments provide comprehensive services, with 15% providing basic services and just 3% saying that the service is not available. Most other public sector respondents provide some level of service (31% comprehensive, 49% basic). A large minority (43%) of commercial OH providers and 36% of other private sector employers offer no facilities to prevent or manage sharps and needlestick injuries. The vast majority (88%) of NHS respondents consider that such services are essential. Of interest, is that around half of both commercial OH providers (49%) and other private sector (52%), and more than two-thirds (68%) of other public sector respondents also view this service as essential; figures that far outweigh the level of comprehensive service provision in these sectors (figure 49b). Only a minority consider the service of nil or negligible importance.
Sharps/needlestick prevention and management Figure 49a: Level of provision
Basic
Comprehensive
Non-existent
Not stated
53

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
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).
Table 40: Role in sharps/needlestick prevention and management

185 135 140
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
Immunisation Figure 51a: Level of provision
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
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
OHN role and competence in immunisation Figure 52a: Role in delivery
Table 42: Competence against role in delivering immunisation services

199 105 153
73 37 13
24 55 31
1 4 44
2 4 12
100 100 100

206 154 75
71 31 3
19 38 5
10 31 91
0 1 1
Travel health advice

Around two-thirds of commercial OH providers and other private sector respondents (63% and 61% respectively) provide either basic or comprehensive travel health advice and services, with 29% in both providing comprehensive services in this area (figure 54a). The level of provision is lower in the NHS (52% basic or comprehensive) and other public sector (53%). These trends are largely followed in terms of respondents rating of importance of such services (figure 54b).
57
Travel health advice Figure 54a: Level of provision
Basic
Comprehensive
Non-existent
Not stated
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
OHN role and competence in travel health advice Figure 55a: Role in delivery
60 40
Per cent
20 0 Excellent Satisfactory Unsatisfactory
Table 44: Competence against role in delivering travel health advice/provision

130 117 209
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

107 214 109
63 27 3
21 38 10
16 34 85
1 1 2
59
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
Basic
Comprehensive
Non-existent
Not stated
60
50 40
Per cent 30 20
10
Essential
Desirable
Nil/negligible
Not stated
60
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)
114 187 158
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
Organisation of first aid and first-aid training

Sixty per cent of OH services offer some kind of training and organisation of first aid at work. Around half (52%) of other private sector respondents report that their organisations provide comprehensive first-aid and first-aid training services (59%) (figure 57a). By contrast, 59% of NHS departments provide no such services. These trends are reflected in respondents views on the importance of such services (figure 57b).
Organisation of first aid and first-aid training Figure 57a: Level of provision
Basic
Comprehensive
Non-existent
Not stated
60
50
40
Per cent 30 20
10
Essential
Desirable
Nil/negligible
Not stated
62
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
128 101 226
84 25 15
13 66 31
1 5 39
2 4 15
100 100 100

166 156 96
65 11 1
15 43 5
20 46 93
0 1 1
63
Provision of confidential counselling

The majority of employers (89%) provide some level of confidential counselling services (figure 59a). However, provision of a comprehensive service is much higher in the NHS (66%) and other public sector (69%) than either the commercial OH providers (46%) and other private sector (52%). More than two-thirds (68%) consider that such provision is essential; with more NHS (79%) and other public sector (77%) respondents than commercial OH provider and other private sector respondents (both 62%) taking this view (figure 59b). Only a very small minority (3%) consider the services of negligible or no value.
Provision of confidential counselling Figure 59a: Level of provision
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
Essential
Desirable
Nil/negligible
Not stated
64
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
Table 49: Competence against role in provision of confidential counselling

181 217 67
60 21 6
37 71 36
1 6 39
2 2 19
100 100 100

Competence/Role Excellent Satisfactory Unsatisfactory n Lead % Support % None/negligible % Not stated %
160 246 39
68 27 3
29 63 31
3 10 67
1 0 0
65
General health and wellness screening

Most organisations (79%) provide some form of health and wellness screening (figure 61a). However, comprehensive services are much more likely to be provided by commercial OH providers (55%) than the other sectors. Six of the 11 self-employed practitioners also offer comprehensive health and wellness screening services. Although more than half (51%) of both commercial OH provider and other public sector respondents describe the service as essential, respondents in the NHS and other private sector are more likely to see the service as desirable rather than essential (figure 61b).
General health and wellness screening Figure 61a: Level of provision
60
50
40
Per cent 30 20
10
Basic
Comprehensive
Non-existent
Not stated
Essential
Desirable
Nil/negligible
Not stated
66
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
238 126 100
71 29 19
26 67 49
0 2 18
3 2 14
100 100 100

226 195 21
75 31 5
16 44 10
8 25 86
1 0 0
67
Interpreting and advising on OH law

The vast majority of OH departments in all sectors (91%) provide advice and interpretation on OH law, with 49% describing the service as comprehensive (figure 63a). Three-quarters of all respondents describe the service as essential (figure 63b), a figure not matched by the percentage of firms providing comprehensive services. There was little variation between sectors.
Interpreting and advising on OH law Figure 63a: Level of provision
Basic
Comprehensive
Non-existent
Not stated
Essential
Desirable
Nil/negligible
Not stated
68
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).
Table 53: Competence against role in interpreting and advising on OH law

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
Confidential handling of health and personal data

The vast majority (98%) of survey respondents said that their organisation provided confidential handing of health and personal data (figure 64a). Most respondents (88%) said that a comprehensive service was provided, with little variation between sectors. Just two out of 473 respondents said that such a service was not provided. Ninety-five per cent of all respondents said that such provision was essential again with little variation between sectors (figure 64b).
Confidential handling of health and personal data Figure 64a: Level of provision
Basic
Comprehensive
Non-existent
Not stated

Essential
Desirable
Nil/negligible
Not stated
70
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
362 99 1
83 53 0
15 43 100
0 2 0
2 2 0
100 100 100

354 99 2
85 56 0
15 43 100
0 1 0
1 0 0
71
Results 3: Role and competence

All 26 skill areas have been plotted in terms of respondents self-rated competence against the percentage in a lead role (figure 66). Generally, as the percentage having a lead role increases (circles), the percentage having excellent self-rated competence (triangles) also increases. The x-axis refers to the 26 skill areas, arranged in order of increasing percentages in lead roles. Where the paired points are closest there is a closer match between the percentage of nurses in lead roles and the percentage with excellent levels of competence. Some are very close such as data handling (77% lead role, 75% excellent competence) others are further apart, such as disability assessments, where nearly half (46%) of nurses have a lead role and a much smaller percentage (32%) of respondents describe their competence as excellent.
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
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).
Table 57: Competence area ranking by percentage in lead role

Ranking Competence area % in lead role
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
Table 58: Competence area ranking by percentage rating their competence as excellent
Ranking Competence area % excellent
1 2 3 4 5 6 7 8 9 10 11 12 13 14= 14= 14= 17= 17= 17= 17= 21 22 23 24 25 26
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
Essential services and level of provision

The extent to which respondents organisations provide a comprehensive service in the various practice areas is plotted against respondents views as to whether the service is essential (figure 67).
Figure 67: Essential services and level of provision

100
26
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
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
Table 59: Service delivery ranking as essential with comparison figures for organisations provision as comprehensive (all sectors)
Ranking Competence area % essential % comprehensive
1 2 3= 3= 5= 5= 7 8 9 10 11 12 13 14 15 16= 16= 18= 18= 20= 20= 22= 22= 24 25 26
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
Table 60: Service delivery ranking by percentage rating the organisations provision as comprehensive (all sectors)
Ranking Service % comprehensive
1 2 3 4 5 6 7 8 9 10= 10= 10= 13 14= 14= 16 17 18 19 20 21 22 23 24 25 26
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
Service delivery ranking as essential with comparison figures for organisations provision as comprehensive (by sector)
Table 61: Commercial OH provider
1 2 3 4 5 6 7 8 9 10= 10= 12 13 14 15= 15= 17 18 19 20 21 22 23 24 25 26
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
Table 62: Other private sector

1 2 3 4= 4= 6 7 8= 8= 10 11 12 13 14= 14= 16 17= 17= 17= 20 21 22 23 24 25 26
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
Table 63: NHS

1 2= 2= 4 5= 5= 7 8 9 10 11 12 13 14 15 16 17= 17= 19 20= 20= 22 23 24 25 26
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
Table 64: Other public sector

1 2 3= 3= 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19= 19= 21= 21= 23 24 25= 25=
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
Essential services and OH nursing competence

The match between respondents rating of what functions they consider essential and the overall self-ratings of competence in delivering those services is less good (figure 68). As can be seen, 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 many 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. And a third of OH nurses describe their competence in this area as unsatisfactory the poorest ranking of all the studied functions. Perhaps of even greater significance is that 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 the seventh-highest ranked function in terms of competence (48% of respondents rate their competence as excellent and only 4% as unsatisfactory), it is 24th out of the 26 functions in terms of its perception as important (only 39% of respondents view it as essential). It could be argued that some of the functions perceived as essential such as health and safety risk assessment and advising on work organisation and design could be undertaken by other professionals in a multidisciplinary team (such as the health and safety manager or ergonomist). A high level of competence in the OH nurse would not necessarily be an issue if other professional colleagues undertook these functions. However, functions such as disability assessments and workplace counselling are central roles of OH nurses and these results highlight areas where levels of competence could be raised and training targeted. It can also be argued that 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, nurses are more likely to 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 in the provision of confidential counselling.
83
Figure 68: Essential services and self-rated competence

100
26
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
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
Results 4: Generic OH nursing skills

Research skills and awareness
Nearly two-thirds (63%) of OH nurses rate their competence in research skills and awareness as satisfactory (figure 69a). Less than one-quarter (23%) rate their competence as excellent and 13% as unsatisfactory (1% not stated). More than half (51%) rate this skill as essential and 43% desirable only 3% felt it was of nil/negligible importance (2% not stated) (figure 69b).
OHN competence in research skills and awareness Figure 69a: Level of competence
70 60 50 40 Per cent 30 20 10 0 Excellent Satisfactory Unsatisfactory
Figure 69b: Importance rating
60 50 40 Per cent 30 20 10 0 Essential Desirable Negligible
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
OHN competence in team working Figure 70a: Level of competence
100 Per cent 50 0 Excellent Satisfactory Unsatisfactory
100 50 0 Essential Desirable Negligible
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).
OHN competence in budget management Figure 71a: Level of competence
60 40 Per cent 20 0 Essential Desirable Negligible
86
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).
OHN competence in resource management Figure 72a: Level of competence
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
80 60 Per cent 40 20 0 Essential Desirable Negligible
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
Interpreting developments in OH practice

Most respondents rate their competence in interpreting developments in OH practice as either excellent (33%) or satisfactory (59%) (figure 75a). Virtually all nurses rate this as either essential (71%) or desirable (24%) (2% nil/negligible; 3% not stated) (figure 75b).
88
OHN competence in interpreting developments in OH practice Figure 75a: Level of competence
Communication with clients and OH colleagues

Most OH nurses (81%) rate their competence in communication with clients and OH colleagues as excellent (18% satisfactory) (figure 76a). Nearly all (respondents (94%) see this function as essential (4% desirable, 2% not stated) (figure 76b).
OHN competence in communication with clients and OH colleagues Figure 76a: Level of competence
100 50 0 Excellent Satisfactory Unsatisfactory
Per cent
100 50 0 Essential Desirable Negligible
Per cent
89
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).
OHN competence in conflict management Figure 77a: Level of competence
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).
OHN competence in presentation skills Figure 78a: Level of competence
90
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).
OHN competence in coaching and mentoring Figure 79a: Level of competence
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
OHN competence in clinical supervision Figure 80a: Level of competence
Importance rating and competence

The 12 OH nursing skills discussed above were plotted in pairs according to whether OH nurses rate them as essential and whether nurses rate their own skills as excellent. As can be seen from figure 81, as the essential rating increases, the percentage describing their competence as excellent also increases. However, in all 12 areas, fewer OH nurses describe their competence as excellent compared with the number rating the skill area as essential. The biggest gaps in this context were for conflict management (58% rated as essential, 23% rate competence as excellent) and interpreting developments in OH practice (71% essential, 33% excellent). The closest fit was for communication skills (94% essential, 81% excellent).
92
Figure 81: Importance rating and competence

100
12
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
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
Table 65: Competence ranking by perceived importance

Ranking Competence area % rating as essential
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
Table 66: Competence ranking by self-rated competence

Ranking Competence area % excellent
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
Results 5: OH performance indicators

ManagementOH referral times
Respondents were asked to estimate the average time taken, in days, between a management referral and a worker being seen by an OH professional. Table 67 shows that across all sectors the mean referral time is 6.05 days (standard deviation, sd = 6.05). The mean delay was longest in the NHS (8.23 days) and shortest in the other private sector (4.51). The mean score for self-employed respondents was 4.15 days, but with only 11 respondents this figure needs to be interpreted with caution.
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)
35 30 25 20 Per cent 15 10 5 0 1 to 2 3 to 5 6 to 10 11 to 20 > 21 Dont know
Average days to referral
95
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
* Note there were just 11 self-employed respondents
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.
Table 68: Average time (days) to deliver a fitness-for-work report

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
Figure 84: Average time (days) to deliver a fitness-for-work report (all sectors)
70
60 50 40 Per cent 30 20 10
0 1 to 2 3 to 5 6 to 10 11 to 20 > 21 Dont know
Average days to referral
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
Time taken to be seen by external specialist

Respondents were asked to estimate the average time in days for an employee to be seen by an external specialist following a referral. One-third of respondents (31%) were unable to answer this question. The mean response time was 13.4 days (sd = 6.32) with slightly longer times recorded for the NHS and other public sectors (table 69).
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Table 69: Average time (days) to be seen by external specialist

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
15 10 5 0 1 to 2 3 to 5 6 to 10 11 to 20 > 21 Dont know
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
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
98
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
Note: respondents could tick more than one box
99
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
Note: respondents could tick more than one box
Provision of post-exposure prophylaxis

Respondents who work with 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 113 NHS respondents reported 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%) some respondents say PEP is provided both by the OH department and through A&E (figure 90). The vast majority (94%) of NHS respondents say that PEP is available outside normal hours (8.00 am to 5.30 pm) (figure 91). Figure 92 shows the time taken between a reported needlestick injury and the worker being seen by the OH professional (NHS only). The spread of responses from NHS respondents (38% less than one hour; 25% one to two hours; 6% three to six hours; 14% seven to 24 hours and 4% more than 24 hours; 13% not known) reflects the fact that where PEP is provided by A&E the employee will not be seen immediately by the OH professional the vast majority of cases are seen by the OH department within a relatively short time. (Department of Health guidelines recommend that PEP is give within one hour of a needlestick injury, but this concerns administration of the PEP drugs, not whether or not the individual receives secondary OH care.)
100
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
A&E or other provider
No provision
Note: respondents could select more than one option n = 113 NHS; 22 other public sector; 20 OH provider; 46 other private sector
Figure 91: Out-of-hours provision of PEP (5.30 pm to 8.00 am)
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
n = 113 NHS; 22 other public sector; 20 OH provider; 46 other private sector
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Figure 92: Time taken between needlestick injury and worker being seen by OH professional (NHS only)
40 35 30 25 Per cent 20 15 10 5 0 <1 1 to 2 3 to 6 7 to 24 >24 Dont know
Average time in hours
102
Results 6: Role in OH policies and policy development

Respondents were asked to state whether or not their organisation had a policy covering various areas of OH practice and, if so, whether they had a lead, support or negligible role in the development and/or delivery of that policy.
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.
Figure 93: Medical confidentiality and health data security policy
45 40 35 30 25 Per cent 20 15 10 5 0 Lead Support None/negligible No policy Dont know
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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Figure 94: Sickness absence policy
70
60
50
40 Per cent 30
20
10
0 Lead Support None/negligible No policy Dont know
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).
Figure 95: Disability policy
70
60
50
40 Per cent 30
20
10
n = 473
104
Bullying and harassment

Most respondents organisations have a policy on bullying and harassment (4% have no policy). Two-thirds of respondents (62%) have a support role, 5% a lead role and 28% no/negligible role (figure 96).
Figure 96: Bullying and harassment policy
70 60 50 40 Per cent 30 20 10 0 Lead Support None/negligible No policy Dont know
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.
Figure 97: Stress policy
50 45 40 35 30 Per cent 25 20 15 10 5 0 Lead Support None/negligible No policy Dont know
n = 473
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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.
Figure 98: Manual handling policy
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).
Figure 100: Health and safety policy
70 60 50 40 Per cent 30 20 10 0 Lead Support None/negligible No policy Dont know
n = 473
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Figure 100: RIDDOR policy
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).
Figure 101: Bloodborne virus policy
40 35 30 25 Per cent 20 15 10 5 0 Lead Support None/negligible No policy Dont know
n = 473
107
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.
Figure 102: Substance misuse policy
50 45 40 35 30 Per cent 25 20 15 10 5 0 Lead Support None/negligible No policy Dont know
n = 473
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Results 7: Clinical governance

Respondents were asked to rate various areas of OH nursing practice within their organisation as excellent, satisfactory or unsatisfactory. The ratings for 10 generic performance indicators are shown in tables 70 to 79, with separate scores given for all respondents and by sector. Tables 7079 also show the mean scores and standard deviations according to the arbitrary rating: +1 = excellent; 0 = satisfactory; -1 = unsatisfactory. These calculations give a general idea of whether OH nurses rate the performance higher (positive mean scores) or lower (negative scores). The all-sector responses are shown in figures 103105, which have been grouped according to the mean overall performance ratings. Nurses tend to rate their organisations OH nursing practice highly on access to occupational physicians (90% of respondents rate the performance as excellent or satisfactory; 9% as unsatisfactory), ethics (91% excellent or satisfactory; 7% unsatisfactory), evidence-based practice (88% excellent or satisfactory; 10% unsatisfactory) and opportunities for professional development (79% excellent or satisfactory; 20% unsatisfactory) (figure 103). The ratings are not quite so good for peer support and mentoring (70% excellent or satisfactory; 27% unsatisfactory), legal support (71% excellent or satisfactory; 27% unsatisfactory) and clinical supervision (66% excellent or satisfactory; 32% unsatisfactory) (figure 104). The lowest scores are for strategic planning (62% excellent or satisfactory; 32% unsatisfactory), service delivery auditing (62% excellent or satisfactory; 36% unsatisfactory) and opportunities for trainee OH nurses/interns (55% excellent or satisfactory; 42% unsatisfactory) (figure 105). There are few meaningful differences between sectors, though other public sector respondents tend to mark their practice down compared with the overall response (tables 7079). Half (50%) of the public sector respondents describe service delivery auditing as unsatisfactory, compared with 31% to 37% in the other sectors; just 11% of public sector respondents describe this aspect of their practice as excellent (all-sector average = 21%). A slightly higher percentage (35%) of respondents from the public sector described peer support and mentoring as unsatisfactory, compared with 27% for the overall mean. Similarly, 36% of other public sector respondents describe legal support as unsatisfactory, compared, for example, with 21% of the other private sector. And just 11% of the public sector respondents described clinical supervision as excellent (all-sector mean = 18%). The other public and other private sectors were marginally ahead on scores for opportunities for professional development (41% and 42% respectively said it was excellent) compared with the NHS and commercial OH providers (34% and 33%). NHS respondents reported better opportunities for trainee nurses, compared with the other sectors (table 79). A limited number of additional cross analyses were made.
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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.
Rating of clinical governance by sector

Table 70: Access to occupational physician (% 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
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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Table 71: Ethics (% 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
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
Table 72: Evidence-based practice (% responses and mean ratings)

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)
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
Table 74: Peer support/mentoring (% responses and mean ratings)

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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Table 75: Legal support (% responses and mean ratings)

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
Table 76: Clinical supervision (% responses and mean ratings)

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
Table 77: Strategic planning (% responses and mean ratings)

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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Table 78: Service delivery auditing (% responses and mean ratings)

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)
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
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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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Clinical governance Impact of working alone or as part of a team

Table 83: Evidence-based practice
Lone worker % Excellent (+1) Satisfactory (0) Unsatisfactory (-1) Not stated Mean rating* Standard deviation Part of a team %
40 54 5 1 0.36 0.57
34 53 12 1 0.22 0.64
Table 84: Clinical supervision

Lone worker % Excellent (+1) Satisfactory (0) Unsatisfactory (-1) Not stated Mean rating Standard deviation Part of a team %
15 50 31 5 -0.17 0.68
18 49 31 2 -0.13 0.70
Table 85: Strategic planning

Lone worker % Excellent (+1) Satisfactory (0) Unsatisfactory (-1) Not stated Mean rating* Standard deviation Part of a team %
15 50 34 1 -0.19 0.68
16 50 32 1 -0.16 0.68
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Table 86: Ethics

45 48 7 0 0.37 0.62
41 50 7 2 0.35 0.61
Table 87: Access to occupational physician

60 31 9 0 0.50 0.66
59 32 8 1 0.52 0.64
Table 88: Opportunities for professional development

35 46 20 0 0.15 0.72
40 39 21 1 0.19 0.76
Table 89: Service delivery auditing

19 35 46 1 -0.27 0.76
18 48 33 1 -0.15 0.70
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Table 90: Peer support and mentoring

17 47 33 4 -0.17 0.70
29 47 23 1 0.07 0.72
Table 91: Legal support

22 49 29 0 -0.07 0.72
20 51 27 2 -0.07 0.69
Table 92: Opportunities for trainee nurses/interns

6 30 57 7 -0.56 0.61
27 38 34 2 0.08 0.78
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Figure 103: Clinical governance in OH nursing practice I good performers
60
50
40
Per cent 30
20
10
0 Access to occupational physician Ethics Evidence-based Professional development
Excellent
Satisfactory
Unsatisfactory
Figure 104: Clinical governance in OH nursing practice II mixed performers
60 50 40
Per cent 30 20
10 0 Peer support Legal support Clinical supervision
Excellent
Satisfactory
Unsatisfactory
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Figure 105: Clinical governance in OH nursing practice III poor performers
50 45 40 35 30 Per cent 25 20 15 10 5 0 Strategic planning Service auditing Opportunities for trainee nurses
Excellent
Satisfactory
Unsatisfactory
Occupational health support for the OH team

Respondents were asked to state who provides OH support for the members of the OH team: in-house; independent OH provider; or no provision. Figure 106 shows the all-sector response, with almost a third (31%) having no provision and only 27% having independent OH support. Two-fifths (42%) of respondents rely on the in-house OH team for their OH support. NHS respondents were least likely to report that they did not have access to OH provision 20% said there was no provision, compared, for example, with 35% of commercial OH providers and 36% in the other private sector. Nearly half (47%) of NHS respondents report that they rely on in-house OH provision for their own OH support. Nearly half (45%) of self-employed OH nurses have no access to OH support, though 36% use an independent provider.
Figure 106: OH support for OH team (all sectors)
No provision
In-house
Independent provider
In-house provision Independent provider No provision
42% 27% 31%

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Figure 107: OH support for OH team (by sector)
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
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.)
Figure 108: OH support by sole practitioner or part of OH team
50 45 40 35 30 Per cent 25 20 15 10 5 0 Lone practititioner Part of OH team
In-house
No provision
Not stated
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Competence of occupational medicine

Respondents were asked to rate the general level of occupational medicine competence that they have access to: excellent, satisfactory, unsatisfactory or non-existent. The vast majority (96%) of respondents report that they have access to occupational medicine (figure 108). A large majority of respondents (87%) rate the occupational medicine competence as either excellent (46%) or satisfactory (41%). There is little variation between sectors (figure 109). Table 83 also shows the mean scores and standard deviations according to the arbitrary rating: +1 = satisfactory; 0 = satisfactory; -1 = unsatisfactory. Positive mean scores, suggesting a generally high rating, were found across all sectors.
Figure 109: Occupational medicine competence (all sectors)
50 45 40 35 30 Per cent 25 20 15 10 5 0 Excellent Satisfactory Unsatisfactory Non-existent
Figure 110: Occupational medicine competence (by sector)
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
n = 469; four respondents did not answer the question
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Table 93: Rating of occupational medicine competence

Sector Excellent (+1) Satisfactory (0) Unsatisfactory (-1) Non-existent Dont know Mean rating* Standard deviation All sectors Commercial OH provider Other private sector NHS Other public sector Self-employed
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
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Results 8: Core competences

The final item on the survey questionnaire invited respondents to give an open response to the question: What do you think is the most important competency of an OH nurse, and why? Of the 394 responses, by far the most common theme was that of communication and listening, mentioned by 129 respondents (33% of the total). This was followed by interpersonal skills, indicated by 47 respondents, which is perhaps another way of describing the same attribute. The full list of responses is given in table 94. The importance of communication was exemplified in some of the specific comments: Excellent communication skills ability to communicate at all levels and make good use of the pivotal role of an OH nurse OH adviser, NHS Effective communication skills to enable the OH adviser to communicate effectively with the customer and the OH organisation in order to deliver a professional standard of service regional OH adviser, commercial OH provider Another nurse explained the importance of interpersonal skills: Interpersonal and influencing skills. Technical skills will only be applied if you can get heard! group OH and safety manager, private sector One respondent explained the reasoning behind knowledge as the most essential competency: Knowledge such a diversity of illnesses and individual needs. Understanding the impact of these on a persons capabilities OH nurse adviser, NHS Other comments included appropriate updating of skills, hands-on experience, common sense, and tact, knowledge, competence and diplomacy.
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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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Results 9: Focus group

Around 50 delegates at the RCN/SOHN annual conference took part in a focus group discussion of the survey results. There was some debate on the survey itself, with a number of nurses commenting that they found difficulty in completing certain items of the questionnaire because of their responsibility to more than one organisation. Turning to the survey findings, discussion focused on three themes: qualifications and education; manpower; and perceptions of service delivery.
OH education and qualifications

The focus group considered the question: should there be a minimum level of qualification in order to practice as an OH nurse? If so, how could this be achieved? One delegate said that the requirement to be fully OH-qualified would depend on the nature of the work and depended particularly on whether or not the OH nurse in question had access to other OH expertise. It depends on whether you are working in isolation or whether you are working as part of a larger team where you have access to other qualified nurses, she said. Another delegate said that it wasnt always easy for nurses to become qualified in occupational health, particularly when nurses are funding their own training. He cautioned against what he saw as an exclusive focus on degree-level qualifications and called for more training courses at all levels. Lets have a stepwise approach so someone can come in [to OH] with basic state registration, do certain courses to move up to certificate or diploma status. We can all aim for the degree but lets not inhibit people trying to get on through a different route. Another delegate agreed that the profession was moving too quickly towards a degree-only approach. While she wanted to encourage more nurses to take degrees, this should not be the only approach. Im a programme organiser at a university and if [the students] go on to do a degree and an MSc thats fantastic, but what I want to do is give them the confidence Some of them would be terrified doing a degree. At least a diploma having 11 competences gives them confidence and I hope that it will inspire them to go on and do further study afterwards and thats what education should be about. Another delegate complained that too many jobs demanded an OH degree and that this discriminated against some of the older nurses in the profession who did not come through this academic route. Do I need or want to be taking on another level of study? she asked. This was echoed by a delegate who called for greater focus on vocational training. I think we are getting bogged down in certificates, diplomas and degrees. We need to look at the core competences to see what we would expect of an occupational health nurse, she said.
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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
126
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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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.
The role and required competences of OH nurses

International work to scope and define occupational health covers the role and required competences of occupational health nurses (OH nurses). OH nurses are often the first point of contact for many users of OH services, and perceptions of their role can appear anachronistic. Employers and employees are more familiar with the role of the OH nurses than the occupational physician, and OH nurses are perceived to have a more caring than diagnostic role (OHara et al, 2004). OH nurses are the most frequently used professionals, before physicians and GPs. They are seen by users as sources of comfort and sympathy, but are also viewed as competent to deal with health screening and the treatment of injuries. They are considered approachable and accessible, and cheaper than physicians. But nurses are not considered to be familiar with employers needs and have a lower status than other professionals, so there is also scope for their value to be undermined. Employers see an overlap between the two roles of nurse and doctor and believe there is a need to differentiate them more clearly.
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Performance indicators and benchmarking in OH nursing Literature review
Role of the OH nurses

The most detailed attempt to describe the role of OH nurses in workplace health management was undertaken by the WHO regional office for Europe in 2001 (Whitaker and Baranski, 2001)). OH nurses fulfil several, related and complimentary roles in the workplace, including those of clinician, specialist, manager, coordinator, adviser, health educator, counsellor and researcher. The OH nurse is a unique front liner and gets approached for help and advice on a range of issues that extend beyond traditional work health and safety ones (for example, the health of workers spouses). These may be beyond an employers duty of care, but could affect the workers ability to concentrate, attend or be productive. OH nurses are often on site and accessible providing opportunities for early intervention. Although roles differ between EU countries, the broad thrust of developments in recent years is the same that is, a move away from the OH nurse acting as a doctors assistant towards a position where s/he works as an independent, autonomous professional, responsible and accountable for their own professional practice. Drawing up core activities and tasks is not easy OH nurses are constantly learning new skills, adapting current practices and developing new approaches to problems. Their roles also vary with the needs of the employing organisation, with the expectations of management, and with the ability of the organisation to use the full range of expertise possessed by the OH nurses. (The WHO has produced guidance on how to determine the function of an OH nurse in an individual organisation, including the need to identify goals for the service and matching resources to achieving these goals. These form part of the document on the role of the OH nurse.) OH nursing practice is not static but is based on a core range of skills according to the different roles being performed: Clinician: primary prevention: including formulating plans to modify working environments, systems of work, or change working practices in order to reduce the risk of hazardous exposure. Because of their proximity to workers, and their knowledge and experience of the working environment, OH nurses are in a good position to identify early changes in working practices, and to identify workers concerns over OH. OH nurses can present these concerns to management in an objective, independent way, which can act as a catalyst for changes in the workplace; emergency care: the OH nurse is a registered nurse with clinical experience and may provide initial emergency care in cases of workplace accidents. This is likely to be a large part of the job in sectors/areas that are remote from emergency services (for example, oil rigs), or where hazardous conditions exist at work; treatment services: often in conjunction with other primary care workers, such as a family doctor or OH physician;
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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
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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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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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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.
Source: Whitaker and Baranski, 2001
Competences of the OH nurse

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 (WHO, 2003). This could form a valuable model for a framework in the UK. Key principles for the training and practice of OH nurses are: 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 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.
Provision and delivery of occupational health

UK-wide provision
A 2002 study concludes that only 14.9% of all UK employers provide a basic occupational health service, using a broad definition drawn up by the Health and Safety Executive (HSE). This broad definition of an OH service includes hazard identification, risk management and the provision of health information. Only 3.3% of employers provide a more comprehensive range of interventions, including the modification of work activities, training on health-related issues, the
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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:
Table 95: Occupational health provision by employer size

OH support Micro (%): (broad/stringent definition) Small (%): (broad/stringent definition) Medium (%): (broad/stringent definition) Large (%): (broad/stringent definition)
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
Source: Pilkington et al, 2002.
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.
OH provision in the NHS

Three studies of OH provision for NHS staff paint a variable picture of the development of the service since the late 1990s:
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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.
Small and medium-sized employers

Many recent initiatives in the area of widening access to OH have focused on one particular group of hard-to-reach employers small and medium-sized enterprises (SMEs). Research in 2001 (Bradshaw et al, 2001) suggests that 14.4% of small employers use the services of a part-time OH physician; that 7.2% employ a health and safety adviser; and that 10.8% use a part-time OH nurse. A quarter of SMEs nominate a person in the company to have responsibility for OH issues, and 67% believe that a doctor or nurse is the best person to provide an OH service. In terms of OH activity, 28% carry out pre-employment screening and 14.2% carry out health promotion. Just over half collect health-related absence data. Managers in many SMEs are confused over 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. This reflects the findings for micro/small employers in the HSE research conducted in 2001. Researchers seeking to undertake studies of SMEs and OH encounter great difficulties in securing this sectors involvement and participation. OH provision in SMEs: I only three out of the 28 SMEs in the 2001 research (Bradshaw et al, 2000) had a written OH policy; I the use of OH professionals varied significantly, for example, one employer used a consultant for only one session every two years; I employers have low levels of awareness of the qualifications held by the OH professionals they use, for example, only one manager in the study of 28 organisations was aware that their OH physician was an AFOM;
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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.
Table 96: Small employers attitudes to the provision of OH

Statement We are constantly on the lookout to improve the health of our employees We recognise occupational health is important, but it is not a major priority We provide measures required by law, but not much beyond that Health issues are not really relevant to us No. (%) employers agreeing
6 (21.4%) 14 (50%) 2 (7.1%) 1 (3.5%)
Source: Bradshaw et al, 2001
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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Accepted standards and performance measures for OH

Definitions of OH activities
Various bodies, including the World Health Organisation (WHO), the International Labour Office (ILO), and the medical schools and government agencies of individual states, have sought to draw up recommended elements for an occupational health service in recent years. A number of studies exploring the OH needs and priorities of stakeholders use the Occupational health services convention and recommendation published by the ILO in 1995, which is summarised below:
Table 97: Elements of an OH service

Surveillance of individuals health in relation to work: Provision of curative services for occupational diseases/accidents: Provision of general healthcare services: Securing future working environment: pre-employment health examination periodic health examination of all workers specific examination of selected groups of workers diagnosis and treatment of occupational diseases treatment and first aid for occupational accidents rehabilitation and resettlement of employees with diseases diagnosis and/or treatment of non-occupational diseases vaccination of employees strategies of occupational health programmes the planning of new or changed workstations/practices/ work organisation walk through surveys with guidance/checklists risk assessment of chemical/physical/ergonomic hazards psychological/psychosocial assessments ergonomics/climate/dust exposure/chemical hazards/noise personal protective equipment general health information to the workers information about healthy lifestyle/health promotion information/training in first aid
Surveillance of the current working environment:
Advice on the control of hazards at work: Health education and health promotion:
Source: ILO, 1995
Employer and employee OH priorities

Employers, employees and other stakeholders in an OH service have different, but overlapping needs in a workplace health service, and attach different priorities to occupational health generally. For example, a study of the Irish civil service finds that more HR managers than employees perceive OH as important or very important (Reid and Malone, 2003). HR managers prioritise OH functions connected with assessing fitness for work (for example, pre-employment health assessments), whereas employees see the preventative role of OH departments as more important (for example, medical screening, health education and medical surveillance).
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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):
Table 98: Most valued functions of an occupational health unit

Function General medical screening Occupational health education General health education Medical surveillance Research Ill-health retirement assessments Pre-employment/promotional medical assessments Return-to-work (after sick leave) assessments HR managers ranking Employees ranking
1 2 3 4 5 6 7 8
7 2 3 6 8 4 1 5
Source: Reid and Malone, 2003
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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I research methods I health promotion I management
Source: Reetoo et al, 2004
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.
Table 99: Different quality criteria, according to stakeholder demands/needs

Stakeholder Structure Process Outcome
OHS professionals Employees
Premises; equipment; staff Accessibility; continuity; acceptability Efficiency; safety
Professional performance Communication; information Referrals; prescriptions; tests Adaptability; flexibility; speed
Clinical data; morbidity; mortality Quality of life; satisfaction
OHS managers
Costs; complaints; incidents
Employers
Costs-benefit; validity for reimbursement or lower EL premiums Cost-benefit; coverage; legislation
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
Evidence based judgements
Source: MacDonald et al, 2000
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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Performance indicators and benchmarking in OH nursing References
APPENDIX 1
The performance indicators questionnaire
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Performance indicators and benchmarking in OH nursing Appendix
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Performance Indicators

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PERFORMANCE INDICATORS AND BENCHMARKING IN OH NURSING

Performance indicators and benchmarking in occupational health nursing

John Ballard Sarah Silcox Paul Suff

The At Work Partnership

PERFORMANCE INDICATORS AND BENCHMARKING IN OH NURSING

Introduction and background Methods

Results and analysis

Results 2: OH functions and competences

Results 3: Role and competence

PERFORMANCE INDICATORS AND BENCHMARKING IN OH NURSING

Results 4: Generic OH nursing skills

Results 5: OH performance indicators

Results 6: Role in OH policies and policy development

Results 7: Clinical governance

Results 8: Core competences Results 9: Focus group

Discussion Literature review

Provision and delivery of occupational health

Accepted standards and performance measures for OH

Performance indicators and benchmarking in OH nursing Contents

Box 1: Essential OH nursing functions (all sectors)

Box 2: Comprehensive provision of OH services (all sectors)

Role and competence

OH policies and policy development

INTRODUCTION AND BACKGROUND

SOHN conference and performance indicators workshop

RESULTS AND ANALYSIS

Figure 1: Employers business

40% 35% 30% 25% 20% 15% 10% 5% 0%

20% 38% 28% 16% 2%

Note: some respondents work in more than one sector

Figure 2: Job title

45 40 35 30 25 Per cent 20 15 10 5 0 OH adviser/nurse adviser OH manager OH nurse OH sister Other/unstated

Figure 3: Working alone or part of an OH team

80 70 60 50 Per cent 40 30 20 10 0 Sole OH practitioner Part of OH team

Note: figures based on 412 respondents answering the question

Figure 4: Full time or part time

Figure 5: Contracted working hours

Per cent 40 30 20 10 0 less than 20 hours 21 to 30 hours more than 31 hours

Figure 6: Respondents OH qualifications

Figure 7: Responsibility for more than one place of work

Don't know/not stated

Table 1: OH provision by sector: full-time and part-time nurses

6.14 2.94 4.55*

2.24 1.01 1.60*

0.73 0.25 0.42

0.65 0.43 0.53

0.98 0.5 0.79

1.24 0.63 1.00

0.19 0.06 0.10

0.11 0.06 0.10

3.17 1.68 2.53

Table 2: OH provision by sector: full-time equivalents

75 146 127 68 416

4.79* 2.96 4.83 2.26 3.66*

1.43* 0.90 1.63 0.68 1.18*

0.42 0.20 0.61 0.22 0.36

0.41 0.39 0.51 0.37 0.42

1.19 0.49 0.76 0.41 0.64

1.02 0.84 1.08 0.51 0.88

0.13 0.05 0.16 0.06 0.09

0.16 0.10 0.10 0.04 0.09

2.92 1.86 2.61 1.40 2.12

Table 3: Ratio of nurses working in OH capacity per 1,000 employees