A report conducted by the At Work Partnership for the Royal College of Nursing Society of Occupational Health Nursing

Transcription

1 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 25

2 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 25 The At Work Partnership Ltd 19 Bishops Avenue Elstree Hertfordshire WD6 3LZ info@atworkpartnership.co.uk

3 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 HSE s 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 joint initiatives have included research sponsored by the healthcare group AXA PPP. For further information, 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.

4 PERFORMANCE INDICATORS AND BENCHMARKING IN OH NURSING 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 Conclusions iii iii iii iii v vii viii xi xii xiii xv Introduction and background 1 Methods Questionnaire 3 Survey analysis 4 SOHN conference and performance indicators workshop 4 Results 1: General information 5 Physicians in the workplace 11 OH facilities 13 Out-of-hours cover 14 OH support for off-site and home workers 15 Results 2: OH functions and competences 16 Attendance monitoring 16 Return-to-work interviews 18 Home/off-site visits to workers on sick leave 21 Disability assessments and adjustments 23 Vocational rehabilitation 25 Analysis of pre-employment/pre-placement questionnaires 27 Assessment of fitness for work 3 Developing fitness-for-work standards 32 Health surveillance provision and interpretation of health surveillance 34 Health and safety risk assessment 38 Assessment of risks to mental health (including stress) 4 Advising on work organisation and design 42 Provision of personal protective equipment 45 Monitoring work-related accident, injury and illness data 47 Cost benefit analysis of OH interventions 49 Display screen equipment assessments 51 Sharps/needlestick prevention and management 53 Immunisation 55 Travel health advice 57 Provision of training and education (eg manual handling) excluding first aid 6 Organisation of first aid and first-aid training 62 Provision of confidential counselling 64 General health and wellness screening 66 Interpreting and advising on OH law 68 Confidential handling of health and personal data 7 Results 3: Role and competence 7 Essential services and level of provision 75 Essential services and OH nursing competence 83 i Contents

5 PERFORMANCE INDICATORS AND BENCHMARKING IN OH NURSING Results 4: Generic OH nursing skills 85 Research skills and awareness 85 Team working 85 Budget management 86 Resource management 87 Leadership skills 87 Interpreting developments in OH practice 88 Communication with clients and OH colleagues 89 Conflict management 9 Presentation skills 9 Coaching/mentoring 91 Clinical supervision 91 Importance rating and competence 92 Results 5: OH performance indicators 95 Management OH referral times 95 Fitness-for-work reports 95 Time taken to be seen by external specialist 97 Provision of post-exposure prophylaxis 1 Results 6: Role in OH policies and policy development 13 Medical confidentiality 13 Attendance 13 Disability 14 Bullying and harassment 15 Stress 15 Manual handling 16 Health and safety and the reporting of injury and illness data 16 Bloodborne viruses 17 Substance misuse 18 Results 7: Clinical governance 19 Occupational health support for the OH team 119 Competence of occupational medicine 121 Results 8: Core competences 123 Results 9: Focus group 125 OH education and qualifications 125 Manpower: is there an ideal ratio between the number of OH nurses and the number of employees in an organisation? 126 The balance between what customers expect from the OH service and what OH practitioners perceive as essential 127 Discussion 128 Literature review Aims and objectives 129 The role and required competences of OH nurses 129 Role of the OHN 13 Competences of the OHN 134 Provision and delivery of occupational health 136 UK-wide provision 136 OH provision in the NHS 138 Small and medium-sized employers 141 Multi-national organisations 142 Accepted standards and performance measures for OH 144 Definitions of OH activities 144 Employer and employee OH priorities 144 Benchmarking OH performance 146 Developing competences in OH 147 Summary of sources 15 References 156 Appendix The performance indicators questionnaire 157 ii Contents

6 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 24. 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 s: commercial OH providers; other private ; NHS; other public ; 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 24. Survey findings General information Survey and response A total of 473 OH nurses responded to the survey (24% response). Employment s Responses came from all employment s: 2% commercial OH provider; 38% other private ; 28% NHS; 16% other public ; 2% self-employed (some respondents worked across more than one ). The survey covers organisations that employ, in total, nearly 2.2 million people. The median size of employer in the survey is 1,8 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

7 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 s 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 (just over two FTE nurses per place of work). The data gives crude estimates of roughly one nurse working in OH for every 1,14 employees, or one FTE for every 1,42 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 1,76 employees, or one FTE per 2,92 employees. Overall, there is around one fully qualified OH nurse for every 2,5 employees, or one FTE per 2,45 employees. The NHS employs the highest ratio of OH nurses per employee (1.28 nurses per 1, staff), with the other public the lowest ratio (.52 per 1,). 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 s, there are around.32 FOM-qualified OH physicians per 1, employees highest in the commercial OH providers (.51 per 1, employees) and lowest in the other private (.25 per 1,). There are around.2 FTE qualified OH physicians per 1, employees across all s. 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.

8 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 OH departments are much more likely than those in the public to offer a comprehensive attendance monitoring service. However, private respondents are also much more likely to rate such a service as essential than are their public 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 ). 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 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; 8% 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 are less likely to report a comprehensive service. Health surveillance Nearly all services across all s 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 9% 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 respondents describe the service as comprehensive. By contrast, 91% of respondents say that provision of mental health risk assessments is essential.

9 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 OH services monitor such data more than in the other s and 7% of respondents in that say that this function is essential. Cost benefit analysis Just over half (57%) of respondents say that their service carries out cost benefit analyses of OH interventions, with most of those that do offering only basic provision. By contrast, 9% 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 services offer at least some level of provision, while no service is offered in 43% of commercial OH providers and 36% of other private employers. Provision of immunisation is virtually universal among NHS respondents (85% comprehensive, 9% basic). More than half (53%) of other public 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. Nearly two-thirds of commercial OH providers (63%) and other private 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 (53%). Private respondents are also more likely to rate this function as important than their public 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 s. 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 (69%) than in either the commercial OH providers (46%) and other private (52%). More than two-thirds

10 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 s 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 cost benefit 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 cost benefit of OH interventions, yet 5% 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 s, both in terms of provision and perceived

11 importance. There are some difference between s. Notably, sharps and needlestick prevention and management is ranked as the fourth most important service in the NHS, but 2th by respondents from commercial OH providers. Box 1: Essential OH nursing functions (all s) 1 Confidential handling of health and personal data (95%) 2 Assessment of fitness for work (88%) 3 Delivering health surveillance (84%) 4 Interpretation of health surveillance (84%) 5 Disability assessments and adjustments (81%) 6 Assessing risks to mental health (81%) 7 Analysing of pre-employment/preplacement questionnaires (77%) 8 Interpreting and advising on OH law (76%) 9 Developing fitness-for-work standards (71%) 1 Confidential counselling (68%) 11 Health and safety risk assessment (66%) 12 Sharps/needlestick prevention and management (63%) 13 Display screen equipment assessments (62%) 14 Vocational rehabilitation (61%) 15 Advising on work organisation and design (59%) 16 Delivering return-to-work interviews (58%) 17 Monitoring work-related accident, injury and illness data (58%) 18 Attendance monitoring (53%) 19 Provision of training and education (53%) 2 Immunisation (5%) 21 Cost benefit analysis of OH interventions (5%) 22 Organisation of first aid and first-aid training (44%) 23 Provision of personal protective equipment (44%) 24 General health and wellness screening (39%) 25 Travel health advice/provision (25%) 26 Home/off-site visits to workers on sick leave (23%) Note: the figures show the percentages of OH nurses who rate each function as essential Box 2: Comprehensive provision of OH services (all s) 1 Confidential handling of health and personal data (88%) 5 Interpretation of health surveillance (73%) 9 Interpreting and advising on OH law (49%) 2 Assessment of fitness for work (84%) 6 Disability assessments and adjustments (64%) 1 Developing fitness-forwork standards (47%) 13 Immunisation (46%) 14 Health and safety risk assessment (43%) 17 General health and wellness screening (41%) 21 Advising on work organisation and design (33%) 25 Travel health advice/provision (24%) 18 Organisation of first aid and first-aid training (39%) 22 Provision of training and education (31%) 26 Cost benefit analysis of OH interventions (21%) 3 Analysing of pre-employment/preplacement questionnaires (8%) 7 Display screen equipment assessments (62%) 4 Delivering health surveillance (74%) 8 Confidential counselling (57%) 11 Vocational rehabilitation (47%) 12 Delivering return-to-work interviews (47%) 15 Sharps/needlestick prevention and management (43%) 16 Assessing risks to mental health (42%) 19 Attendance monitoring (38%) 2 Monitoring work-related accident, injury and illness data (37%) 23 Provision of personal protective equipment (26%) 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 cost benefit 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: at least 7% excellent confidential handling of health and personal data; analysis of preemployment/pre-placement questionnaires

12 5% 69% excellent assessment of fitness for work; delivering health surveillance; display screen equipment assessments; interpretation of health surveillance 3% 49% excellent 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 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; cost benefit 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: at least 7% lead role confidential handling of health and personal data; analysis of preemployment/pre-placement questionnaires; assessment of fitness for work 5% 69% lead role delivering health surveillance; interpretation of health surveillance; general health and wellness screening 3% 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 less than 3% 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; cost benefit 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

13 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, 6% 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 cost benefit analysis of OH interventions as excellent, yet 5% 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.

14 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.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 1 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 one s own limitations; teamwork; and evidence-based practice.

15 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 6.5 days slowest in the NHS (8.2 days) and quickest in the other private (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 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 and other public 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 1 days. Reports and external consultations Fitness-for-work reports take on average 3. days to be delivered from the time the worker has seen the OH professional (mean across all s). There is relatively little variation between s. 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 ). 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 7% of respondents); time taken by employee s 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 (1%). Post-exposure prophylaxis Respondents who work within either the healthcare 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 5.3 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.

16 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 (3% 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 (5% support, 22% lead, 18% no role). Clinical governance Performance ratings Respondents were asked to rate 1 areas of OH nursing practice within their organisation as excellent, satisfactory or unsatisfactory. These were then scored according to an arbitrary rating +1 = excellent; = satisfactory; -1 = unsatisfactory. A score of zero suggests, on average, that the performance is satisfactory, less than zero suggests that improvements are needed. The 1 performance areas are ranked in descending order access to occupational physicians +.34 ethics +.25 evidence-based practice

17 +.18 opportunities for professional development -.2 peer support and mentoring -.8 legal support -.14 clinical supervision -.17 strategic planning -.18 service delivery auditing -.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 +.7; for those working alone it is Nurses working as part of a team are more likely to rate opportunities for trainee nurses as good (score = +.8) than are OH nurses working alone (score = -.56). Opportunities for professional development are similar for both lone and team workers. There are few meaningful differences between s though there appear to be more opportunities for trainee OH nurses within the NHS (score = +.1), compared with the all- score (score = -.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 s. Using the arbitrary scoring system above, occupational medicine competence is given an average score of +.38 (ranging from +.33 to +.42 between s). 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).

18 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 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 s, 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 s, and evidence that OH providers, educators and policymakers can consider when deciding how to address gaps in OH nursing provision.

19 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: a literature search to set the findings in context a questionnaire-based survey of 2, practising occupational health nurses, stratified by, region and size of service, to establish service delivery benchmarks and draft performance indicators a workshop at the RCN Society of Occupational Health Nursing annual conference in November 24, 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 Office s (NAO) 23 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, 23). 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

20 percentage of employers (15%) provide access to some kind of OH support (Pilkington and Graham, 22). 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 of this report. 2 Performance indicator and benchmarking in OH nursing Introduction and background

21 METHODS Questionnaire A 29-item questionnaire was sent to 2, OH nurses taken from the RCN Society of Occupational Health Nursing (SOHN) membership database with freepost return envelopes. They were mailed in October 24. 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: general information about the respondent (job title, formal qualifications, years OH experience, employer s business) 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) availability of OH nursing services and competences for various generic OH services (eg basic/comprehensive/non-existent) rating of the importance of the generic services (essential/desirable/nil or negligible) respondent s role in delivery of the generic services (lead/support/negligible or none) respondent s level of competence in delivering the generic service (excellent/satisfactory/ unsatisfactory) respondent s self-assessment of competence in core OH nursing skills (excellent/ satisfactory/unsatisfactory) and rating of their importance for their work (essential/ desirable/negligible) performance indicators as a function of the time taken to deliver the service (days/ weeks/months) and factors that limit the service delivery role of OH nurse in policy development and delivery (lead/support/negligible or no policy) clinical governance quality of OH nursing practice at respondent s organisation (excellent/satisfactory/unsatisfactory) 3 Methods

22 provision of OH services for the OH professional (in-house/independent provider/none) 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, 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 s and within each. 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 24. 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 Methods

23 RESULTS AND ANALYSIS Results 1: General information Of the 2, questionnaires mailed in October 24, 473 were returned (24% response). Fifty-eight per cent of respondents are from the private, 44% from the public (28% NHS), with 2% describing themselves as self-employed (figure 1). Twenty-one respondents say they work in more than one (the totals thus add up to more than 1%). Of the private respondents, around one-third (34%) are from commercial OH providers. A small minority (4%) work in more than one. Figure 1: Employer s business 4% 35% 3% 25% 2% 15% 1% 5% % Commercial OH provider 2% Other private 38% NHS 28% Other public 16% Self-employed 2% Note: some respondents work in more than one 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 s (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. 5

24 Figure 2: Job title 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 1 and 13% more than 1. 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 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 2 hours or fewer per week; 2% 21 to 3 hours; and 69% 31 hours or more (figure 5). 6