Occupational Health

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

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

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

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

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

Changing nature of working life and the new challenges

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

The Need for Workplace Management

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

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

Workplace Health Management

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Workplace Health Management (WHM) There are four key components of workplace health management:

  • Occupational Health and Safety
  • Workplace Health Promotion
  • Social and lifestyle determinants of health
  • Environmental Health Management

In the past policy was frequently driven solely by compliance with legislation. In the new approach to workplace health management, policy development is driven by both legislative requirements and by health targets set on a voluntary basis by the working community within each industry. In order to be effective Workplace Health Management needs to be based on knowledge, experience and practice accumulated in three disciplines: occupational health, workplace health promotion and environmental health. It is important to see WHM as a process not only for continuous improvement and health gain within the company, but also as framework for involvement between various agencies in the community. It offers a platform for co-operation between the local authorities and business leaders on community development through the improvement of public and environmental health.

The Healthy Workplace setting – a cornerstone of the Community Action Plan.

The Luxembourg Declaration of the European Union Network for Workplace Health Promotion defined WHP as the combined effort of employers, employees and society to improve the health and well-being of people at work

This can be achieved through a combination of:

  • Improving the work organization and the working environment
  • Promoting active participation of employees in health activities
  • Encouraging personal development

Workplace health promotion is seen in the EU network Luxembourg Declaration as a modern corporate strategy which aims at preventing ill-health at work and enhancing health promoting potential and well-being in the workforce. Documented benefits for workplace programs include decreased absenteeism, reduced cardiovascular risk, reduced health care claims, decreased staff turnover, decreased musculoskeletal injuries, increased productivity, increased organizational effectiveness and the potential of a return on investment.

However, many of these improvements require the sustained involvement of employees, employers and society in the activities required to make a difference. This is achieved through the empowerment of employees enabling them to make decisions about their own health. Occupational Health Advisors (OHA) are well placed to carry out needs assessment for health promotion initiatives with the working populations they serve, to prioritize these initiatives alongside other occupational health and safety initiatives which may be underway, and to coordinate the activities at the enterprise level to ensure that initiatives which are planned are delivered. In the past occupational health services have been involved in the assessment of fitness to work and in assessing levels of disability for insurance purposes for many years.

The concept of maintaining working ability, in the otherwise healthy working population, has been developed by some innovative occupational health services. In some cases these efforts have been developed in response to the growing challenge caused by the aging workforce and the ever-increasing cost of social security. OHA’s have often been at the forefront of these developments.

There is a need to develop further the focus of all occupational health services to include efforts to maintain work ability and to prevent non-occupational workplace preventable conditions by interventions at the workplace. This will require some occupational health services to become more pro-actively involved in workplace health promotion, without reducing the attention paid to preventing occupational accidents and diseases. OHA’s, with their close contact with employees, sometimes over many years, are in a good position to plan, deliver and evaluate health promotion and maintenance of work ability interventions at the workplace.

Health promotion at work has grown in importance over the last decade as employers and employees recognize the respective benefits. Working people spend about half of their non-sleeping day at work and this provides an ideal opportunity for employees to share and receive various health messages and for employers to create healthy working environments. The scope of health promotion depends upon the needs of each group.

Some of the most common health promotion activities are smoking reducing activities, healthy nutrition or physical exercise programs, prevention and abatement of drug and alcohol abuse.

However, health promotion may also be directed towards other social, cultural and environmental health determinants, if the people within the company consider that these factors are important for the improvement of their health, well-being and quality of life. In this case factors such as improving work organization, motivation, reducing stress and burnout, introducing flexible working hours, personal development plans and career enhancement may also help to contribute to overall health and well-being of the working community.

The Healthy Community setting In addition to occupational health and workplace health promotion there is also another important aspect to Workplace Health Management. It is related to the impact that each company may have on the surrounding ambient environment, and through pollutants or products or services provided to others, its impact on distant environments. Remember how far the effects of the Chernobyl Nuclear accident in 1986 affected whole neighbouring countries.

Although the environmental health impact of companies is controlled by different legislation to that which applies to Health and Safety at work, there is a strong relationship between safeguarding the working environment, improving work organization and working culture within the company, and its approach to environmental health management.

Many leading companies already combine occupational health and safety with environmental health management to optimally use the available human resources within the company and to avoid duplication of effort. Occupational health nurses can make a contribution towards environmental health management, particularly in those companies that do not employ environmental health specialists.

Occupational Health

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It is not possible to describe a highly complex and dynamic process such as occupational health nursing simply in terms of core activities or tasks. Occupational Health Nurse (OHA) are constantly learning new skills, adapting current practices to meet new needs and developing new approaches to solving problems and therefore their practice is not static but is constantly improving based upon a core range of skills.

However, within this limitation it is possible to describe those core areas of knowledge and competence that occupational health nurses use. The following list is not intended to be exhaustive, but rather to give an indication of the wide range of competencies that occupational health nurses demonstrate in practice.

The Clinician

Primary prevention

The OHA is skilled in primary prevention of injury or disease. The nurse may identify the need for, assess and plan interventions to, for example modify working environments, systems of work or change working practices in order to reduce the risk of hazardous exposure. Occupational health nurses are skilled in considering factors, such as human behavior and habits in relation to actual working practices. The nurse can also collaborate in the identification, conception and correction of work factors, choice of individual protective equipment, prevention of industrial injuries and diseases, as well as providing advice in matters concerning protection of the environment. Because of the occupational health nurses close association with the workers, and knowledge and experience in the working environment, they are in a good position to identify early changes in working practices, identify workers concerns over health and safety, and by presenting these to management in an independent objective manner can be the catalyst for changes in the workplace that lead to primary prevention.

Emergency care

The OHA is a Registered Nurse with a great deal of clinical experience and expertise in dealing with sick or injured people. The nurse may, where such duties form part of their job, provide initial emergency care of workers injured at work prior to transfer of the injured worker to hospital or the arrival of the emergency services. In many instances, where hazardous conditions exist at work, or where the workplace is far removed from other health care facilities, this role will form a major part of an occupational health nurse’s job. Occupational health nurses employed in mines, on oil rigs, in the desert regions or in areas where the health care systems are not yet fully developed will be familiar with a wide range of emergency care techniques and may have developed additional skills in order to fulfill this role. For others, who are working in situations where the emergency services are on hand, they may simply provide an additional level of support beyond that provided by the industrial first aider.

Nursing diagnosis

Occupational health nurses are skilled in assessing client’s health care needs, establish a nursing diagnosis and formulating appropriate nursing care plans, in conjunction with the patient or client groups, to meet those needs. Nurses can then implement and evaluate nursing interventions designed to achieve the care objectives. The nurse has a prominent role in assessing the needs of individuals and groups, and has the ability to analyze, interpret, plan and implement strategies to achieve specific goals. By using the nursing process the nurse contributes to workplace health management and by so doing helps to improve the health of the working population at the shop floor level. Nursing diagnosis is a holistic concept that does not focus solely on the treatment of a specific disease, but rather considers the whole person and their health care needs in the broadest context. It is a health based model rather than a disease based model and nurses have the skills to apply this approach with the working populations they serve.

General Health advice and health assessment

The OHA will be able to give advice on a wide range of health issues, and particularly on their relationship to working ability, health and safety at work or where modifications to the job or working environment can be made to take account of the changing health status of employees.

In many respects employers are not solely concerned with only those conditions that are directly caused by work, but do want their occupational health staff to help address any health related problems that may arise that might influence the employees attendance or performance at work, and many employees appreciate this level of help being provided to them at the workplace because it is so convenient for them. In particular the development of health care services to men at work, younger populations and those from ethnic groups can be most effective in reaching these sometimes difficult to reach populations.

Research and the use of evidence based practice

In addition to utilizing information and knowledge produced by research in various fields to support activities that relate to the occupational health component of their role, occupational health nurses will also utilize fully research information available from many fields to help support the general health of the working population.

Specialist

Occupational health policy, and practice development, implementation and evaluation

The specialist occupational health nurse may be involved, with senior management in the company, in developing the workplace health policy and strategy including aspects of occupational health, workplace health promotion and environmental health management. The OH nurse is in a good position to advise management on the implementation, monitoring and evaluation of workplace health management strategies and to participate fully in each of these stages. Possibility to perform that role will depend upon level of nurse education, skills and experience.

Occupational health assessment

OHA’s can play an essential role in health assessment for fitness to work, pre-employment or pre-placement examinations, periodic health examinations and individual health assessments for lifestyle risk factors.

Collaboration with occupational physician may be necessary in many instances, depending upon exiting legislation and accepted practice. The nurse can also play an important role in the workplace where informal requests for information, advice on health care matters and health related problems come to light. The nurse is able to observe the individual or group of workers in relation to exposure to a particular hazard and initiate appropriate targeted health assessment where necessary. These activities are often, but not exclusively, undertaken in conjunction with the medical adviser so that where problems are identified a safe system for onward referral exists.

Health surveillance

Where workers are exposed to a degree of residual risk of exposure and health surveillance is required by law the OHA will be involved in undertaking routine health surveillance procedures, periodic health assessment and in evaluating the results from such screening processes. The nurse will need a high degree of clinical skill when undertaking health surveillance and maintain a high degree of alertness to any abnormal findings. Early referral to an occupational health physician or other appropriate specialist will be the responsibility of the occupational health nurse where any abnormality is detected. The nurse will be involved in supporting the worker throughout any further examination or investigation, and may help to monitor their health on return to work. Once alerted to the possibility of an adverse health effect the occupational health nurse is in a good position to co-ordinate efforts to re-evaluate working practices in order to help protect others who may be similarly affected.