Occupational Health Nursing (Paperback)

Chapter One

Introduction

This chapter covers the key points involved in setting up an occupational health service across a range of settings. A standard ''off-the-shelf'' package cannot be slotted into any organisation - the service will meet the needs of the employer and employee only if care and attention is paid to their particular requirements while implementing the health-related legislation relevant to the workplace in question. A systematic appraisal of the needs of particular organisations is required, which should involve consultation with them. This can be followed by the development of individualised services.

A structured approach is essential when setting up a new service or changing the focus of an existing service, and this chapter gives some guidelines and practical suggestions for achieving this. Good diplomacy and communication skills, coupled with expert knowledge and experience are crucial in establishing a successful occupational health service.

As organisations become leaner and are affected by rising costs, such as employers'' liability costs, sickness absence and claims on pension funds for early retirement due to ill health, they are beginning to look more critically at their occupational health service: how is it resourced, what is it doing and, most importantly, how is it benefiting the organisation? The occupational health department will increasingly be measured in the same way as any other department within the organisation and will have to demonstrate the quality of the service it provides; the speed with which it delivers its service, i.e. responds to its customers; the dependability with which it delivers the service it has promised; the flexibility that may be demanded to respond to the organisation''s changing needs; and the cost of delivering the service.

Understanding Organisations

Most organisations still do not have an occupational health service. Whether you are setting up a new service or changing the focus of an existing one, a structured approach will assist in achieving this.

Organisations may vary in size, culture and structure, but the initial approach to establishing the type of occupational health service appropriate to a particular organisation is often the same. Some essential questions need to be asked to ensure that an occupational health service meets the needs of the organisation. What are the business objectives of the organisation? What are the business objectives of individual departments? What are the key health and safety legislation issues? Are there any litigation concerns? How can employee health affect the foregoing?

It is also important to understand the culture of the company, along with how it is structured to achieve its objectives. The culture of the organisation affects the style of communication - formal written communications or oral contact; the dress code - formal or casual; decisionmaking - whether through committees and senior management or individuals retaining some autonomy; management style - whether they expect obedience or individual initiative; and so on. The culture is also likely to affect the structure of the organisation; it may have many levels of management or it may have achieved a ''flat'' structure. Irrespective of the style of structure, it is important for the occupational health professional to understand the lines and levels of communication.

As already mentioned, it is important that an occupational health service understands and is subject to the same business criteria as the rest of the organisation. All too often an occupational health nurse can be heard to say: ''My manager does not understand what occupational health does!'' Should not that nurse instead be asking, ''Do I understand what the organisation needs?'', it being all too easy simply to implement a programme because ''it seemed like a good idea'' as it follows the broad principles of occupational health. Therefore, it is essential that the setting up of an occupational health service is carefully planned and communicated. This is equally important whether the organisation is a large multinational or a small local family firm, with the approach remaining the same. One approach discussed in this chapter has separate elements involving five stages: assessment, planning and control, endorsement, implementation and monitoring.

Assessment

This is a critical element in the setting-up of an occupational health service, and needs to be carried out by occupational health staff whether they are commencing a new service or taking over or developing an existing one. The staff needs to ascertain where they are now, where they need to be and how they are going to get there. To gain this understanding, many questions need to be asked and a knowledge of the culture of the organisation acquired. This involves much discussion with all areas of the organisation and may be quite time-consuming. It is therefore useful to have a checklist to assist in the process of assessment, and an example can be found in Figure 1.1.

Key Personnel Key personnel must be identified as a priority to ensure that nothing is missed when investigating the needs of the organisation. To assist in this, the construction of a ''family tree'' of the organisation showing the organisational structure can be an invaluable aid; key personnel include the human resources manager, health and safety manager, general manager, reporting manager and union representatives.

Initially, close cooperation is likely to be required with the human resources department to investigate the organisation''s health-related policies, and subsequently to operate effective health-related programmes. Such programmes may include policies on smoking, alcohol and drugs, AIDS and health surveillance. An important issue for most organisations is the absence-management policy, and the way this is operated needs to be established. Is there a formal written policy? Who is responsible for managing it - managers or the human resources department? How is occupational health seen in respect of supporting it? Is the practice of proactive intervention supported?

Early contact with those responsible for health and safety is also necessary to establish the organisation''s approach to health and safety, the existence of health and safety policies, and to provide access to existing risk assessments under health and safety legislation. It may also be necessary to clarify areas of responsibility, as occasionally these may appear to overlap in the areas of safety and occupational health.

For the majority of occupational health services the reporting manager is likely to be within the human resources or health and safety department. In either case it is preferable that this person should be a member of the organisation''s board or have direct access to the board.

Discussions with senior and middle managers provide an opportunity to understand the business objectives of the organisation, and to initiate an understanding with the managers about how an occupational health service can benefit them. Similarly, discussions with union representatives promote an understanding of the benefits that an occupational health service brings to their members. Support from all levels of the organisation is crucial for the success of the occupational health service, and the various expectations need to be identified.

Other personnel within the organisation may also be able to provide valuable information. The wages and/or salaries manager may shed light on absence-recording issues, whereas someone in the insurance or legal department may be able to advise on compensation claims that have been taken against the organisation by employees. This can be an important measurable benefit to the company, as health programmes can be put in place to minimise the risk of claims; for example, if there are claims for noise-induced deafness it is important to ensure that there is a functioning hearing conservation programme in place.

Structure and Demographics of the Organisation The family tree has already been mentioned as a useful tool for providing the occupational health professional with an understanding of the organisation; however, this needs to be broken down further to obtain information about certain specifics of its profile. The family tree includes demographic information such as age, sex and ethnic minority distribution along with the types of workers, i.e. white or blue-collar, and their job categories. Decisions can then be made on the health programmes that will be most suitable and most effective for the organisation, including health surveillance and voluntary health screening programmes. For example, there is little point in investing time and resource in a ''well-woman'' programme if 95% of the workforce is male.

Absence Management It is important to understand how the organisation sees the role of human resources, line managers and the occupational health service in this procedure; therefore, the existence of any formal written policies needs to be established before recommendations can be made. Knowledge of specific details includes: absence statistics and procedures for recording absence; procedures for employees reporting absence; procedures for managing employees on long-term absence (e.g. over two or three weeks); procedures for managing employees with frequent short-term absences; procedures for seeing employees returning to work after absence; procedures for ill-health retirement (discussions will likely need to take place with the pensions manager); and procedures for monitoring work-related illness and injury.

This is an important area for the involvement of the occupational health service, as it can again provide some measurable benefits to the organisation. However, it also has to be recognised that these benefits cannot be delivered by occupational health alone, but only in cooperation with managers and/or human resources departments.

Pre-Employment Procedures An understanding of the organisation''s recruitment procedures is required. In some organisations the process allows forward planning, and the procedure can be well controlled; whereas with others the process may require mass recruitment within 24 hours. The occupational health service must be able to respond to these requirements while ensuring the company is not laying itself open to future litigation related to health issues. Therefore, careful consideration needs to be given to the style of questionnaire to be used, the point at which the prospective employee needs to complete it (before or after a job offer) and who sees it. In addition, the requirement for a full medical examination - depending on whether there are any pension issues involved - or baseline screening needs to be ascertained.

Site Visit The occupational health staff needs to have a good understanding of the working processes of the organisation, which can only be gained through visiting all areas of operation with personnel who understand the process and are able to explain it. Through this, an understanding of the extent of machinery and equipment used on-site, along with any products, is gained, and a start made on determining the presence of health hazards. Where a site is extensive or contains many different processes it is useful to obtain a site plan.

While undertaking site visits, hazard and risk identification may be carried out, along with assessment of compliance with health and safety legislation and good hygiene practice.

Hazard and Risk Identification A structure is provided under the Management of Health and Safety at Work Regulations 1999, which requires all organisations to carry out a general risk assessment to identify health and safety hazards in their workplace. This provides an excellent format for looking in more detail at the health hazards in the workplace and for deciding the requirement for health surveillance, health education and other health programmes. Where risk assessment is not available, the issue of non-compliance must be highlighted to the organisation.

The general risk assessment should highlight the need for further detailed risk assessment under other health and safety legislation, including: Control of Substances Hazardous to Health Regulations 2004; Workplace (Health, Safety and Welfare) Regulations 1992; Health and Safety (Display Screen Equipment) Regulations 1992; Provision and Use of Work Equipment Regulations 1998; and Manual Handling Operations Regulations 1992.

When carrying out a risk assessment it is necessary first to identify the presence of any hazards, which may be chemical, biological, physical, mechanical or psychosocial. Once the hazards have been determined, the risk of their actually causing harm can be assessed - which is where an in-depth understanding of the products and processes is required. If a risk has been established then a full programme must be instigated, starting with elimination of the hazard where at all practicable. The initial part of the programme is likely to be under the control of safety and/or operations staff - where elimination of the hazard has proved impossible this involves control measures, maintenance of control measures, staff training and the monitoring and recording of training, control and maintenance measures. Generally ''historical'' hazards such as noise and asbestos are well controlled, but have been replaced by ''new'' ones such as vibration and stress, for which programmes for control are still being evaluated. Where appropriate, health surveillance is carried out to monitor the health of the employees, which will be managed by occupational health. They may also be involved in training.

Compliance with Health and Safety Legislation All qualified occupational health staff must be fully conversant with current health and safety legislation, so that when carrying out an occupational health assessment they are able to identify where there may be non-compliance and to advise management, particularly in respect of health issues.

Non-compliance may be identified where there is poor hygiene practice, including the non-wearing of personal protective equipment, and lack of warning notices, inadequate training programmes and the absence of risk assessments and safe systems of work.

Reporting of work-related illness and injury under RIDDOR (Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995) is likely to require the input of occupational health. It must be ensured, therefore, that the organisation''s procedure for this includes occupational health.

First Aid In many organisations the management of first aid in the workplace is often the responsibility of the occupational health service, so a full assessment of the current facilities and procedures needs to take place, including whether there is a formal first aid policy in existence. The assessment should look at the following areas in relation to the organisation''s full first aid risk assessment required under the Health & Safety (First Aid) Regulations 1981: the numbers and distribution of first aiders; whether all first aiders are in possession of an up-to-date First Aid at Work certificate; the number and location of first aid boxes and eye-irrigation facilities; the contents of the first aid boxes; the location and contents of a first aid room, if this is required; the procedures for recording the treatment of illness and injury; and the procedures for the disposal of casualties.

Report Once the assessment is completed, a full report needs to be compiled, which forms the baseline for the service and provides the basis for decisions when producing the occupational health strategy. This remains an important historical document, as it provides findings and makes recommendations that, once priorities have been defined, may have to wait for some time before being implemented if resource is limited.

Planning and Control

Some occupational health services within organisations today appear to lack focus, such that resources are often under-utilised or ineffective, leading to a lack of credibility with both senior management and the workforce. This generally derives from a lack of planning and control. Planning is normally the act of setting down expectations of what should happen, whereas control is the process of coping with changes when they occur.

After the assessment has been carried out, and a better understanding of the organisation achieved, the planning stage of the approach to setting up an occupational health service can proceed, which aids decisions on the strategy for the service. This is developed by looking at the available resources and deciding on the service requirements and number and type of customers, so that the service is able to respond to the demand (see Figure 1.2).

Resources This is the most important factor in planning and control, as resources automatically impose constraints on any decision-making. These include numbers of staff, available equipment and the facilities for the occupational health department. When setting up an occupational health service, resources may already have been fixed by the organisation, or else there may be an opportunity to start with a ''clean sheet'', although the former situation is more common. If this is the case then resources are more likely to influence priorities; however, in the case that there is a ''clean sheet'', priorities may be able to influence resources.

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Excerpted from Occupational Health Nursing Copyright © 2008 by John Wiley & Sons, Ltd. Excerpted by permission.
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