Occupational health nurses in the armed forces

Occupational health nurses play a vital part in assessing, rehabilitating and resettling Britain's armed forces. Katie Oakley reports.

On this page:
Role in the forces
Fit-for-role assessment
PULHHEEMS system of medical classification
Regional teams
Assessment and advice
Complex cases
Reconnecting Britain with armed forces
Recovery plan
Nurses' contribution
References.

Occupational hazards do not come much higher than those faced by soldiers - physical, chemical, biological, psychosocial and ergonomic - all the textbook hazards are there. Frequent media reports of fatalities and injuries sustained in Afghanistan and Iraq remind us of the price paid by our armed forces and their families.

We do not hear much about army occupational health nurses, but they are involved in health assessment, rehabilitation and resettlement and in helping soldiers cope with the physical and psychological effects of warfare. And for the right person, the armed services offer a challenging and fulfilling career.

Occupational health nurse practitioner Major Philip Disney-Spiers is based in Merville Barracks, Essex, home of 16 Air Assault Brigade, and joined up as an experienced intensive care nurse in 1995 and was later sponsored to train in OH.

"I am on a full career commission. But as a nurse, doctor, vicar, lawyer, vet, physio or dentist you can join at any age, as long as you commit for six years. I'd been in the Territorial Army for years and decided I wanted to be a regular, so I joined on a short-service commission (three years)," Disney-Spiers explains.

His experiences shed light on the development of the army OH nursing service, its relationships with other health professionals and the impact of military operations.

Before moving into OH, Disney-Spiers' army career included two postings to Bosnia, one to Iraq and a spell in South Africa on Loan Service with the British Military Advisory and Training Team as a staff officer to the SA Army Medical Services.

So, why the move into occupational health? "Having done so much critical care, I wanted to work with well people and keep them well. So I did two years primary healthcare, which I loved, and then the army sent me to do my nurse practitioner degree," he says.

"This was initially a distance learning package with Robert Gordon University, Aberdeen, but I was soon posted to a medical regiment and sent on operation TELIC 1 in Iraq. Rather than put the degree on hold, I took a Dictaphone with me and when I returned I typed up the OH issues I'd been involved with. I then completed my degree full-time.

"I like to see people well and doing well at work physically, and good work is good for you. I'm also interested in the effect of the job on peoples' health," he says.

Role in the forces

Army OH nurses are part of the Army OH Service. The Navy and Royal Air Force also have an OH service. Braithwaite et al (2009) summarise the work of OH armed force services as follows: "While the assessment of fitness to work in home bases and deployed operations remains the primary output of OH, the provision of support to command policy, procurement and research are also key to the ability to operate worldwide."

There are 10 trained Army OHNs; a major for each of the seven army primary healthcare regions; a major and lieutenant colonel at Army Personnel Centre in Glasgow; and a major in Germany. There are two army trainees and two civilian trainees. In total, nine civilian OH nurses work alongside their military colleagues. The RAF also has uniformed OH nurses. The Navy has civilian nurses working in the dockyards.

The army's UK primary healthcare regions each have a regional clinical director and regional health governance. Disney-Spiers is the OH nurse practitioner for eastern region, with a population at risk of about 11,000, whose primary healthcare is provided by 11 Army medical centres. Each medical centre has GPs (Army and civilian), plus civilian and military nurses.

Fit-for-role assessment

Regional OH teams are not responsible for health promotion or pre-recruitment screening, as Disney-Spiers explains, but rather in fit-for-role assessment and rehabilitation, the recovery pathway for trained soldiers.

"Our function involves force health protection and force generation. We're responsible for providing a service to all ranks commissioned and non-commissioned, from private to general, and for providing advice to the chain of command," says Disney-Spiers.

The armed forces have a standard system of medical functional classification PULHHEEMS (see box right). This is supported by force-specific regulations for land, sea and air. Braithwaite et al (2009), in its comprehensive review of OH in the armed services, explains that the PULHHEEMS system (MOD 2006) "is designed to provide a functional assessment of the individual's capacity for work and assist the executive in assigning service personnel to appropriate employment and deploy them on operations".

Regional teams

OH has been enhanced over the years. Where there used to be one staff officer grade 2 - major (SO2) grade in an OH nursing job to advise on employability and deployability to the medical centres and chain of command, there is now an OH team in each region. The eastern region team comprises: consultant OH physician; Disney-Spiers; office manager; two clerks; a civilian nurse (currently sponsored on a day-release nurse practitioner degree); and a healthcare assistant.

Although the unit's main function is to assess fitness for role, every day is different for the major. "I coordinate the activity of the team, liaise with the chain of command and GPs. I'm responsible for ensuring that all the right information is there when we run an OH clinic. I also do workplace assessments. Recently, for example, I was under a vehicle with an engineer assessing how he was working with his neck problem. I love doing graduated return-to-work/civilian life programmes (GROWs)."

Medical centre GPs refer individuals to Disney-Spiers using defence medical information capability programme (DMICP) software. He reviews the referral, books appropriate OH physician clinic appointments and gathers all the information required.

"A difference here from civilian OH is that we have access to the electronic Army primary healthcare notes when someone is referred," says Disney-Spiers. "We provide a joint OH/primary healthcare facility with the Army medical centres, which is also accessed by the mental health teams and physiotherapy."

OH also updates the primary healthcare records. "If a soldier has been sent off to secondary care, say in a local NHS trust, or to the Royal Centre for Defence Medicine at Birmingham or Headley Court, we scan the discharge reports on DMICP."

As well as referrals from GPs, Disney-Spiers receives referrals from the chain of command and reports back following medical assessment. "It depends on their medical grade or joint medical employment standard (JMES), as we call it now."

Assessment and advice

He explains the process. "When the chain of command has someone of a medical grade who they're not sure if they can deploy or where they can deploy him or her to, they ask the OH team for advice. I send an assessment form to the chain of command, they fill out a section saying where the soldier will be going to, what facilities are there and what they'll be expected to do. We look at their functional capacity and decide if they are fit to go, or if they can go, but work only in a restricted capacity, such as in Camp Bastion [the main British military base in Afghanistan].

"Someone who is fully fit would have a JMES score of medically fully deployable (MFD). If a soldier is fully fit they can go on the list to go on the next tour to Afghanistan, for example. It's the medical officers who conduct the medical element of the risk assessment. Nurses contribute to the advisory process too, but it's the chain of command as the employer that carries the ultimate decision-making process."

Complex cases

All complex cases are assessed by a regional OH physician; more straightforward cases are dealt with by GPs at medical centre level.

Rehabilitation of medically downgraded soldiers is an important part of the army OH function. When a unit is going on operations, Disney-Spiers visits the unit. He looks at the list of the soldiers they want to deploy on operations and asks the GPs if they want help with any of the risk assessments. "Soldiers may have sustained training or sporting injuries or simply be suffering from everyday disease," he explains.

On return from deployment, OH assists the unit with assessment of all medically downgraded personnel. "We give them advice on battle casualties - those who've been injured on operations. We're a multi-agency pathway with a recovery plan. All soldiers who need to see a particular specialist are sent to either the Royal Centre for Defence Medicine, in Birmingham, other Ministry of Defence hospital units, or the Defence Medical Rehabilitation Centre, in Headley Court, Surrey. The OH team works closely with Headley Court and, in particular, the vocational occupational therapists. There are also links with community mental health services around the UK. We liaise with many agencies when we are looking at medical grade."

Reconnecting Britain with armed forces

Disney-Spiers works in partnership with other bodies, such as the MoD's Defence Career Partnering (external website), which is about "reconnecting Britain with its armed forces - an opportunity for long-term sick and injured personnel of the three services."

This scheme enables placements in civilian industry. He also makes placements with Army Education and Skill Force, initially an MoD project and now a youth education charity. It works with young people disengaged from secondary education.

"We've got soldiers in employable grades but they can't return to their old job at present," he says. "The commanding officer doesn't want to lose them but, for the time being, they are working in the Skill Force. They are trained in areas such as first aid at work and on-site safety management."

This process of designing a GROW involves a lot of co-ordinating to ensure these programmes are individually tailored. When a soldier is not fit for work, they still remain under the administrative control of their unit, even if they are at home with their parents. Soldiers are visited regularly to ensure the correct level of support. The OH service aims to help them back to work once treatment is completed in Birmingham or Headley Court.

Under the Army Recovery Capability (ARC), the OH team also assists in supporting personnel back into civilian life.

"OH looks at placing people in their own unit, in stores or other appropriate places, probably part-time initially and then building up slowly," says Disney Spiers.

"Others, I may place with a unit near where they live so it is not so far for them to travel. We won't put people straight back in to the workplace unless we are sure it's appropriate. We do the GROWS at a medical grade, where they are medically unfit for duty and under medical care so they are supernumerary. It is done on an individual basis within the policy framework depending on the condition, whether the soldier lives on base, or some distance away with their family, and what they want to do."

The aim is to get people back to work, although, in certain cases, it will be retirement on health grounds and some people apply for early termination of service and return to civilian life. Disney-Spiers supervises the recovery progress. For example, if he gets reports from a line manager that someone is doing well in full-time hours and he feels they are ready, he calls them to a medical board to decide on a medical grade.

Recovery plan

The concept of ARC has been launched by the MoD in partnership with Help for Heroes, the Royal British Legion and other service charities to provide an end-to-end management system of injured and sick personnel (regardless of the cause).

"OH input will be critical to the development and delivery of the recovery plan and the overall success of ARC, as the aim of the programme is for personnel to either regain fitness and return to duty or to make a smooth transition to an appropriately skilled and supported civilian life where more appropriate," says Disney-Spiers. "The ARC will ensure that the needs of personnel are met and that individuals are afforded tailored recovery plans that focus on their specific medical, welfare, administrative, educational and developmental needs during, in-between, or after their medical care to deliver a suitable outcome to the recovery pathway - however long that takes."

There will be four purpose-built personnel recovery centres (PRCs) providing medical support and direct access to existing welfare, medical, administrative, education and training facilities, in a conducive military environment. The Erskine Centre in Edinburgh is being trialled as a pilot PRC and the following three will be built, in partnership with Help for Heroes and The Royal British Legion, in Colchester by spring 2011, and Catterick and Bulford/Tidworth by April 2012.

Nurses' contribution

OH nurses make an important contribution to the army's efforts to maximise the number of people fit to deploy on operations. Devising individually tailored rehabilitation plans for soldiers following injury or illness is a major part of their work. The job is important and satisfying and, as Disney-Spiers says: "The army is a good career. I haven't looked back for a moment. It's a great life. It is a good employer - it has provided for my education and looked after my family too, especially when I'm deployed."

Katie Oakley is a freelance writer and editor of Occupational Health Nursing (Wiley-Blackwell)

References

Braithwaite M, Nicholson G, Thornton R, Jones D, Simpson R, McLaughlin D and Jenkins D (2009) Armed Forces occupational health - a review. Occupational Medicine 59:528-538

Ministry of Defence. Joint Service Publication 346. PULHHEEMS - A Joint System of Medical Classification. 2006.