a nurse may supply (or in the case of injectables administer), it must be borne in mind that as the doctor is not prescribing for an individual patient, the nurse must exercise professional judgement and discretion when considering which product to administer or supply for the nature of the condition or combination of conditions from which the patient may be suffering.
(RCN: Occupational Health Nursing Services Handbook (1991))
Careful records must be kept and the nurse, who should be specifically named in the doctor’s authorisation, must never delegate her authority to a first‐aider or other nurse (Chapter 2).
The Human Medicines Regulations 2012 permit registered nurses employed in an occupational health service to be in possession of controlled drugs (like morphine) for the purpose of administration to persons injured or taken ill at the place of work at which the nurse is employed. The drugs must have been supplied to the nurse by a doctor employed at the place of work for the medical supervision of workers. Security must be efficient and the nurse must keep a register detailing every administration of the drugs. If the drugs are lost or stolen the nurse must report to the police as soon as possible.
Apart from the legislation about medicines, the division between the roles of doctor and nurse in any setting rests essentially on custom and practice. Both professions have something to say about the matter in their ethical rules. The Faculty of Occupational Medicine’s Good Occupational Medical Practice (Royal College of Physicians, 2017) states:
Occupational health services may be multi‐disciplinary. Other professionals may include occupational health nurses, physiotherapists, counsellors and safety advisors. In delegating within the team, occupational physicians are still responsible for the overall occupational medical care of the patient. You must only delegate professional tasks to those who are specifically trained and competent to perform the task in question.
The NMC, in its Code of Professional Conduct (2018), states that a nurse should acknowledge any limitations of competence and refuse to perform tasks outside those limitations.
Sometimes conflict arises with others in the workplace about the proper role and function of the OH nurse. Although a joint committee of the BMA and RCN advised that there should be a procedure for consultation between OH personnel to define their relative responsibilities, there can still be friction. The nurses in particular sometimes find themselves in conflict with safety officers. If the problem proves intractable, the best advice is for the nurse to contact EMAS at the local HSE offices. The Faculty of Occupational Medicine’s Ethics Guidance for Occupational Health Practice (2018) advises as follows:
Occupational health staff may work alongside safety professionals, occupational hygienists and others who do not have a clinical background. Sharing information with these non‐clinical colleagues can generate substantial health benefits and failure to do so may constitute a culpable act of omission. Nonetheless, care must be taken to appropriately safeguard clinical information when working with groups that do not have a professional duty of confidentiality.
Health professionals are themselves legally liable for any acts of negligence which cause damage. The OH doctor is only liable for the negligence of another member of the occupational health team if they were themselves negligent in asking the team member to do something without checking that they were competent. If they are employees acting in the course of employment, their employer is also vicariously liable for their negligence. It does not follow that, just because an employee is acting in an unauthorised way, they are exceeding the scope of their employment (Chapter 6).
1.8 The relationship between the occupational health service and the general practitioner
The preventive aspects of the OH specialists need not impinge on the general practitioner’s function. If the worker is found to be suffering from some work‐related illness, or has an accident at work, the GP should be informed, if the patient gives consent. Treatment is more problematic. The Faculty of Occupational Medicine advises that the occupational physician should treat a patient only in co‐operation with the patient’s GP except in an emergency. If he thinks that the worker should consult his GP, he should urge him to do so. The occupational physician should refer a patient directly to hospital only in consultation or in agreement with the GP. He should not influence or appear to influence any worker in his choice of GP. The RCN advises OH nurses not to undertake specific treatments without the request of the GP in writing, other than treatment for minor injuries and in an emergency. Vaccination and immunisation programmes for workers at risk must be supervised by a registered medical practitioner.
An area of potential conflict is the confirmation that absence from work is due to sickness so that the worker can claim sick leave and sick pay from his employer. This is usually the GP’s job and he is only obliged by his contract to give a fit note free of charge after seven days’ absence. However, the employer may ask the OH department for their advice as to the fitness of the worker. The employer’s motive may be suspicion that the employee is malingering. Frequent or lengthy absence may indicate a serious health problem which may put other workers at risk. The worker’s absence may be causing the employer financial problems and other employees may be showing resentment. The BMA advises consultation with the GP (with the employee’s consent). If the GP and the OH doctor disagree, and there is the prospect of disciplinary action, the employer may allow the employee within company procedures the right to go ‘on appeal’ to an independent consultant, or the employer may decide to prefer OH advice on the ground that OH knows the work as well as the worker (Chapter 7).
Where the occupational physician is also the worker’s general practitioner (a not uncommon event), the physician must be careful to keep the two functions separate. In such cases, it might be preferable to encourage the patient to see another doctor in the practice (if there is one) or even to register with a different GP. Information about the employee must not be transferred from the OH to the GP records, or vice versa, without the employee’s consent.
In addition, wherever possible, a doctor should avoid acting as an occupational health adviser to an individual where another relationship exists, eg as manager, departmental colleague or primary care physician. If this is unavoidable, particular care should be taken to ensure that the patient understands the context of the consultation and agrees to its terms
(Good Occupational Medical Practice).
2
The Legal Status and Liability of the OH Professional
Occupational health professionals should be clear about whether they are classified as employees, workers or self employed contractors, as that has important legal consequences.
An occupational health professional can be convicted of a crime under the Health and Safety at Work Act 1974, in addition to the employer, or may be solely responsible, if a failure of reasonable care leads to employees and others being put at risk.
The Court of Appeal has held that an occupational health professional does not owe a duty of care to a worker pre‐employment, but it is likely that this applies only to economic loss and not to physical harm. A duty of care extending to both physical and economic harm is owed to workers in employment.
Occupational health professionals always owe a legal and ethical duty of confidence to those who confide in them.
Although an occupational health
