Rapid changes in clinical practice, patient demands and national targets in the UK have led to ophthalmology departments expanding the roles of ophthalmic specialist nurses (OSNs) (Needham, 2000; Siempis, 2014; Moradi, 2016). OSNs are taking on advanced roles previously only performed by doctors, including intraocular injections (Kirk et al, 2015), preoperative cataract assessment (Kirkwood et al, 2006), corneal collagen cross linking and glaucoma assessment (Slight et al, 2009), oculoplastic minor procedures (Dunlop, 2010), botulinum toxin injections, YAG (yttrium aluminium garnet) laser capsulotomy and emergency eye care triage and examination (Gibbons, 2010; Siempis, 2014).
With a long-term demographic trend of an ageing UK population, there is a growing gap between the demand for ophthalmology services and the available workforce (Lee et al, 2007; Royal College of Ophthalmologists (RCOphth), 2018). Broader training for additional responsibilities in expanded roles needs to be consistent between providers to continue to provide safe levels of care.
Guidelines for practice for OSNs are provided by the Nursing and Midwifery Council (NMC) (2018) and the Royal College of Nursing (RCN) (2016), which also provides an idea of the areas in which OSNs should have knowledge and training. A number of higher education institutions provide education for non-medical ophthalmic professionals. Some courses are delivered almost entirely online, where theory and research are emphasised (University of Edinburgh, 2021). Although basic knowledge is an important foundation in ophthalmic nursing, clinical skills are less heavily focused, creating discrepancies in real-life application.
The Ophthalmic Common Clinical Competency Framework (OCCCF), developed in 2016, provides standards and guidance setting expected knowledge and skill levels required for non-medical eye health professionals, such as OSNs, to deliver patient care in a multidisciplinary team setting. The framework was developed into a curriculum in 2019 (RCOphth, 2019), with corresponding workplace-based assessments and resources, covering four clinical areas: acute and emergency eye care, cataract assessment, glaucoma and medical retina (RCOphth, 2016; Health Education England, 2019; RCOphth 2019).
Is this study, the authors explored the learning needs and the diversity of roles currently undertaken by OSNs in the UK.
Method
A survey was undertaken with questions targeted around respondent demographics, roles and educational needs based on a previous RCN ophthalmic workforce survey (Table 1). This opportunistic survey was completed by members attending the annual South West Ophthalmic Nursing Society meeting at the Cardiff Eye Unit, University Hospital Wales, in May 2018. Inclusion criteria were outpatient OSNs from band 4 (health care assistants), band 5 and band 6 (registered nurses), band 7 (senior registered nurses) and band 8 (consultant nurses).
Table 1. Information recorded in the survey
| Demographics | n=73 (%) |
|---|---|
| Age (Mean ± SD, range) | 48.7 ± 8.9 (26−63) |
| Gender | |
| Female | 69 (95) |
| Male | 4 (5) |
| Hospitals | |
| Royal Glamorgan Hospital, Newport | 16 (22) |
| Bristol Eye Hospital, Bristol | 13 (18) |
| Great Western Hospital, Swindon | 11 (15) |
| Prince of Wales Hospital, Bridgend | 7 (10) |
| University Hospital Wales, Cardiff | 4 (6) |
| Royal United Hospitals, Bath | 4 (6) |
| Torbay Hospital, Torbay | 3 (4) |
| Gloucestershire Royal Hospital, Gloucester | 3 (4) |
| Basingstoke and North Hampshire Hospital | 3 (4) |
| Singleton Hospital, Swansea | 1 (1) |
| Royal Devon and Exeter Hospital Exeter | 1 (1) |
| Cheltenham General Hospital | 1 (1) |
| North Devon District Hospital | 1 (1) |
| Not specified | 5 (7) |
| Years of working experience (Mean ± SD, range) | 7 ± 3.7 (1−10) |
| Average number of nurse practitioners in an eye unit (Mean ± SD, range) | 8 ± 3.3 (3−8) |
| Average number of trainee ophthalmologists in an eye unit (Mean ± SD, range) | 5.3 ± 3.1 (0−10) |
SD = standard deviation
Results
Demographics
The survey was completed by all outpatient clinic OSNs, a total of 73 respondents from 13 different hospitals in the south of England and Wales. The average age of participants was 48.7 years ± 8.9 years (range 26 to 63). Sixty-nine (95%) respondents were female (Table 1). The highest number of OSNs were in band 5 (47%) and ranged from band 4 to band 8 (Figure 1). Respondents had an average of 7 ± 3.7 years of experience working in ophthalmology at the time of the survey (range 1 to more than 10 years). Surveyed eye units had an average of 8 ± 3.3 (range 3 to 8) nurse practitioners and an average of 5.3 ± 3.1 (range 0 to 10) ophthalmology trainees.
Figure 1. Number of respondents in each pay band
Active roles and skills
See Figure 2. In total, 53 (73%) of the OSNs surveyed undertook more than one active role and 31 (42%) of OSNs reported not having the same timetabled sessions each week. The majority of OSNs had active roles in high volume clinics such as emergency ophthalmology services (58; 79%) and cataract pre-assessment clinics (37; 51%). Forty-three (59%) OSNs undertook nurse-led clinics such as cataract pre-assessment and intravitreal injections. The average number of patients seen in each nurse-led clinic session were 17 patients in the glaucoma clinic (range 5 to 25) and 16 patients in intravitreal injection clinics (range 15 to 17) (Table 2). Other OSN responsibilities included obtaining patient consent to undertake procedures (15; 21%), independent prescribing (7; 10%), assessment of referrals and management activities (4; 5%).
Figure 2. Active role and skills of ophthalmic specialist nurses
Table 2. Average number of patients seen by ophthalmic specialist nurses in one clinic session
| Skills | Average number of patients seen in one clinic session |
|---|---|
| Eye casualty triage | 11 |
| Eye casualty patient examination | 8 |
| Cataract pre-assessment | 8 |
| Assessment of glaucoma patients | 17 |
| Intravitreal injections | 16 |
| YAG laser | N/A |
| Botulinum toxin injections | 13 |
| Minor operations | 10 |
Training and assessment
Forty-seven (64%) OSNs were assessed on their skills annually. An average of 37 (50%) OSNs acquired their ophthalmic skills through attendance at departmental teaching, 42 (58%) from fellow nurses, 39 (53%) from doctors and 2 (3%) from other sources. Figure 3 shows how skills were acquired for specific activities, where one OSN could use one or more educational resource.
Figure 3. How some specific skills were acquired by ophthalmic specialist nurses
Forty-six (63%) felt formal learning resources were limited. Learning resources needed to further their skills and knowledge included training opportunities (46; 63%), time (15; 21%), the manager's understanding of their needs (9; 12%) and funding (2; 3%). Twenty-eight (38%) OSNs felt they did not learn better from attending courses, whereas 40 (55%) neither agreed nor disagreed. Five (7%) reported that prescribing courses would benefit their learning.
Confidence and satisfaction
Forty-three (59%) respondents felt confident with their skill set and 29 (40%) felt confident teaching. Fifty-three (73%) felt satisfied with their current job; 23 (32%) felt overworked.
Discussion
The authors sampled a cohort of OSNs from different stages in their careers, and different ophthalmic set-ups to collate information on the spectrum of roles and their educational needs.
The findings suggest that there are few opportunities for OSNs to develop skills and knowledge, particularly through departmental teaching, despite an increase in their responsibilities in clinical and non-clinical roles. Previous second and third national UK surveys commissioned by the RCN Ophthalmic Nursing Forum also found a large number of nurses reporting a lack of training and fewer opportunities to access courses, despite fewer difficulties in obtaining funding (Waterman and Waterman, 1999; Czuber-Dochan et al, 2006). Despite these findings between 1999 and 2006, the authors found no significant change in OSN opinion on the provision of training opportunities since.
Competency framework and curriculum
In 2018, the RCN collaborated with the NMC, higher education institutions, professional organisations and service providers to develop a credentialing process. This included a competency framework as an assessment for registered nurses to have their knowledge and skills formally recognised to practice at an advanced level (RCN, 2018). The current four pillars in advanced level nursing practice are clinical practice, education and research, leadership and management, and development of self and others (RCN, 2018). The RCN competencies were originally developed earlier in the 2000s and these elements were agreed and further developed into country-specific documents on advanced nursing practice. Each country had country-specific competencies. An example is the Department of Health, Social Services and Public Safety in Northern Ireland (2016). The Northern Ireland Practice and Education Council for Nursing and Midwifery (NIPEC) led the development of this framework. The fourth edition of the Nature, Scope and Values of Ophthalmic Nursing guideline, published by the RCN, provided the fundamental key clinical standards expected of ophthalmic nurses (RCN, 2016).
The RCOphth has published guidance on the skills and knowledge required for non-medical ophthalmic health professionals (RCOphth, 2016). The OCCCF curriculum covers competencies required to become certified in each of the four clinical domains—cataract, glaucoma, medical retina and emergency eye care—now operationalised through an ophthalmic practitioner training programme. These skills can be recognised through a series of certification levels, 1 to 3, in each clinical domain. Learners will require completion of a portfolio where evidence such as work-based assessments, audit, logbook and multisource feedback are accumulated to fulfil the 13 domains of the OCCCF curriculum, see Box 1.
Box 1.Domains of the Ophthalmic Common Clinical Competency Framework Curriculum
- Clinical assessment
- Patient investigation
- Patient management
- Practical skills
- Surgical skills
- Health promotion/disease prevention
- Communication skills
- Information handling
- Basic and clinical science
- Attitudes, ethics and responsibilities
- Decision making, clinical reasoning and judgement
- Role in the health service
- Personal development
Source: Royal College of Ophthalmologists, 2016
Active roles and skills
Since the beginning of the 21st century, there has been an increase in the number of OSNs conducting clinics independently (Marsden et al, 2013; Stanford and Ewing, 2020). In the present study, 57 (78%) OSNs were involved in cataract pre-assessment nurse-led clinics. Marsden et al (2013) similarly reported emergency care and pre- and postoperative cataract assessment as the two largest areas of advanced practice in ophthalmic nursing. This can be explained by the rapid increase in the number of older people in the UK as the population ages, with cataracts accounting for more than a third of the cases of vision impairment in those over the age of 75 years (Evans et al, 2004). The global shortage of ophthalmologists (Resnikoff et al, 2020) has created a demand for support from advanced ophthalmic nurse practitioners. OSNs play an integral role in providing emotional support and addressing patients' expectations (Rozenblum et al, 2017) while maintaining a holistic approach for those undergoing ophthalmic procedures. Weingessel et al (2019) found that patients equate a positive experience in cataract surgery with the emotional and psychological support given. High-quality nursing care can reduce waiting times and may be more cost-effective, hence ongoing evaluation and concise protocols in departments are essential to optimise the efficiency of nurse-led clinics (Kippenbrock et al, 2019).
Intravitreal injection training programmes have been developed in the UK owing to the growing demand for anti-vascular endothelial growth factor therapy for the treatment of multiple eye conditions. The RCOphth authorised intravitreal injections by non-medical health professionals in May 2013 as a response to the enormous pressure that eye departments are under to provide new and follow-up treatment for patients (RCOphth, 2013). Nineteen (26%) OSNs in the authors' survey conducted nurse-led intravitreal injection clinics. Published studies show nurse-delivered injections to be safe with adequate supervision and assessment by ophthalmologists (Michelotti et al, 2014). Nurse-administered injections were found to be cost-effective, with good patient satisfaction. They also demonstrated no difference in risk to visual function compared to those injections administered by doctors (Bolme et al, 2020). To maintain safety and their skills, OSNs undertaking such services should receive continual feedback, assessment and training by appropriate assessors, including ophthalmic specialist doctors, optometrists, orthoptists and senior OSNs. This would include local audit of outcomes and patient satisfaction.
Training and assessment
OSNs in the present study acquired most of their skills through fellow OSNs, followed by doctors and then departmental teaching. Therefore hands-on, clinic-based training should be emphasised as more than 38% (n=28) of OSNs felt this had a greater impact on their educational needs. Seven (9%) of the OSNs were non-medical prescribers and Courtenay et al (2011) found an improved efficacy in clinic services and good patient confidence in nurse prescribing roles. This particular role would be beneficial in promoting independence in emergency ophthalmology clinics, for example, a service often over burdened with low-risk pathology.
The results of the present survey raised concerns about the barriers OSNs face in gaining further training. Common contributors from this study included time constraints, low staffing levels and lack of learning opportunities. Other studies cited unpaid leave, financial costs and geographic distance as known barriers to participation in educational activities (Hegney et al, 2010; Shahhosseini and Hamzehgardeshi, 2014). Moreover, undertaking educational programmes and professional development courses may affect work-life balance and has been negatively associated with financial costs and loss of leisure time (Aw and Drury, 2016). Online learning, however, may be beneficial as it overcomes some barriers, offering flexibility and convenience in continuing professional development (CPD) (Karaman, 2011). Although some studies found nurses experiencing greater satisfaction (George et al, 2014; Rouleau et al, 2019) and a positive attitude towards online learning compared with traditional learning, some studies reported no statistical significance in knowledge, skills and satisfaction (Lahti et al, 2014).
Continuing education is needed to provide up-to-date knowledge for new interventions and safe practices, while self-reflective skills (Hughes, 2005) and the ability to implement skills in practice (Griscti and Jacono, 2006) are major determinants of becoming a life-long learner. A positive attitude towards collaborative learning, where a sense of belonging is achieved through interaction and communication within group activities, provides motivation for self-directed learning (Chiang et al, 2013) and can work well in both nursing (Qalehsari et al, 2017) and online learning (Chatterjee and Correia, 2020). Peer group learning and support at local and national level needs to be appreciated and implemented.
In the present study only 47 (64%) of the OSNs were assessed on their skill annually. Encouragement from nominated educational supervisors such as trainee ophthalmology colleagues and self-assessment through goal development and self-directed learning is necessary for tracking CPD progress and achievements (Li et al, 2010). The OCCCF allows nurses to fulfil their CPD activity requirements, including coaching and mentoring fellow nurses. Various educational materials are provided by the OCCCF through e-learning, articles and books; however, it is up to individual departments to provide training for these nurses. Eye departments should be aware of the new OCCCF framework and target teaching accordingly. Further review of the uptake of the OCCCF will need future assessment.
Confidence and satisfaction
Forty-three respondents (59%) felt confident with their skillset and 29 (40%) felt confident teaching. The lack of confidence in performing their role and teaching others in some OSNs could indicate minimal supervised training and opportunities to practise skills in a safe environment. Nurses should be supported through activities to increase their clinical confidence such as through simulation (Kiernan, 2018; Hamilton, 2020). Confidence in teaching others can be developed by attending educational courses and teaching fellow nurses within clinical practice with appropriate supervision (Liu et al, 2019).
Studies report workload, working conditions, salary and relationships with colleagues as major influences on stress and job satisfaction (Bimpong et al, 2020). Nurse resilience to stressors were significantly correlated with years of experience, age and education (Leng et al, 2020). In the present study, a good proportion of the respondents (53; 73%) were satisfied with their current job while 23 (32%) felt overworked. Five nurses in the study specifically mentioned that better working conditions and their manager's interest would help with their training. Managers were perceived as gatekeepers to accepting and creating opportunities to implement new knowledge as all nurses have individual needs (Gould et al, 2007). Hollinger-Smith and Ortigara (2004) found that work motivation and increased autonomy have been directly linked to nurse retention and increased patient satisfaction. To date, there are limited published data on staff satisfaction and retention specific to ophthalmic nurses in the UK compared to patient outcomes and satisfaction.
Strengths and limitations
The limitations of this study include selection bias as the sample was selected from one conference and was conducted in one region of the UK. The study design was limited by response bias and non-generalisable data. Attempts to reduce bias included a pilot survey and adjustment of questions. This study provides a snapshot in time of current roles and educational needs of ophthalmic nurses. It gives perspective to current practice and provides reference for comparisons to studies in the future.
Conclusion
The findings of this study indicate that there are limitations to how effectively the OCCCF is being implemented. More institutions with the capacity to provide facilities for training and additional funding are required. The OCCCF should be applied early on in an OSN's career so they can be well equipped with the skills necessary to meet the demands of current eye departments, as well as maintaining a good level of job satisfaction.
To meet changing needs in society, it is important to reinforce the need for updating knowledge, skills and self-reflection to maintain high standards of care. Since the undertaking of this study, the COVID-19 pandemic has made clinical prioritisation of individuals through risk stratification, integration of community services and eye screening crucial in monitoring patients. This need will continue in the foreseeable future. With a backlog of patients and missed appointments, a shift in robust referral refinement, discharge and follow-up guidelines has increased the demand of OSNs (RCOphth, 2020a).
The authors acknowledge the essential role of OSNs and their contribution to the challenges in modern ophthalmic care. They recommend further work comparing different teaching methods, reviewing nationally available educational resources and a future review of the effectiveness of the OCCCF once implemented nationally through the RCOphth ophthalmic practitioner training programme (RCOphth, 2020b; 2020c).
KEY POINTS
- Ophthalmic nurses have taken on expanded roles including intravitreal injections, pre-operative cataract assessments and managing nurse-led practices to meet the demands of hospital eye services
- This study highlights a vast range of potential skills and knowledge that can be acquired through local clinical training and the need for repeatable clinic-based assessments to maintain and update competences and knowledge
- The recently published Ophthalmic Common Clinical Competency Framework provides ophthalmic nurses with specific guidance on clinical competencies
- Barriers to training include the lack of scheduled time, learning resources, and sponsorship
CPD reflective questions
- Think about what additional skills and knowledge ophthalmic nurses need in order to adapt to modern ophthalmic care
- What resources do you need to complete Ophthalmic Common Clinical Competency Framework domains?
- What should the role of the ophthalmic nurse be? If you currently work in such a role, think about how you could develop your practice