A Handbook of Ophthalmic Standards and Procedures

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Communication

Communication is a wide and varied subject that we do not intend to discuss in depth within this handbook. We intend to discuss communication from the perspective of the ophthalmic nurse using a common sense approach that has guided our practice for many years working within the ophthalmic arena.

Ophthalmology as a specialty includes a wide range of patients from all age groups and walks of life, with differing levels of visual ability, from acute A&E attendances to long-term chronic follow up. However they all have one thing in common – an eye problem which can cause extremes of anxiety and distress for conditions which we sometimes view as ‘minor’.

In our experience, most people will experience a level of anxiety relating to any eye disease and their ability to manage this stressor can be enhanced by using effective communication skills. It is important to help the patient become involved as we need to elicit accurate information from them. An example springs to mind about how a patient reacts within a stressful situation although admittedly not linked to ophthalmology.

A very stressful situation caused a lady to hyperventilate, feel dizzy and unsteady. She was attended by an efficient and kind healthcare professional, making the lady comfortable before asking about her medical history. The lady proceeded to explain that she had angina and an enlarged heart. This was news to the relative accompanying the lady. It was half an hour later before the lady realised she had given a detailed medical history for her mother rather than herself…

Stress and anxiety create a variety of responses from each individual so it is up to us, as the ophthalmic nurse, to ensure we create an environment which allows our patient to relax and impart accurate information. This assists with clinical decision making, developing an effective professional–patient relationship and ultimately improving the patient experience.

Most books relating to ophthalmology will include some information about communicating with visually impaired people. Madge (2006a) suggests an introduction of oneself to the patient should be ‘followed by a relevant preamble’ before taking a history from the patient. It is uncertain what a relevant preamble is but I can envisage from experience what this type of loose discussion between clinician and patient before the ‘real’ work of history taking gets started might look like. However it is recommended that a rapport between clinician and patient should be developed.

Many ophthalmic nursing books allow the nurse to explore appropriate strategies to enhance effective communication with visually impaired people. Shaw et al. (2010) identifies communication ‘etiquette’, suggesting that the HCP is within the patient’s field of vision, using a quiet room, free from distraction, addressing the patient (not the carer if accompanied) and avoiding shouting as most patients have retained their other senses. The first step in the process is to introduce yourself, clearly identify your role and say that you will be asking some questions before the patient sees the doctor or other clinical specialist for the complete clinical examination. Finding a quiet room, free from distraction, in a busy ophthalmic unit may feel like an impossible task. Often new designs for ophthalmic outpatient departments utilise every small area to the maximum. Quiet spaces are rarely readily available. However you should agree within your team how to optimise privacy and dignity for your patients so that interruptions can be avoided completely or, at the least, handled discreetly without a patient feeling secondary to the running of the unit, which is difficult to achieve in the very busy environment of the ophthalmic outpatient department.

It is important to remember that many non-verbal communication clues may be missed by patients with significant visual impairment (Whitaker, 2006). It might be advisable to start with a small amount of ‘small talk’, perhaps about the weather to help relax the patient and show you are solely interested in them at that moment. This may be the preamble suggested by Madge (2006a). The patient in front of you should be the most important aspect of your professional life at that point in time. Be aware that sometimes it is possible to appear to be talking to the medical records rather than the patient if there is an absence of eye contact and perceived interest from the patient’s perspective. Accurate documentation is important but the ophthalmic nurse needs to create a sense of ‘being there’ for each patient by making eye contact, smiling encouragingly, leaning a little forwards as if you are interested, ensuring you do not invade someone’s personal space. Offer your hand as a greeting as you introduce yourself but ensure you only use touch appropriately. Use a common sense approach to touch – some patients interpret touch as a comforting or relaxing gesture whilst others may find touch inappropriate. The patient is only interested in the quality of the time spent with you, even in a busy clinic environment.

There is an initiative called the 15 Step Challenge resulting from patient feedback where a mother stated that she knew the care her child, who had been a frequent visitor in various hospital settings, would receive within 15 steps of entering a ward or unit. This parent was able to accurately predict the quality of care offered to her child by her first impressions. The toolkits that have developed from this initiative remain available for all to use and can be accessed via the NHS Improving Quality website. The challenge is to optimise the first impressions for our patients and their carers so that we instil confidence about the quality of our service before the patient reaches the reception area.

You will have to clarify some things using open questioning techniques to ensure you have accurate information; however there is little need to repeat everything the patient has said to you. Try to summarise the salient facts. In today’s busy clinics it may be tempting to allow the patient uninterrupted time to wander through their entire life history but actually you only have a few minutes to determine the relevant details. You can interrupt a patient (albeit with tact) and return the patient to the point in question. One way to do this is to use a closed question or paraphrase the most recent point.

Every patient is different and will need a slightly different approach. If you use these tips to build a rapport with your patient, combined with some common sense and good manners, you will most likely obtain the information you need and improve the patient experience.

A group of ophthalmic nurses undertook a survey across three different NHS Trusts which prioritised the qualities of a ‘good’ eye nurse from the patient’s perspective. The results showed that patients want us to be knowledgeable, skilled and competent; an excellent communicator; someone who listens and pays attention; someone who is empathetic and gives sound advice; honest and trustworthy; warm and friendly (Ring, 2010). This may sound impossible to achieve in a busy clinic or day surgery unit but we should all be aspiring to deliver care from the patient’s perspective, particularly when we need to be effective communicators during history taking and patient education.

Educating Staff

Patients want staff who are knowledgeable, skilled and competent. This book helps with skills and competency assessment but nothing takes the place of learning, education and knowledge to enable the HCP to practise in an informed way. Ophthalmic nursing courses are few and far between, with organisations finding financial pressures reducing in all areas, one of which is education. If your local higher education provider does not operate an eye course, what can be done?

In the UK, ophthalmic nursing courses have steadily declined over the last three decades. Marsden (2016) spoke eloquently about the lack of courses, no national curriculum and the very clear possibility that most nurses with a recognised ophthalmic qualification are now entering their last decade of working life, leaving the future of ophthalmic nursing on shaky ground. A number of organisations in the UK do deliver Masters level courses but not all the nurses working in ophthalmic departments have the necessary first degree to pursue this course. Many units are converting their establishments to increase numbers with non-registered technical or associate practitioner staff although this is anecdotal evidence only. An organisation called the Association of Health Professions in Ophthalmology has developed an online course for Ophthalmic Support Workers at level 4, creating a specific Ophthalmic Associate Practitioner course. More information can be obtained via the website: www.ahpo.net. Many units have developed their own in-house ophthalmic nursing foundation courses; however, without a national curriculum, these have little consistency and may lack credibility when used as transferable knowledge.

History Taking

All authors identify the composition of a ‘good’ history (Shaw et al. 2010; Marsden, 2007; Ledford, 1999). It consists of:

Presenting condition – why has the patient arrived or been referred to the eye casualty or outpatient clinic?

Past ophthalmic history – is there anything that might be contributing to this episode of care?

Past medical history – is there an element of other medical problems that is likely to impact or create ophthalmic problems?

Medications – are there current medications that could cause ophthalmic problems or impact on future prescribing?

Allergies – this will influence a prescriber’s choice of treatment.

Family ophthalmic history – do any members of the family have ophthalmic problems with a familial or genetic component?

Occupation – could the ophthalmic condition have an impact on employment or is the occupation impacting on the condition?

Hobbies – has the ophthalmic condition impacted on any hobbies such as reading or sewing?

Driving status – this may impede the ability of the ophthalmic nurse to dilate the pupils appropriately or the nurse may need to assess the visual acuity and how it relates to the current DVLA driving standards.

Other social history – include smoking, alcohol consumption, recreational drug use as they all may impact on visual function; identify the patient who lives alone and may need additional support.

This list is not exhaustive. You may need to ask additional questions within your own workplace and you should always act in accordance with any specific local guidance and policy. All these details will, however, assist the doctor or HCP with clinical decision making as you will have clearly documented this in the individual’s medical records (NMC, 2016b).

History taking also includes observation of the patient and attention should be paid to visual cues, as well as explicit spoken responses. It is possible that concerns will be raised regarding vulnerable adults and child protection issues during any interaction with the patient and non-verbal cues may trigger these concerns. The HCP should be aware of the local policy and guidance in relation to vulnerable adults and child protection to ensure prompt action is taken if the HCP is uneasy during or following an interaction. For example: when asking a child to sit on the accompanying adult’s lap or knee for visual acuity – signs of fear or unusual compliance may be cause for further investigation. However it is quite normal for a child to be scared of the test but not usually the adult.

Further information can be obtained from http://www.scie.org.uk/publications/ataglance/69-adults-safeguarding-types-and-indicators-of-abuse.asp (accessed 31.05.16) in relation to Protection of Vulnerable Adults, and the NSPCC 2010 provides guidance around the legislation surrounding Safeguarding Children available at: https://www.gov.uk/government/publications/safeguarding-children-and-young-people(accessed 31.05.16)

We hope you find these resources useful.

Patient Education

Every ophthalmic nurse becomes involved in educating patients to care for themselves at home at some point within their career. This may be to prepare a patient for long-term eyedrop treatment which requires adherence and persistence, preparing a patient to manage their altered lifestyle due to sudden or gradual visual impairment or for short-term post operative care following ophthalmic surgery.

Davies (2006) suggests that the ophthalmic nurse has to develop lateral thinking when providing patient education particularly when discussing drop instillation. The home environment needs to be considered specifically around any physical limitations, lifestyle routines and timings for drops. The ophthalmic nurse may be faced with many challenges to support patients with drop instillation and in today’s healthcare economy nurses from primary care cannot be relied upon to deliver post operative eye drops.

Over the years, the ophthalmic nurse discovers from other nurses and patients themselves tips and tricks to help with drop instillation. Our advice would be to have a discussion among the experienced nurses to find out how they teach, what do they do and if it works. In all cases the patient must be supported to demonstrate how they would put in drops at home and encouraged to use appropriate techniques.

Many patients have found benefit from discussing their visual impairment with an independent person specifically trained in helping visual impaired patients, particularly following a devastating diagnosis of permanent sight impairment. In the UK, Eye Clinic Liaison Officers provide such a service. The specific training for any person interested in developing this type of role is provided by the Royal National Institute for the Blind (RNIB), with more details available at http://www.rnib.org.uk/ecloinformation.

You may also be called upon to help a patient understand a specific condition. We encourage you to locate appropriate patient-friendly literature, have support telephone numbers available such as Sightline (01233 648170), a helpline provided by the International Glaucoma Association (http://www.glaucoma-association.com). You need to be able to access