An evaluation of the Ophthalmic Nurse Practitioner in Eye Examination of Post -Operative Cataract Patients. Katy Pedwell. MA Practitioner Development

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1 An evaluation of the Ophthalmic Nurse Practitioner in Eye Examination of Post -Operative Cataract Patients Katy Pedwell MA Practitioner Development

2 An evaluation of the Ophthalmic Nurse Practitioner in Eye Examination of Post -Operative Cataract Patients Abstract This project evaluated the role of the Ophthalmic Nurse Practitioner in the management of cataract patients whose surgery was uncomplicated, at their first clinic review, a minimum of 3 weeks post surgery in the Eye clinic at Solihull Hospital. The theoretical framework used was Ovretveits (1988) evaluation of health care interventions model. This model identified that evaluations can be undertaken to provide a decision on whether to expand or curtail a programme of care, this is the rationale for the study. The method selected for the evaluation was a retrospective case note review, using historical data to compare patient management by a Nurse with that of a Doctor. The data was collected from the case notes using a proforma for eye examination which was devised to allow both quantitative and qualitative data to be collected and analysed, allowing a judgement to be made on equivalent care. The results of the data demonstrated that Nurse consultation, was equivalent to that of a Doctor; provided a high standard of documentation and was seen to be cost effective. Recommendations Nurse post operative clinics should be expanded to the Heartlands Eye clinic to provide equitable care across both sites of the same Trust. An increase in the nursing establishment by an additional D grade per site 2

3 would backfill senior posts and support further nurse training. A report will be submitted to Directorate Manager to demonstrate cost effectiveness of Nurse v Doctor so that service provision can be expanded. The Cataract practitioners should receive training to take consent for 2 nd eye surgery, in line with Royal College of Ophthalmology guidelines (2004) This will enable the Nurse to provide total care for the post - operative patient alleviating the need for the patient to wait and see the Doctor for this single aspect of the consultation. Protected training time needs to be agreed for specialist nurses to learn to perform fundal examination. The proforma for eye examination, with some modifications will be suitable for the Nurse practitioners to audit their documentation against the proforma. The Cataract Practitioners should audit their practice annually and meet to discuss any issues resulting from the audit. New documentation of post operative consultation should be implemented for use by Doctors and Nurses, with re-audit 6 months after implementation using the proforma for eye examination. There needs to be some documentation of reasons for not listing patients for second eye surgery. 3

4 Introduction The Government NHS Plan (2000) encourages the development of nurse-led clinics to minimise the gap in health care provision. Many ophthalmic units in Britain have implemented nurse - led clinics to review post operative cataract patients. This practice is thought to be a successful utilisation of resources, but this is purely anecdotal, as there has been little evidence in the literature to support this theory. At Birmingham Heartlands and Solihull NHS Trust we are an ophthalmic department based on two hospital sites in the East of Birmingham, nurse post operative clinics are held on one site only, it is planned to extend this facility at the Eye clinic at Birmingham Heartlands hospital to provide equitable care for all patients and meet the demand for service provision. The Nurse - led clinics are undertaken by senior Ophthalmic Nurse practitioners F grade and above. As the nurse manager of the department I decided to undertake a formal evaluation of the role; to find out if Nurse consultation is comparative with Doctor consultation, to ensure a high standard of care is given to the patient and that it is cost effective to the Trust to expand these nurse -led initiatives. This evaluation research will focus on two specific questions: Do Nurses provide equivalent care to Doctors? Is Nurse Consultation cost effective? 4

5 The benefit of undertaking this project to the department is: 1 To provide an audit tool for the nurse practitioners, with the development of a proforma for post operative eye examination. 2 To compare documentation of patient consultation by nurses and medical staff. 3 To investigate if nurse practitioners give equivalent care to Doctors in managing the care of uncomplicated post operative cataract patients at 3 week review; and on the basis of these results identify if Nurse consultation is an efficient use of resources. This project will debate the issues surrounding the development and effectiveness of the nurse practitioner role in general and specifically related to ophthalmology. Background It is a priority on the Government agenda to reduce inequalities in health care provision and improve access to services, ( DOH 2000 a) making the issue a high priority in the Ophthalmology department at Birmingham Heartlands and Solihull NHS Trust. There is sufficient evidence in the literature to suggest that social and economic factors, influence health behaviour, may prove a barrier to accessing health care and place a demand on provision of health care. This is supported by Naidoo and Wills (2000 : p48) who identified that poverty, unemployment, inadequate 5

6 housing, stressful and dangerous working conditions and risk factors associated with personal behaviour - smoking, nutrition, exercise are influenced by the social environment To plan effective service provision, therefore requires an assessment of the local population served, in regard to these factors. According to the index of Local Deprivation, Solihull ranks as one of the least deprived districts in England rd out of 354. However, within the wards of Solihull there are pockets of high deprivation as measured by Townsend et al (1987) where a range of factors such as unemployment, overcrowding, housing tenure and car ownership are scored to indicate affluence or deprivation. High positive scores indicate a higher level of deprivation, negative scores indicate affluence. When three of our most deprived wards are considered in isolation, Solihull jumps to 57 th out of 354 Authorities, so demonstrating an inequality of affluence within our own area. Another factor affecting the provision of health care is population level and demographics. It has been estimated that between 1998 and the end of 2004 the borough of Solihull will have an 8% increase in population aged over 65 compared to a 2% increase in the West Midlands and a 1% increase in the whole of England and Wales (PHCDS 1999) this ageing population will impact significantly on the provision of ophthalmic services generally and specifically on the demand for cataract services. The ophthalmology department at Birmingham Heartlands and Solihull NHS Trust is based on two hospital sites and accommodates 45,000 Patient visits a year, Day case cataract surgery is provided on the Solihull site only. Between April 6

7 there were 2,500 cataract operations performed which is below target for the standard requirement of 3,200 cataract operations per 100,000 population aged over 65 (DOH 2000 b) There has been no increase in the following years activity due to issues with capacity, simply because there are no additional theatre slots available. There has only been an increase in by about 100 operations because of evening and weekend operating sessions, a temporary measure and not a sustainable solution. The Eye unit at Birmingham Heartlands and Solihull NHS Trust is a major provider of ophthalmic services in Birmingham. When compared to the three other eye units in Birmingham, our new patient referrals for the first three months of this year are the highest in the city, totalling 5,270, compared to 1,005 in North Birmingham, 1,831 in South Birmingham, our Eye centre in West Birmingham merged with Sandwell two years ago and their combined referrals are 4,314.(DOH 2004) Of these referrals some are Consultant to Consultant referrals for specialist opinion eg corneal, ocular plastic and diabetic retinopathy but a large proportion are due to increased G.P. referrals. In order to meet these demands the provision of services needs to be assessed, this is not just a local problem but has affected other ophthalmic units in Britain similarly ( Brogden 2005 ) As a response to meet the increased demand for ophthalmic services nationally, and cataract surgery in particular, a working party of ophthalmologists were asked to review the services offered and identify how the process could be streamlined to provide improved access with an efficient high quality service. This resulted in the publication Action on Cataracts (DOH 2000 b) which recommended a strategy to 7

8 streamline the cataract pathway and reduce the number of hospital visits for the patient by efficient working practice. The improved pathway suggested ophthalmic units implement a system for optometrists to refer cataract patients for Ophthalmologist consultation directly, rather than via General Practitioners. The patient will attend hospital for one pre operative visit, have confirmation of diagnosis, pre operative assessment and leave with a date for surgery. Following surgery, it was suggested that patients were seen by a Nurse for post operative review and discharged or referred back to the ophthalmologist as appropriate. The impetus was again provided for Ophthalmic nurses to capitalise on their specialist skills and expand practice to meet these demands for service provision, in collaboration with their colleagues. In response to the ' Making a Difference document (DOH 1999) which encourages nurses to look at new ways of working, most ophthalmic units have developed nurse - led pre-operative assessment clinics. Where, following medical history taking, ophthalmic nurses also undertake technical roles such as biometry, phlebotomy and ECG recording, so enabling the provision of holistic care for the patient by one individual nurse, this maximises the efficiency of the visit for the patient and reduces the nurses dependency on other members of the multidisciplinary team.. The other area of the cataract patient pathway that lends itself to nursing role expansion is the medical examination of post operative cataract patients, reducing the need for these patients to be seen by a Doctor unless there is a complicating 8

9 factor to their surgery or post operative recovery. The ophthalmic Nurses would be trained by their Consultant colleagues and work within protocols developed by their individual ophthalmic unit. The Consultant Ophthalmologist responsible for the post operative care of his patient would delegate this care to an appropriately trained nurse who will manage the patients post operative care in accordance with the protocol devised. There are some units who have delegated this responsibility to local optometrists who will follow up the patients in the community, but this relies upon the optometrist receiving post operative review training (Gaskell et al 2001) and this training would need to be arranged in the Eye unit under Consultant supervision. This may work well in a rural area which has very few optometrists, but with the population of Birmingham and high numbers of optometrists, this would be impossible to achieve. One option would be for the Eye unit to have a limited list of optometrists who would receive training by our Consultants and the patients would be discharged to their care post operatively. There would be many issues surrounding the implementation of this. Such as how the optometrists would be recruited and selected to undertake the training. If there was a high demand from optometrists it would need negotiation to decide who would have access, there would also be an issue of when the training would fit into a busy clinic schedule. Pressure to achieve government waiting time standards already means Consultants in my unit are undertaking evening initiative clinics to ensure that Patients are seen in clinic within 13 weeks of GP referral to Hospital. 9

10 As an approach to shared care between the hospital and the Community Optometrists, a rapid access service was developed in Croyden involving 19 of 52 optometry practices, allowing direct referral from optometrists and also involved optometrists in post operative review for 85% of all operated patient. Whilst encouraged by a patient satisfaction survey that patients thought the service excellent Kerr and Kavanagh (2002) highlighted concerns in the administrative process that sent Patients to their optician for review post operatively, as it was identified that only 74 patients out of 109 were given a form to take to the optician and they were not certain that all patients who had undergone an operation had actually had a post operative eye examination. It would be expected that these problems have now been addressed; however this supports the case to undertake post op reviews in clinic. In our unit it was decided not to pursue this option but to train ophthalmic nurse practitioners who would undertake their clinics in conjunction with the Consultants general ophthalmology clinic and he would be available for advice should the need arise. In ophthalmic units where this role is undertaken by the nurse, it is perceived to fulfil many needs. It provides the nurse with professional development and job satisfaction, it frees up a doctor to spend more time in surgery or clinic thus enabling more patients access to surgery or a clinic appointment. From a managerial perspective waiting time targets can be met and it is seen to be cost effective nurses being cheaper than doctors; and from a patients view point they are seen by a competent health professional who they find easy to communicate with and who will allow time to answer their questions. This is potentially, an ideal 10

11 solution for all the stakeholders involved. However, we are practising in an era of evidence based medicine, where clinical effectiveness and audit of practice is important. When I started to develop the protocols for the unit it soon became apparent that there has been no thorough evaluation of the nurses role in post operative eye examination, documented in the literature that I reviewed. The evidence of the effectiveness of the role is purely anecdotal and gained from colleagues undertaking the role in their respective ophthalmic units. This lack of evaluation of clinical nurse specialist roles is not confined to ophthalmic nurses. Armstrong et al (2002) study of expanded Nursing roles in Scotland cites lack of time or expertise to undertake evaluation, none of the C.N.S. in her study had carried out definitive evaluation of the roles even though an element of research and audit is part of the C.N.S. role. Mc Sherry et al (2002) suggested, the need for nurses to have an evidence base on which to make clinical decisions for patient care and give patient information in a style that is appropriate to patients needs. It is important to evaluate if this new nursing role is primarily meeting the care needs of the patient but also the needs of the department. Nurse preparation for the role requires extensive training and development to provide underpinning theoretical and practical knowledge to a recognised level of competency expected by the Clinical Director of the unit and the individual consultant in whose clinic the nurse will work. In order to do this requires a strong commitment to training and allocation of the 11

12 nursing resource. I want to evaluate the current situation and audit my practice, as there seems little point expanding this Nurse led clinic if the role is not as effective for all concerned, as it is perceived to be. For the purpose of this project I intend to examine this Nursing role and to evaluate it utilising Ovretveit s (1998) work on evaluating health care interventions. This approach is preferred by the author as, Ovretveit s (1998) description of each stage of the evaluation process - eleven stages in all, identifies the whole process of evaluation with the division of responsibility suggesting who may undertake it. This will provide a comprehensive and systematic framework for my study. Literature Review. A systematic review of the literature was undertaken in accordance with Carnwell and Daly s work (2001) the scope of the review was literature published from 1980 to This period was selected as it coincided with the introduction and development of specialist practitioners in the United Kingdom. The absence of published evidence about nurses undertaking post operative cataract clinics required an expansive search to look at the following related key word topics; advanced nursing practice, nurse practitioner roles, nurse specialists, nurse - led clinics, nurse discharge and to determine the context of the study, inequalities in health care provision. To review the literature the following sources were utilised, Cinhal and Med line electronic data bases, Primary research and narrative literature (academic and professional) on nurse led clinics, nurse discharge, the role of the nurse in cataract care and nurse practitioner roles. Commissioned reports included were Action on 12

13 Cataracts (DOH 2000b),The National Plan (DOH 2000a), Patient and consumer organisations, independent policy organisations e.g. Policy studies institute, Kings fund, healthcare charities and disease societies such as the RNIB. Professional bodies - the R.C.N and UKCC. The literature reviewed identified three main themes : Ophthalmic service provision How expanded roles develop in practice Effects of nurse consultation These themes will be considered in relation to Ophthalmic Nursing practice in my unit. Ophthalmic Service Provision A government policy document highlighted the issues surrounding inequalities in health care provision and formulated a plan for service provision ( DOH 2000 a). In related studies it was identified that at the current level of service provision of cataract surgery in England and Wales there would be a shortfall of operations by over 2.5 million in 2001 per head of population age over 65 years.( Minassian et al 2000) This study also estimated that about 700,000 people would die with un -operated impaired vision, this was a need that must be addressed. The government guidance document Action on Cataracts (DOH 2000 b) provided NHS Trusts capital funding to target waiting times for cataract surgery and set the 13

14 standard to ensure all patients can have cataract surgery within 6 months of referral. However recent Government targets demand that this is now 3 months. To achieve this requirement involves streamlining the care pathway to improve efficiency of referral and diagnosis and provide resources which include staff and equipment so that extra surgery may be possible. In 1998,170,000 cataract operations were carried out in England and Wales, the Action on Cataracts plan was to increase this to 250,000 by There are various issues to be considered before this can be achieved, one is number of ophthalmologists / head of population this is 1.7 per 100,000 British residents, this compares less favourably than in Europe and as pointed out by Seward (2002) is the lowest rate in the European Union in comparison France has 8.7, Germany 7.8 Italy 12.8 and Spain 12.5 ophthalmologists per 100,000 of population The government plan was to increase the number of extra consultants by 7,500 by 2004 but with no indication of how many of these posts will be allocated to ophthalmology. Another concern is provision of service is dependant on geographical location and whilst services in some areas may be excellent. there are areas where it may be poor Allen (2002). The demographic changes and the increase in the ageing population has led to increased demand for cataract surgery with reduced waiting times, Allen (2002 : p3) calls for high standards of practice and highly motivated clinical teams to work together, with the support of high quality imaginative managers The influence of effective leadership cannot be underestimated, in motivating 14

15 teams to perform efficiently and maximise resources available. Alimo - Metcalfe and Alban - Metcalfe (2003 : p15) stated the detrimental impact on staff and consequently organisational efficiency were some of the effects of poor leadership. Whilst the funding for resources of extra staff and equipment may be negotiated, there may be other reasons that prohibit the delivery of this standard. Within my trust operating theatre time is at a premium, not having a dedicated ophthalmic theatre, we have only eight operating lists per week allocated for cataract surgery - clearly not enough to meet the demands of our population. In order to maintain our targeted activity, some weekend or evening operating lists have to be undertaken, which require flexible working patterns for staff. It has been suggested by senior managers that the department considers new patterns of work i.e. a 3 session operating day starting earlier and finishing later, to increase the surgical output. This is a short term solution only and would require extra resources of theatre and administration staff and equipment as well as a reorganisation of Consultants clinic sessions.the impact on ophthalmic out-patient attendances would also require an establishment uplift in all areas. Unfortunately, capital funding from Action on Cataracts monies ( DOH 2002 b) was not sufficient to build a dedicated eye theatre, however it is surmised that further demands for surgery in the next few years will force this agenda to be a high priority in the Trust Business Plan. Similar issues in Leeds were resolved by their Primary Care Trusts providing extra theatre resources and out patient clinics via out reach facilities ( Cassels - Brown 15

16 2004) There are other projects in place to meet the demand for cataract surgery, linking the public and private sector. It is proposed that Diagnosis and Treatment Centres, providing a block contract for cataract surgery to Primary Care Trusts may address the need for service provision. However there are concerns raised by Ophthalmologists as the contract is for surgery only and not follow up care and local units are expected to manage the legacy of complications (Brogden 2005) similar concerns have been raised with the provision of cataract surgery from overseas Ophthalmologists. The issue has also been raised concerning the training of future Ophthalmologists, as if this practice were to become the norm there could be a generation of surgeons not skilled in cataract surgery. Britain is not unique in trying to meet the demands of service provision and Cavallieri (2005) explains the Government solution in Italy is to create private clinics which are accredited with local national health service authorities, and are paid by them according to the number of operations performed. In theory this seems to be a solution, but in practice the surgeons are paid only a small percentage of the fee charged %, and problems exist as there is ageing or inadequate instruments to do the surgery, and as there is no support system the surgeon has to be on call for any problems that may arise. Cavallieri (2005) suggests it is not morally correct for Governments to pay competitors of public hospitals to reduce waiting lists, rather resources should be provided within the public sector. It could also be suspected that NHS Foundation Trusts could perpetuate this situation as they will have the independence to commission services from PCT s or other NHS partners and will have greater financial 16

17 freedom to borrow money from the public and private sources, ( Limb 2003) This will enable them to design the services to meet their patient needs and mean they can establish public private partnerships with other organisations. Although the Foundation Trusts will be subject to independent regulation to ensure the licence conditions are maintained, there is still the potential that Britain could be perpetuating a two tier system of Health care, which exists to a certain extent with the postcode lottery where provision of services is dependant on location. This need to increase capacity in local Eye units followed some recommendations included in the framework of the ten year plan (DOH 2000) by encouraging the development of more expanded nursing roles and nurse - led clinics, a solution proposed by the Government as a way to cut hospital waiting times (National Audit Office 2001) and supported by (Dinsdale 1999) It is significant that government legislation has again become a catalyst for nursing development, this started in 1991 with the reduction in junior Doctors hours and in conjunction with the Scope of Professional practice (UKCC 1992) provided the impetus for nurses to expand their roles. In Ophthalmology this legislation legalised the un-official role that had been undertaken by Nurses for years (Read et al 1992 : p ) as expanded roles were originally part of an ophthalmic nurses daily clinical practice. The development of expanded roles Initially confusion existed about the role and use of the title nurse practitioner, this 17

18 has still not been clarified. The terms such as specialist nurse clinical nurse specialist advanced nurse practitioner expert practitioner consultant nurse are used interchangeably and synonymously with each other ( Goodall 2002 ). The title does not guarantee any level of academic status as confirmed by Waterman et al (2003) whose study identified Nurse Consultants practising, in the field of ophthalmology without a recognised qualification in ophthalmic nursing. Perhaps this issue of title will be addressed with the implementation of Agenda for Change (RCN 2002) This proposed strategy aims to link competency and practice to a modernisation of pay and career development, providing financial reward for nurses undertaking advanced clinical practice. In my unit all ophthalmic nurses undertake expanded nursing roles, some at higher level, which includes discharge of post operative patients. It is hoped that this level of responsibility will be recognised and reflected in the pay band awarded, we are still at the negotiation stage with accompanying uncertainties. The pay structure has to be funded through the hospital trust, which is continually in a state of financial overspend, it is difficult to see how the monies will be available, anecdotally it is thought to be another exercise similar to clinical grading and will cause a lot of discontent among various staff groups. In the USA a clinical nurse specialist was identified as a registered nurse who through study and supervised practice at graduate level (masters or doctorate) has become expert in a defined area of knowledge and practice in a selected clinical area of Nursing (American Nurses Association1980 p 23 ) Recently the International Council of Nurses (2002) published a definition and 18

19 described the characteristics of a Nurse Practitioner /Advanced Practice Nurse as A registered nurse who has acquired the expert knowledge base, complex decision making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and or country in which s/he is credentialed to practice. A master s degree is recommended for entry level. Differences exist in the nursing educational structure between Britain and the USA. In the USA student nurses are educated to degree level status, to obtain registration. In Britain, the diploma course is the accepted career structure with individual option to pursue higher education, post registration. This suggestion that masters degree should be held by a Nurse Practitioner (ICN 2002) is contentious. Castledine (1983) thought this level of academic achievement was inappropriate at present in the UK, this still applies today - the NHS Trust scheme has insufficient funds to meet the demands of service provision. It has relied on nurses expanding their roles to meet some of these demands, few nurses undertaking these roles hold a masters qualification but have many years experience in their speciality and have increased their knowledge base to undertake the role (Walsh 2000). In common with specialist ophthalmic practice, Loftus and Weston (2002 : p ) acknowledged that whilst nurses in cancer care should hold a post registration qualification in oncology in order to provide the best quality of care, not every nurse involved in cancer care needs to have a masters degree. However nurses who wish to be leaders in cancer care and develop an advanced practitioner role will obviously require a more specifically focused educational course at a higher level 19

20 Whilst masters level qualification may not be the requirement for the majority of nursing posts, it is feasible that the Nurses of the future will be educated to degree level. This has been recognised nationally and the RCN support a commitment for all pre registration nursing education to be at degree level (Denton 2004). However there is no set timescale for this to be mandatory and the onus remains on the nurse herself to seek higher education in preparation for the expanding roles she wishes to undertake. It can be demonstrated that little has changed over the last decade as Carter (1995) observed the responsibility is left to the individual nurse to identify her own training needs and seek out suitable teaching to develop appropriate skills. Whilst the traditional roles are blurring ( Hunt and Wainwright 1994) which allow for innovative nursing practice to develop, most nurses do not want to be regarded as mini Doctors and Castledine and McGee (1998: p87-92) called for a clearer distinction between Nurses who are primarily focussing on medicine and nurse practitioners who are integrating medicine into their primary nursing role. This former category of nurses have developed their roles to become physicians or surgeons assistants or nurse clinicians working as Doctor s assistants. Their role has been defined as someone who is able to demonstrate the necessary knowledge and skill to supplement and support a physician or surgeon in his/her medical work. They will have acquired knowledge and skill in the medical field and be accountable to a Doctor (Castledine 1997: p ) In ophthalmology nurse practitioner roles developed through the implementation of local policies and protocols devised in conjunction with medical staff Marsden 20

21 (1995: p ) This still applies and was how my protocol was developed for the cataract practitioner role. This is in line with role expansion in general accident and emergency departments as well, Dolan et al (1997) confirmed Accident and emergency medical staff had undertaken most of the teaching with little involvement of local colleges of Nursing. This lack of involvement with formalised educational requirements to confirm the Nurses ability to undertake the role prompted Rose, Waterman and Tullo (1997: p31-37) to suggest there should be some discussion of whether statutory regulation of Nurses extending their roles should be introduced, to ensure such levels of competency. This suggests there should be a trend away from local arrangements towards a formal Nationally recognised attainment of competency. Freeman (2005) supports this view as in house courses are often unaccredited There is work being undertaken currently in conjunction with the Royal College of Ophthalmologists to look at National Occupational Standards in Ophthalmic Practice (Harrison 2002) to formalise attainment of skills and assessment of these skills to denote competency. Practitioners would be assessed and when deemed competent would hold recognised accreditation which would then be transferable. These standards would also be accessible to other members of the multi disciplinary team who are performing the same roles for example, orthoptists, ophthalmic technicians, optometrists and potentially some skills required by junior Doctors such as biometry. Whilst it cannot be argued that practitioners obtaining these skills would be competent to practice, this follows the medical model, rather than the nursing 21

22 model of training looking at a holistic approach to advance nursing practice. The Royal College of Nursing Ophthalmic Nursing Forum are devising a system of assessing a competency for practice framework, this focuses on experiential learning rather than further academic attainment to denote competency for practice, which is in alignment with Agenda for Change (2002) In my experience there are many excellent ophthalmic Nurse Practitioners who do not want to pursue degree level courses but are functioning at that level in practice every day, utilising research evidence, critical thinking skills and maintaining their professional and specialist knowledge, to provide a high quality of patient care. The competency framework acknowledges this experience and expertise. Many studies have been written about the role expertise plays in clinical judgement in comparison to novice practitioners (Benner 1984). One common theme of an expert practitioner is the use of past experience when dealing with clinical situations and states that judgement can be based on causal significance when a particular outcome has been achieved previously, this past knowledge of the situation and what outcome was achieved provides the basis for the clinical decision to be made (Thompson and Dowding 2002) This system of educating nurse practitioners needs to be explored too, as there are increasing expectations of the clinical Nurse Specialist role. Hamric and Spross (1989 p 53) identified direct and indirect sub roles that nurse practitioners have, where direct care functions include those of expert practitioner, role model and patient advocate and indirect care functions which include change agent, consultant resource person clinical teacher, supervisor, researcher, liaison person 22

23 and innovator Quite a high order considering, when launched, the UKCC Scope of Professional Practice (1992) document issued no formal guidelines on attaining competency for role expansion. Denner (1995: p27-9) highlighted although it rejects the need for certificates for extra roles it does nor give any indication as to how the practitioner is to prove that He or she has had any training on how to perform these tasks the onus was on the individual practitioner to prepare themselves for the role and Needham (2000) recommended that ophthalmic Nurse Practitioners have clearly documented guidelines and standards, ensure their role is research based and should carry out their own training needs analysis against this In agreement with this Castledine (2002) confirmed that specialist nurses had become expert in the treatment of the patient in conjunction with the development of strict protocols and guidelines. In ophthalmology there are many opportunities for nursing role expansion, in ophthalmic A&E there is the need for telephone triage to prioritise emergency treatment. In anaesthetics, Mayer (2002) expanded her role to inject sub tenons capsule for local anaesthesia for day case cataract patients. Many units have nurse - led fluorescein clinics and Nurses involved in glaucoma clinics and some ophthalmic Nurses are undertaking YAG capsulotomy. Whilst these opportunities are available it is the individual practitioners responsibility to decide whether to undertake the role and be accountable for that individual Patients care as the UKCC (1996) point out whatever decisions you take and judgements you make, you must be able to justify your actions 23

24 The Nurse Practitioner is also responsible for her own knowledge and competence and should acknowledge any limitations in knowledge and competence and decline any duties or responsibilities unless able to perform them in a safe and skilled manner UKCC (1996) When I was asked to undertake further training to undertake post operative cataract clinics it was an exciting opportunity, to develop the practitioner skills I had used in Eye casualty. I had encountered a few ophthalmic nurses who were undertaking this role and it was thought to be an opportunity for my personal professional development, cost effective for the trust and a quality consultation for the patient. As previously documented (Marsden 1995) training sessions and clinical supervision were undertaken by Consultant Ophthalmologists and protocols for practice were devised and agreed by all the Consultants in the unit, ( see appendix 1 ). As not all Consultants post operative patients are seen by myself, I have only 3 sessions clinically, the individual consultants signed competency certificates for me to manage the care for their patients, this was required as the Consultant retains overall responsibility for their Patients care. This documentary evidence of training and competency is held in my portfolio. This role has been disseminated in our unit with the training of G and F grade Nurses to provide continuity of clinic cover. From personal experience I know the training requirements are demanding. There needs to be a commitment within the department that training should not be interrupted or the Nurse called away to provide cover elsewhere should there be staff sickness. 24

25 In common with my own training it took about 12 months for the practitioners to attain competency and undertake the role without clinical supervision, the practical skills of Anterior segment examination not a problem, the theoretical aspects of Optics and refraction required for underpinning knowledge of operative outcomes taking longer. Effects of Nurse Consultation This role is thought to be successful in my unit and it has been suggested that more clinics should be implemented, before this commitment is made I intend to look for evidence that the role fulfils the criteria of cost effectivity and identify if the management of the patient is comparable to that of a Doctor. There has been no formal audit of the role and this is needed. After searching the literature I discovered that although there is evidence evaluating nurse led clinics and nurse consultation in other fields of nursing, I could find little written about nurse led post operative cataract clinics therefore I decided to evaluate the role in comparison with other findings. Rossi and Freeman (1993: p ) identified that evaluations may be undertaken for a variety of reasons to identify ways to improve the delivery of interventions, or to meet the accountability requirements of funding groups or as in this study to decide whether to expand or curtail programs When considering the design of the evaluation the aim is to provide an assessment that would be unchanged if the evaluation were replicated by either the same evaluators again or another group Rossi and Freeman (1993). 25

26 Within a health service of finite resources it is essential to evaluate the effectiveness of clinical practice, to identify if meets the desired outcomes and benefits in relation to costs ( Rossi and Freeman 1993 ). From the authors perspective as a manager of nursing resources it is important to evaluate the success of the role. The lack of evidence in the literature to support the effectiveness of post operative cataract clinics forced the author to broaden the search to look at the effectiveness of nurse led clinics and nurse practitioner roles to identify common themes, which my study could confirm and gaps where there needs to be further investigation, which my study could help to address. Carnwell and Daly (2001: p59) suggest the self evident gap in knowledge then becomes the justification for conducting empirical research It will be interesting to identify if Patient consultation in Nurse ophthalmic clinics has similar results to other nurse led clinics. The evidence reviewed came to the conclusions that nurse led clinics offer a high quality of consultation for Patients - provide more information than Doctors and give equivalent care Horrocks et al (2002) and Mundinger et al (2003 ) It was found that most studies identified longer consultation times when the patient was seen by a nurse, Byrne (2002) and Kinnersley et al (2003), but this was counter balanced by a high level of patient satisfaction. The studies also showed patients appreciated the length of time spent with them and they received more information and advice about what to do if they experience any deterioration in their condition and nurses provided more accurate documentation in comparison to their medical colleagues. Overall, patients were happy to be seen by a nurse 26

27 and if needed continuing treatment happy to be seen by a nurse again (Byrne et al 2000 and Dinsdale 1999) This evidence is supported by an unpublished study undertaken in the Birmingham and Midland Eye Centre A&E dept in 1999 which was a qualitative study to identify patients perceptions of ophthalmic nurse practitioners, most patients were happy to be treated by a nurse and assumed that they would be attended to by a Doctor should their eye condition warrant, which was a true reflection of practice. Is the Nurse Practitioner Role Cost Effective? The economics of substituting a Nurse for a Doctor is another area considered by my study, evidence can be conflicting Moore (1997: p 26-27) stated nurse - led clinics may not be as cost effective as once thought Lee et al (2004) disputes this, their study results showed that Community health practitioner services in Korea were half the cost, than when the equivalent services were provided by a physician. Sharples et al (2002) concluded nurse practitioners in chronic chest clinics provide safe and effective care as Doctors but may use more resources. Venning et al (2000) and Kinnersley et al (2003) corroborate this when comparing General Practitioners and nurse practitioners in primary care. Nurses carried out more tests and asked the patient to return more often but admitted the care provided was the same. Whereas McInnes and McGhee (1995) found when delivering care for hypertensive patients, shared care between hospital and consultant clinics was more cost effective than either conventional or nurse - 27

28 practitioner follow up. This could have been accounted for by the drop out rate of attendance which was only 3% for the shared care scheme in comparison to 9% for the Nurse Practitioner whose clinic was held at the hospital and 14 % for the Consultants clinic, also held at the hospital, suggesting that patients are more likely to avail themselves of review appointments when they are held locally. It would have been interesting to see the results of this study had the Nurse practitioner clinics been held in the G.P. surgery. Cost effectivity is not just about halving salary costs, it has been suggested that nurse led clinics reduce waiting times. Dinsdale (1999) perceives that is why the government is so supportive of their development. This impact on waiting times has been supported by Williams -Cox (1999) who looked at the effectiveness of a nurse led fast track prostate assessment service not only were the outcomes of results and diagnosis confirmed as 100 % accurate by a consultant urologist ; but the service reduced waiting times from 6 months for an appointment in the general urology clinic to 28 days for a nurse - led service. I am not sure how my role will impact on waiting times as the demand for ophthalmic services increase yearly, but there is no doubt that a nurse to see post op patients frees a Doctor session to see new Patient referrals. Thus ensuring the Trust meets the government standard for out patient waiting times. When comparing salary costs it is not disputed that a nurse hourly rate is less than that of the most junior Doctor. Consultation time in clinic may not be quicker, but Patients are normally seen by Nurses quickly. Byrne (2002 :p108) pointed out that patients in an A&E department waited 40 minutes longer to be seen by a doctor 28

29 rather than by an Emergency Nurse Practitioner, but that the ENP s spent an average of 12 minutes longer than Doctors undertaking the first consultation where the patients needs were assessed and documented however this resulted in an improvement in the quality and depth of information and advice given. I did consider undertaking a patient satisfaction survey in my study to test these findings, however these areas have been explored before and are well documented (Venning et al 2002). I thought the satisfaction survey results could have been biased, if a successful outcome resulted from surgery, it could be expected the patients would have expressed satisfaction with the service provided. If the patient suffered an operative complication and were disappointed this could colour their experience of the service, they may also not feel inclined to point out dissatisfaction if they are still receiving follow up care. One area not explored in the literature was how Nurses feel about undertaking expanded roles, and the impact on Nurse recruitment and retention, this is beyond the scope of my project - in fact it would be the basis for a study on its own This evidence from the literature provides a framework for evaluation of my practice, suggesting themes for data collection. I have devised a proforma for post operative review to undertake a retrospective case note study. Three areas for data collection have been selected 1. Patients eye examination 2. Plan of further management 3. Number of unplanned return visits to clinic - within 4 weeks of post operative review. 29

30 The first two areas will allow for, identification of accurate documentation, similar management of the patient compared to a Doctor ; the third area will highlight any training issues or alteration to management issues for either the Doctor or the Nurse. It is suggested that an evaluation in accordance with these criteria enables comparison with Doctor consultation and will answer the question Do Nurses provide equivalent care? The findings of the study will enable me to make a balanced judgement on the cost effectiveness of nurse post op review in my Eye unit. Theoretical Framework and Methodology A retrospective case note study will be undertaken to provide a comparison between the management of the patient by a Doctor and a Nurse. The case notes will be reviewed using the proforma for eye examination developed in the department as a standard for post operative documentation of eye examination and plan of further management. This methodology was selected in an attempt to eliminate bias, consideration was given to a prospective study where patients would be seen by both the Nurse and the Doctor on the same visit. However the Nurse and the Doctor may alter their examination technique and improve their documentation purely for the study so it may not be a true reflection of their usual practice - historical data would not be manipulated. There may have been ethical issues to consider too - patients may 30

31 not have wanted their eye pressures measured by both a Nurse and a Doctor twice - a key component of the post op examination requiring the instillation of local anaesthetic drops. There would be a massive time implication in the duplication of the clinics. I decided to utilise Ovretveit s (1998) framework to evaluate health interventions to provide a structure and ensure my evaluation is systematic. I chose this framework for simplicity and ease of use. It is demonstrated below how my project fulfils the eleven steps of the evaluation process. 1. Target of the intervention. In my study three Nurse Practitioners post operative clinics were under review as they may be subject to change as a result of the evaluation findings. 2. Description of the intervention. The elements of the intervention were the Nurse practitioner s documentation of the post operative consultation. This included documentation of the eye examination of patients, plan of further management, reasons for further review of patients if ordered and identification of patients who returned to clinic un expectedly within 4 weeks of their post operative consultation 3. Users. The users of the evaluation are nurse practitioners, nurse managers, medical staff, directorate manager, clinical director, operations director. 31

32 4. Value criteria and perspective. Explicit criteria were used on the proforma for post op review so that the value of the intervention could be judged, for example the patient must have had uncomplicated surgery and have no ocular co - morbidity of glaucoma or diabetic retinopathy. These patients are normally reviewed on the first post operative day in our unit, so potentially their management may differ. For the purpose of my study the 3 week review must be the first time the patient had been seen by either the Doctor or the Nurse so a reliable comparison can be made. The perspective of the evaluation was initially from a Nursing concern, to find out if we are providing equivalent care to Doctors and identify if our documentation needs to be improved. From my Nurse Manager perspective I needed to know if the role is cost effective and that patients are not returning to see the doctor after having their review undertaken by a Nurse. This would be duplication of effort and generate more work. From an organisational perspective successful evaluation of this service could lead to further clinics being developed and doctors utilised in other clinical practices. 5. Evaluation question. Do nurses provide equivalent care to Doctors in the management of post operative patients who have had uncomplicated cataract surgery? 32

33 6. Type of evaluation design. This was a retrospective study which required a review of the case notes to compare consultation of post operative patients seen by 3 Nurse Practitioners and Doctors. This utilisation of historical data would enable a judgement to be made on the effectiveness of the Nurse Practitioner so that an informed decision can be made to expand the Nurse - led clinics. 7. Data sources and collection methods - details. The case notes were reviewed of 200 patients with the specific criteria of, uncomplicated cataract surgery and patients who do not have any ocular co - morbidity of glaucoma and diabetic retinopathy. There would be 100 patients who had had their 3 week post op review by the Doctor and 100 patients who had their post op review undertaken by a Nurse. The Doctors notes were selected as a convenience sample from our Electronic Patient Record the first 100 patients meeting these criteria from January December 2001 this period was chosen, following advice from the Trust statistician as there were no nurse post op clinics at that time. The Nurses notes were also selected as a convenience sample of 100 patients from our Electronic Patient Record during the period from January December 2003 this period was chosen as 3 practitioners had achieved their training competencies and were undertaking post op clinics. The post op proforma was used to review the notes, I reviewed the Doctor s notes and a medical colleague, a Staff Grade Ophthalmologist reviewed the nurses notes. 33