- Email: [email protected]
The nurse practitioner role in a United Kingdom ophthalmic accident and emergency department—10 years of progress
The nurse practitioner role in a United Kingdom ophthalmic accident and emergency department-l 0 years of progress Janet Marrden, This article considers a unique, nurse practitioner
BSc (Hons),
MSc, RGN, OND, MlMgt
(NP)-led accident and
emergency service within a large ophthalmic hospital in the United Kingdom. The development of this service from a traditional, ophthalmologist-led department is traced, along with the original intent of the NP role and how it has evolved. Positive and negative aspects of the NP role and the results of the service’s first audit are discussed. The service has proved very successful, and the NP role has been and will continue to be dynamic, with NPs totally committed to delivering the best possible care for their patients. (Insight 1999;24:45-50)
I
n 1988, the accident and emergency (A&E) department at Manchester Roy’ al Eye Hospital (MREH) consisted of a traditional, walk-in service that was staffed by junior doctors. Referrals to the department came from many sources, but patients primarily were self-referred. Approximately 35,000 patients were seen each year in the department, and the amount of time patients waited to be seen could be as long as 5 to 6 hours, mainly because of medical staffing problems. The A&E department was not the primary responsibility of any medical staff; rather, the department was staffed by a rota of junior medical staff and 2 doctors who were rostered to the department for each “session.” The theoretic nature of these sessions resulted from the encroachment of ward rounds, operating room sessions and outpatient clinics, emergency surgery, and a host of other “more important” issues. The problem was often compounded by senior house officers (SHOs-the most junior level of medical staff in the area) who were new to the specialty and lacked the appropriate knowledge and skills to perform competently in this comINSlG)lT
The Journal of the American
plex area. Because the department was open from 8 AM until 9 PM, a significant number of patients often were waiting by the time the doctors arrived. The “out of hours” evening and weekend service was provided by the “on call” SHO. The need for change
Because of the A&E department’s medical staffing problems, life for the nursing staff could be extremely frustrating. Verbal abuse of nurses was common, and although physical abuse occurred much less often, occasional instances occurred. The experienced nursing staff were also extremely conscious that they spent a large proportion of their time teaching doctors new to the specialty how to examine, diagnose, and treat patients who came to the department, often teaching techniques and treatments that they themselves were not authorized to carry out. This problem had been ongoing for a long time with few obvious solutions, and the situation desperately needed to change. The turning point in my search for solutions came when I found a paper in the British Medical JaumaP that described the
Society of Ophthalmic
Registered Nurses, Inc.
Volume
Janet Marsden, BSc @Ions), MSc, RGN, OND, MlMgt, is a senior lecturer and chair, RCN Ophthalmic Nursing Forum, The Manchester Metropolitan University, Department of Health Care Studies, Manchester, England. Reprint requests: lanet Marsden, BSc (Hons), MSc, RGN, OND, MIMgt, 94 Woodsend Rd, Flixton, Manchester, England, M41 BQZ. Copyright 0 7 999 by the American Society of Ophthalmic Registered Nurses. 7 060- 7 35x/99 72/l/9669
$8.00 + 0
7
XXIV, No. 2, April-June
1999
45
Marsden functioning of an ophthalmic A&E department during a &month period. The authors believed that experienced nurses were well able to deal with many minor problems and that the public had no reservations about being treated by a nurse. In their study, ophthalmic nurses saw 57% of patients at the first visit and managed 37% of patients alone. The nursing staff in our department had long believed that their skills could be used more effectively, and this paper strengthened that perception. Historically, ophthalmic nurses had carried out similar roles in many ophthalmic units, especially during “unsocial” hours, but on the whole, these roles had been relinquished becauseof the problems of litigation and accountability. However, the climate in nursing in the United Kingdom suggestedthat these autonomous roles were becoming a possibility again and other areas,particularly general A&E departments, were starting to look at nurse practitioner (NP) roles. This development in practice seemedto be one that might be of use to us.
call” hours, evenings, and weekends or when the department was particularly busy and enough nursing staff were available to enable a member of the team to undertake a different role. The committee drew up a list of possible conditions that would be treatable by an NP, and a smallscale study suggesteda significant measure of agreement between doctors and potential NPs about the care and treatment of these patients. A policy for the role was formulated so that the role would be acceptableto our employers. A protocol for the role was also developed, encompassing the conditions that could be treated by an NP and the drops and ointments that could be “prescribed.” Accountability was considered; the NP would be responsible for her own actions, aswere all the medical staff. Vicarious liability would be acceptedby the Health Authority. The district pharmaceutical officer was happy that a named NP would decide on the use of chloramphenico1and write out a hospital prescription to be dispensed at the pharmacy. A training protocol was also devised. Training would be provided by ophthalmologists who How the changes happened Before any change could be contemplatwould record competence in history taked, I believed that obtaining the support ing, examination techniques, diagnosis, not only of nursing management but also and decision making about treatment and of our medical colleagueswas important. referral. A final assessmentwould be The director of nursing believed that this undertaken by a consultant ophthalmolodevelopment was possible and worth gist who would “sign up” the NP on behalf exploring. I approachedthe principal of the consultant body. author of the British Medical Journal paper The final list of conditions treatableby an who, fortuitously, was now a senior regisNP included the following: chalazion, stye, trar at MREH, and explained my ideas conjunctivitis, minor chemical irritation, about this possible development. He was subconjunctival hemorrhage,trichiasis, extremely supportive and continued to be corneal abrasion,and subtarsaland cornea1 so throughout the entire process.Other foreign bodies. Children under age 16 years medical colleaguesat all levels were would not be examined by NPs, and all approached.Most of these colleagueswere patients would be offered a follow-up enthusiastic about the proposals,although appointment either the next day or within some had reservations,particularly about 48 hours if their condition had not accountability and who would take respon- improved. The NP would refer to the medsibility should any malpractice occur. ical staff all patients about whom she or he The first step in the development of the had any worries. Treatment included the role was to form a committee of clinicians use of topical anesthetics,local anesthetics to discuss its parameters. The role, if (lidocaine), homatropine for therapeutic developed, was intended to be undertakdilation, and the provision of chloramen by the 2 senior sisters in the departphenicol drops or ointment. The nurse ment and would be used to “fill in the could adviseon the useof nonprescription topical treatments such asocular lubricants. gaps” and provide a service during “on-
46
Volume XXIV, No. 2, April-June
1999
INSlGtlT
The Journal of the American
Society of Ophthalmic
Registered Nurses, Inc.
Marsden Training
What has become
Training was very much “sitting by Nellie,” that is, watching and listening to medical staff initially, becoming accustomed to using a slit lamp, and then examining patients ourselves and presenting our findings and thoughts for discussion with the ophthalmologist. Although, as experienced ophthalmic nurses, we could often diagnose patients’ problems at triage, the eye was totally different when seen from behind a slit lamp, and adjusting to the change of assuming ultimate responsibility for patient medical care took some time. However, our confidence and level of competence grew. I was assessed as being competent to be an NP in May 1991, and my colleague qualified about 6 months later.
We had to train a number of our most experienced nurses within 6 months to provide enough NPs to run the new service. Some extra nursing staff cover was made available to us during this time, and we were able to allow supernumerary status for several nurses to undertake some theoretic but mainly practical preparation for this role. Medical staff were withdrawn from the department at the end of August 1993, and the Emergency Eye Centre (EEC) became the nurse-led service that it is today. This change was extremely stressful for all the NPs and support nurses. The responsibilities of NPs changed from choosing certain cases that they would handle and passing all other cases directly to medical staff to examining all patients who enter the department, investigating and diagnosing problems in the majority of cases, treating the patients where appropriate, and referring patients to medical staff when necessary. Extra support was needed by all NPs at this stage, and as the nurse manager and an NP, I became accustomed to receiving telephone calls at my home late at night from NPs who wished to discuss issues that were causing insomnia. This situation settled down eventually as we all became more experienced and the newer NPs became more confident.
The vision and the reality
We started work as fully fledged NPs, fulfilling our vision of the role-intervening during medical staffing shortages and during “on call” hours (as well as undertaking our management roles!). The protocol changed fairly quickly to include the treatment of all children and the provision of fusidic acid (Fucidin). The role worked well; patients proved willing to be seen by an NP, especially if it meant that their wait would be shorter. We had been adamant since we began formulating the role that having NPs on staff would add and not detract from the nursing care within the department. We would not use the role unless nurse staffing levels allowed it. None of the nursing staff were prepared to allow nursing care to be reduced to “fill in” for missing medical staff. As is their tendency, events conspired to change this situation. MREH traditionally has had more patients than it is able to deal with given its allowed medical establishment, leading to a shortage of medical staff. The Royal College of Ophthalmologists decided that the A&E department was not a suitable training ground for junior doctors because no consultant input was available. This change and various others within the health service led to the A&E service being split in two, which led to the formation of an NP-led, walk-in A&E department with no medical presence. INSlGflT
The Journal of the American
of the NP role
Problems
We identified several problems associated with the new role. Our uniforms were not conducive to sitting comfortably at a slit lamp, being fairly straight dresses with little room for movement. This situation led to interesting experiences of trying to protect the nurses’ modesty and keep the patient’s concentration on the consultation. This problem was eventually resolved by the introduction of a new uniform including trousers and a dress with more pleats to allow freer movement. New seating alleviated to some extent the newly discovered backache caused by working at the slit lamp for long periods. The NPs are aware that their performance is maximized by taking breaks from the consulting room during the shift.
Society of Ophthalmic
Registered Nurses, Inc.
Volume
XXIV, No. 2, April-June
1999
47
Marsden The vulnerability of the nursesto involvement in litigation quickly becameapparent. NPs arenow askedto write statementsand medical reportsfor lawyersabout their patients. The possibilitiesof actually having to appearin court are alsoreal, although this situation hasnot yet occurred. Various clinical problems became apparent, and the NP’s scope has been expanded to include pupilary dilation for diagnostic purposesand the treatment of other problems. “Prescribing” became an issue after we had written hospital prescriptions for 18 months when it was decided that writing such prescriptions probably was not legal. Instead, the NP fills in a prepared pro forma with tick boxes,which is signed in facsimile by the clinical director! (Specialist nurses in the United Kingdom do not have prescribing rights yet, although this situation is likely to change within the next few years.) The role of the NP
The scopeof the NP now includes the treatment of the following: . Conjunctivitis (viral, bacterial, allergic) . Blepharitis . Trichiasis . Concretions . Foreign bodies (conjunctival, corneal, subtarsal) . Cornea1and conjunctival abrasions . Conjunctival lacerations . Minor chemical injury . Drainageof conjunctival cysts . we . Chalazion . Removal of loose cornea1 suturesfollowing cataract extraction at least 6 months previously . Minor contact lens problems . Dry eyes NPsreferpatientsto optometrists,orthoptists, and ophthalmologistsif the patient’s problem requiresearly intervention by medical staff.Patientsarealsoreferredto the consultant teamsor backto their generalpraciitioner for medical treatment or referral. The NPs undertake the treatment of all patients with straightforward chalaziawho 48
Volume
XXIV, No. 2, April-June
1999
INSKIll
are referredto the hospital, and the NPs also undertake a preassessmentclinic and a list of chalazion proceduresweekly. This role is not new to the NPs but hasbeen an extended role within the department for many years.Patientswhose lid lesion is not a chalazion are referredto medical staff, either directly to a surgical list or urgently for an opinion if required. NP training
and assessment
NP training and assessmenthas also changedwith time and is now undertaken by establishedNPs. The training is still very much “sitting by Nellie,” and the training period has no time limit. Eachnurse has different experiencesand will take a different amount of time to become confident in the techniques neededto practice.A longitudinal assessmenttakesplace and a training booklet is signedas appropriateby experiencedpractitioners asthe trainee is instructed and becomescompetent in examination techniques,recognition of pathology, diagnosis, and decision making regardingtreatment, follow up, and referral.The trainee NP is not supernumerarywithin the department but has designated“sessions”when training takesplace (staffing levelsallowing!). Sessions arealso organizedin which the NP trainee can have some input from medical staff and thus gain a different perspectiveon aspectsof care.When the NP trainee believeshe or she is competent, a formal clinical assessmenttakesplaceover 2 half days to maximize the variety of clinical situations. Within this assessment,which presently is undertakenby myself, several scenariosareusedto facilitate discussion about lesscommon presentationsto the EEC and their investigation, diagnosis,and treatment. After successfulassessment,the new NP undertakesa period of “accompanied” practice in which shehas a more experiencedpractitioner with whom to consult until she is confident within the new role. Outcome
of the role
A survey of patient outcomes in the EEC was undertaken after the EEC service had been operating for a year. A total of 19,969 patent episodes (including 1809 follow-up appointments) took place during this time period.
The Journal of the American
Society of Ophthalmic
Registered Nurses, Inc.
Marsden During the 1Zmonth period, 67.6% of all patients were dischargedby the NPs, and 7.9% received a follow-up appointment and were subsequently discharged.A total of 75.5% of patients were cared for by an NP alone; 22.2% of patients were referred to ophthalmologists on an urgent basis,and a very small number were referred to other areasof the hospital. Patients seenwithin a single month were considered in more detail and were divided into “new” patients who had not attended the hospital previously and “old” patients who had either previously attended A&E/EEC or had hospital notes. Of the new patients, 80.3% were discharged from EEC and 18.5% were referred for an urgent ophthalmologist’s opinion; 1.3% were referred directly to the outpatient department. Of the “old” patients, 64.2% were discharged from the EEC, 23.8% were referred to ophthalmologists, 6% were referred directly to an outpatient department, and the notes of 6% were sent to their consultant’s team for a follow-up appointment. “Old” patients are likely to have many more complex problems, and this likelihood is reflected in the lower numbers dealt with solely by the NP. Successes
These figures indicate that the service is successful. In many areas of the United Kingdom in which NP roles are in place, the NPs are able to choose their patients and patients are able to choose a consultation with a doctor if they wish. The EEC is unique in that the NPs do not have immediate accessto medical staff and must examine and diagnose and make decisions about the care of the patient. That 75% of our walk-in patients are treated solely by an NP compares very favorably with the results of Jones et al, who found that 37% of patients could be treated solely by a nurse. Patients at the EECdo not have the option of seeinga doctor, and surprisingly, in our experiencethis situation has not been a problem. Patients seem to be content to seea nurse rather than a doctor and value the extra time the NP is able to spend INSlGm
The Journal of the American
with them. Our regular patients (eg, for removal of lashes)have good relationships with the NPs and may arrangeto have an appointment with someonein particular. Waiting times have been reduced becausewe are able to provide a seamless serviceand adequatelycover the total hours we areopen, although sicknessstill causesus some problems; SHOshave had to cover for NPs on occasion! Patient care has improved. The NPs are able to spend time with patients and give holistic medical and nursing care rather than having these tasksdevolve to different clinicians. The NPs take time to provide health education and to ensurethat the patient knows exactly what is happening to them in terms of diagnosis, treatment, and follow-up. Continuity of care can be facilitated by timing follow-up appointments to coincide with times that the NP who initially saw the patient is on duty. If such scheduling is not possible, a handover is given to the NP who will assume the patient’s care. NPs have increased job satisfaction under this system. Although the stress of the role can be high, the satisfaction of providing total care for patients is great. On the whole, medical colleagues have been extremely supportive, both during the setting up period and subsequently. Problems
The unavailability of ophthalmologists can occasionally result in triage anomalies in which high-priority patients wait longer for appropriate medical care than do patients who have much less urgent problems. Another significant issueis that of “deskilling” of medical staff. The NP-led EEC ensuresthat junior medical staff very rarely deal with conditions such as conjunctivitis, foreign bodies, or blepharitis, and even more rarely undertake the incision and curettageof chalazia. Fortunately, no SHOs at MREH are new to ophthalmology, but this issue is still significant and has been a problem on a number of occasions. A more academic preparation for the role would be preferablebut does not appearpossible at present.
Society of Ophthalmic
Registered Nurses, Inc.
Volume XXIV, No. 2, April-June
1999
49
Marsden The future
After 5 years of preparation and 5 years of practice, the service seems to be a success. It is still the only wholly NP-led ophthalmic A&E department in the United Kingdom. A 5-year review is in progress. The NP role is dynamic and will change with time. Discussions are ongoing, for example, about the possible use by nurses of nonsteroidal anti-inflammatory drops in the treatment of episcleritis. A location change is planned for the EEC, and it will become a separatearea within a general A&E department. Only time will tell how
this change will affect the service that the NPs are able to provide. Whatever changesoccur within this successfuland unique service,the NPs must ensurethat they do not take on more and more of the work that others no longer wish to do. They arenot and do not want to be “mini-doctors.” Any development must be for the ultimate benefit of patients, and the NPs aretotally committed to this aim. Reference 1. Jones NP, Hayward JM, Khaw PT, Claoue CM, Elkington A. Function of an ophthalmic “accident and emergency” department: results a six month survey. Br Med J 1986;292:188-90.
Did You Know? Fresh Start volunteers
Surgical
Gifts Inc seeks nurse
Eight to ten times a year, Fresh Start assembles a surgical team to perform 10 to 15 operations during a weekend on children in need, Fresh Start is located in Southern California. If you would like to know more about this organization, call Allison Saxman, RN, at (760) 944-7774, e-mail [email protected],or visit their Web site, FSSG.org. APH releases “Listening for the blind or visually
50
Volume
to Windows impaired
95”
The American Printing House for the Blind, Inc, in a joint project with TECSO, Inc, has released its interactive CD-ROM tutorial for Windows 95. The kit contains tactile and large print guides to screen layouts, a manual available in 4 accessible media, and the first interactive auditory software to teach Windows basics. The product received excellent reviews during field tests with adults and students in residential and public schools throughout the United States. Current list price is $150. For more information, contact APH for the Blind, Inc, telephone (800) 223-1839, e-mail [email protected], or visit their Web site
Harvard Ranch Publishing offers a series of large print books for the elderly or visually impaired. Included in the series are Verses from the Bible, A Walk in the Garden and Favorite Hymns. Each book is 9 x 12 and printed on 100 lb book stock with matte finish in 18 pt font. The hardbound books lay flat when open. The print is museum quality color and very high contrast and can be viewed well with additional magnification. Order toll free (800) 815-9533 or on-line at
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XXIV, No. 2, April-June
1999
INWiT
Sample cover of a Harvard
Ranch
Publishing
large print book.
HRP releases series of large print books for the elderly or visually impaired
The Journal of the American
Society of Ophthalmic
Registered Nurses, Inc.
BSc (Hons),
MSc, RGN, OND, MlMgt
(NP)-led accident and
emergency service within a large ophthalmic hospital in the United Kingdom. The development of this service from a traditional, ophthalmologist-led department is traced, along with the original intent of the NP role and how it has evolved. Positive and negative aspects of the NP role and the results of the service’s first audit are discussed. The service has proved very successful, and the NP role has been and will continue to be dynamic, with NPs totally committed to delivering the best possible care for their patients. (Insight 1999;24:45-50)
I
n 1988, the accident and emergency (A&E) department at Manchester Roy’ al Eye Hospital (MREH) consisted of a traditional, walk-in service that was staffed by junior doctors. Referrals to the department came from many sources, but patients primarily were self-referred. Approximately 35,000 patients were seen each year in the department, and the amount of time patients waited to be seen could be as long as 5 to 6 hours, mainly because of medical staffing problems. The A&E department was not the primary responsibility of any medical staff; rather, the department was staffed by a rota of junior medical staff and 2 doctors who were rostered to the department for each “session.” The theoretic nature of these sessions resulted from the encroachment of ward rounds, operating room sessions and outpatient clinics, emergency surgery, and a host of other “more important” issues. The problem was often compounded by senior house officers (SHOs-the most junior level of medical staff in the area) who were new to the specialty and lacked the appropriate knowledge and skills to perform competently in this comINSlG)lT
The Journal of the American
plex area. Because the department was open from 8 AM until 9 PM, a significant number of patients often were waiting by the time the doctors arrived. The “out of hours” evening and weekend service was provided by the “on call” SHO. The need for change
Because of the A&E department’s medical staffing problems, life for the nursing staff could be extremely frustrating. Verbal abuse of nurses was common, and although physical abuse occurred much less often, occasional instances occurred. The experienced nursing staff were also extremely conscious that they spent a large proportion of their time teaching doctors new to the specialty how to examine, diagnose, and treat patients who came to the department, often teaching techniques and treatments that they themselves were not authorized to carry out. This problem had been ongoing for a long time with few obvious solutions, and the situation desperately needed to change. The turning point in my search for solutions came when I found a paper in the British Medical JaumaP that described the
Society of Ophthalmic
Registered Nurses, Inc.
Volume
Janet Marsden, BSc @Ions), MSc, RGN, OND, MlMgt, is a senior lecturer and chair, RCN Ophthalmic Nursing Forum, The Manchester Metropolitan University, Department of Health Care Studies, Manchester, England. Reprint requests: lanet Marsden, BSc (Hons), MSc, RGN, OND, MIMgt, 94 Woodsend Rd, Flixton, Manchester, England, M41 BQZ. Copyright 0 7 999 by the American Society of Ophthalmic Registered Nurses. 7 060- 7 35x/99 72/l/9669
$8.00 + 0
7
XXIV, No. 2, April-June
1999
45
Marsden functioning of an ophthalmic A&E department during a &month period. The authors believed that experienced nurses were well able to deal with many minor problems and that the public had no reservations about being treated by a nurse. In their study, ophthalmic nurses saw 57% of patients at the first visit and managed 37% of patients alone. The nursing staff in our department had long believed that their skills could be used more effectively, and this paper strengthened that perception. Historically, ophthalmic nurses had carried out similar roles in many ophthalmic units, especially during “unsocial” hours, but on the whole, these roles had been relinquished becauseof the problems of litigation and accountability. However, the climate in nursing in the United Kingdom suggestedthat these autonomous roles were becoming a possibility again and other areas,particularly general A&E departments, were starting to look at nurse practitioner (NP) roles. This development in practice seemedto be one that might be of use to us.
call” hours, evenings, and weekends or when the department was particularly busy and enough nursing staff were available to enable a member of the team to undertake a different role. The committee drew up a list of possible conditions that would be treatable by an NP, and a smallscale study suggesteda significant measure of agreement between doctors and potential NPs about the care and treatment of these patients. A policy for the role was formulated so that the role would be acceptableto our employers. A protocol for the role was also developed, encompassing the conditions that could be treated by an NP and the drops and ointments that could be “prescribed.” Accountability was considered; the NP would be responsible for her own actions, aswere all the medical staff. Vicarious liability would be acceptedby the Health Authority. The district pharmaceutical officer was happy that a named NP would decide on the use of chloramphenico1and write out a hospital prescription to be dispensed at the pharmacy. A training protocol was also devised. Training would be provided by ophthalmologists who How the changes happened Before any change could be contemplatwould record competence in history taked, I believed that obtaining the support ing, examination techniques, diagnosis, not only of nursing management but also and decision making about treatment and of our medical colleagueswas important. referral. A final assessmentwould be The director of nursing believed that this undertaken by a consultant ophthalmolodevelopment was possible and worth gist who would “sign up” the NP on behalf exploring. I approachedthe principal of the consultant body. author of the British Medical Journal paper The final list of conditions treatableby an who, fortuitously, was now a senior regisNP included the following: chalazion, stye, trar at MREH, and explained my ideas conjunctivitis, minor chemical irritation, about this possible development. He was subconjunctival hemorrhage,trichiasis, extremely supportive and continued to be corneal abrasion,and subtarsaland cornea1 so throughout the entire process.Other foreign bodies. Children under age 16 years medical colleaguesat all levels were would not be examined by NPs, and all approached.Most of these colleagueswere patients would be offered a follow-up enthusiastic about the proposals,although appointment either the next day or within some had reservations,particularly about 48 hours if their condition had not accountability and who would take respon- improved. The NP would refer to the medsibility should any malpractice occur. ical staff all patients about whom she or he The first step in the development of the had any worries. Treatment included the role was to form a committee of clinicians use of topical anesthetics,local anesthetics to discuss its parameters. The role, if (lidocaine), homatropine for therapeutic developed, was intended to be undertakdilation, and the provision of chloramen by the 2 senior sisters in the departphenicol drops or ointment. The nurse ment and would be used to “fill in the could adviseon the useof nonprescription topical treatments such asocular lubricants. gaps” and provide a service during “on-
46
Volume XXIV, No. 2, April-June
1999
INSlGtlT
The Journal of the American
Society of Ophthalmic
Registered Nurses, Inc.
Marsden Training
What has become
Training was very much “sitting by Nellie,” that is, watching and listening to medical staff initially, becoming accustomed to using a slit lamp, and then examining patients ourselves and presenting our findings and thoughts for discussion with the ophthalmologist. Although, as experienced ophthalmic nurses, we could often diagnose patients’ problems at triage, the eye was totally different when seen from behind a slit lamp, and adjusting to the change of assuming ultimate responsibility for patient medical care took some time. However, our confidence and level of competence grew. I was assessed as being competent to be an NP in May 1991, and my colleague qualified about 6 months later.
We had to train a number of our most experienced nurses within 6 months to provide enough NPs to run the new service. Some extra nursing staff cover was made available to us during this time, and we were able to allow supernumerary status for several nurses to undertake some theoretic but mainly practical preparation for this role. Medical staff were withdrawn from the department at the end of August 1993, and the Emergency Eye Centre (EEC) became the nurse-led service that it is today. This change was extremely stressful for all the NPs and support nurses. The responsibilities of NPs changed from choosing certain cases that they would handle and passing all other cases directly to medical staff to examining all patients who enter the department, investigating and diagnosing problems in the majority of cases, treating the patients where appropriate, and referring patients to medical staff when necessary. Extra support was needed by all NPs at this stage, and as the nurse manager and an NP, I became accustomed to receiving telephone calls at my home late at night from NPs who wished to discuss issues that were causing insomnia. This situation settled down eventually as we all became more experienced and the newer NPs became more confident.
The vision and the reality
We started work as fully fledged NPs, fulfilling our vision of the role-intervening during medical staffing shortages and during “on call” hours (as well as undertaking our management roles!). The protocol changed fairly quickly to include the treatment of all children and the provision of fusidic acid (Fucidin). The role worked well; patients proved willing to be seen by an NP, especially if it meant that their wait would be shorter. We had been adamant since we began formulating the role that having NPs on staff would add and not detract from the nursing care within the department. We would not use the role unless nurse staffing levels allowed it. None of the nursing staff were prepared to allow nursing care to be reduced to “fill in” for missing medical staff. As is their tendency, events conspired to change this situation. MREH traditionally has had more patients than it is able to deal with given its allowed medical establishment, leading to a shortage of medical staff. The Royal College of Ophthalmologists decided that the A&E department was not a suitable training ground for junior doctors because no consultant input was available. This change and various others within the health service led to the A&E service being split in two, which led to the formation of an NP-led, walk-in A&E department with no medical presence. INSlGflT
The Journal of the American
of the NP role
Problems
We identified several problems associated with the new role. Our uniforms were not conducive to sitting comfortably at a slit lamp, being fairly straight dresses with little room for movement. This situation led to interesting experiences of trying to protect the nurses’ modesty and keep the patient’s concentration on the consultation. This problem was eventually resolved by the introduction of a new uniform including trousers and a dress with more pleats to allow freer movement. New seating alleviated to some extent the newly discovered backache caused by working at the slit lamp for long periods. The NPs are aware that their performance is maximized by taking breaks from the consulting room during the shift.
Society of Ophthalmic
Registered Nurses, Inc.
Volume
XXIV, No. 2, April-June
1999
47
Marsden The vulnerability of the nursesto involvement in litigation quickly becameapparent. NPs arenow askedto write statementsand medical reportsfor lawyersabout their patients. The possibilitiesof actually having to appearin court are alsoreal, although this situation hasnot yet occurred. Various clinical problems became apparent, and the NP’s scope has been expanded to include pupilary dilation for diagnostic purposesand the treatment of other problems. “Prescribing” became an issue after we had written hospital prescriptions for 18 months when it was decided that writing such prescriptions probably was not legal. Instead, the NP fills in a prepared pro forma with tick boxes,which is signed in facsimile by the clinical director! (Specialist nurses in the United Kingdom do not have prescribing rights yet, although this situation is likely to change within the next few years.) The role of the NP
The scopeof the NP now includes the treatment of the following: . Conjunctivitis (viral, bacterial, allergic) . Blepharitis . Trichiasis . Concretions . Foreign bodies (conjunctival, corneal, subtarsal) . Cornea1and conjunctival abrasions . Conjunctival lacerations . Minor chemical injury . Drainageof conjunctival cysts . we . Chalazion . Removal of loose cornea1 suturesfollowing cataract extraction at least 6 months previously . Minor contact lens problems . Dry eyes NPsreferpatientsto optometrists,orthoptists, and ophthalmologistsif the patient’s problem requiresearly intervention by medical staff.Patientsarealsoreferredto the consultant teamsor backto their generalpraciitioner for medical treatment or referral. The NPs undertake the treatment of all patients with straightforward chalaziawho 48
Volume
XXIV, No. 2, April-June
1999
INSKIll
are referredto the hospital, and the NPs also undertake a preassessmentclinic and a list of chalazion proceduresweekly. This role is not new to the NPs but hasbeen an extended role within the department for many years.Patientswhose lid lesion is not a chalazion are referredto medical staff, either directly to a surgical list or urgently for an opinion if required. NP training
and assessment
NP training and assessmenthas also changedwith time and is now undertaken by establishedNPs. The training is still very much “sitting by Nellie,” and the training period has no time limit. Eachnurse has different experiencesand will take a different amount of time to become confident in the techniques neededto practice.A longitudinal assessmenttakesplace and a training booklet is signedas appropriateby experiencedpractitioners asthe trainee is instructed and becomescompetent in examination techniques,recognition of pathology, diagnosis, and decision making regardingtreatment, follow up, and referral.The trainee NP is not supernumerarywithin the department but has designated“sessions”when training takesplace (staffing levelsallowing!). Sessions arealso organizedin which the NP trainee can have some input from medical staff and thus gain a different perspectiveon aspectsof care.When the NP trainee believeshe or she is competent, a formal clinical assessmenttakesplaceover 2 half days to maximize the variety of clinical situations. Within this assessment,which presently is undertakenby myself, several scenariosareusedto facilitate discussion about lesscommon presentationsto the EEC and their investigation, diagnosis,and treatment. After successfulassessment,the new NP undertakesa period of “accompanied” practice in which shehas a more experiencedpractitioner with whom to consult until she is confident within the new role. Outcome
of the role
A survey of patient outcomes in the EEC was undertaken after the EEC service had been operating for a year. A total of 19,969 patent episodes (including 1809 follow-up appointments) took place during this time period.
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Marsden During the 1Zmonth period, 67.6% of all patients were dischargedby the NPs, and 7.9% received a follow-up appointment and were subsequently discharged.A total of 75.5% of patients were cared for by an NP alone; 22.2% of patients were referred to ophthalmologists on an urgent basis,and a very small number were referred to other areasof the hospital. Patients seenwithin a single month were considered in more detail and were divided into “new” patients who had not attended the hospital previously and “old” patients who had either previously attended A&E/EEC or had hospital notes. Of the new patients, 80.3% were discharged from EEC and 18.5% were referred for an urgent ophthalmologist’s opinion; 1.3% were referred directly to the outpatient department. Of the “old” patients, 64.2% were discharged from the EEC, 23.8% were referred to ophthalmologists, 6% were referred directly to an outpatient department, and the notes of 6% were sent to their consultant’s team for a follow-up appointment. “Old” patients are likely to have many more complex problems, and this likelihood is reflected in the lower numbers dealt with solely by the NP. Successes
These figures indicate that the service is successful. In many areas of the United Kingdom in which NP roles are in place, the NPs are able to choose their patients and patients are able to choose a consultation with a doctor if they wish. The EEC is unique in that the NPs do not have immediate accessto medical staff and must examine and diagnose and make decisions about the care of the patient. That 75% of our walk-in patients are treated solely by an NP compares very favorably with the results of Jones et al, who found that 37% of patients could be treated solely by a nurse. Patients at the EECdo not have the option of seeinga doctor, and surprisingly, in our experiencethis situation has not been a problem. Patients seem to be content to seea nurse rather than a doctor and value the extra time the NP is able to spend INSlGm
The Journal of the American
with them. Our regular patients (eg, for removal of lashes)have good relationships with the NPs and may arrangeto have an appointment with someonein particular. Waiting times have been reduced becausewe are able to provide a seamless serviceand adequatelycover the total hours we areopen, although sicknessstill causesus some problems; SHOshave had to cover for NPs on occasion! Patient care has improved. The NPs are able to spend time with patients and give holistic medical and nursing care rather than having these tasksdevolve to different clinicians. The NPs take time to provide health education and to ensurethat the patient knows exactly what is happening to them in terms of diagnosis, treatment, and follow-up. Continuity of care can be facilitated by timing follow-up appointments to coincide with times that the NP who initially saw the patient is on duty. If such scheduling is not possible, a handover is given to the NP who will assume the patient’s care. NPs have increased job satisfaction under this system. Although the stress of the role can be high, the satisfaction of providing total care for patients is great. On the whole, medical colleagues have been extremely supportive, both during the setting up period and subsequently. Problems
The unavailability of ophthalmologists can occasionally result in triage anomalies in which high-priority patients wait longer for appropriate medical care than do patients who have much less urgent problems. Another significant issueis that of “deskilling” of medical staff. The NP-led EEC ensuresthat junior medical staff very rarely deal with conditions such as conjunctivitis, foreign bodies, or blepharitis, and even more rarely undertake the incision and curettageof chalazia. Fortunately, no SHOs at MREH are new to ophthalmology, but this issue is still significant and has been a problem on a number of occasions. A more academic preparation for the role would be preferablebut does not appearpossible at present.
Society of Ophthalmic
Registered Nurses, Inc.
Volume XXIV, No. 2, April-June
1999
49
Marsden The future
After 5 years of preparation and 5 years of practice, the service seems to be a success. It is still the only wholly NP-led ophthalmic A&E department in the United Kingdom. A 5-year review is in progress. The NP role is dynamic and will change with time. Discussions are ongoing, for example, about the possible use by nurses of nonsteroidal anti-inflammatory drops in the treatment of episcleritis. A location change is planned for the EEC, and it will become a separatearea within a general A&E department. Only time will tell how
this change will affect the service that the NPs are able to provide. Whatever changesoccur within this successfuland unique service,the NPs must ensurethat they do not take on more and more of the work that others no longer wish to do. They arenot and do not want to be “mini-doctors.” Any development must be for the ultimate benefit of patients, and the NPs aretotally committed to this aim. Reference 1. Jones NP, Hayward JM, Khaw PT, Claoue CM, Elkington A. Function of an ophthalmic “accident and emergency” department: results a six month survey. Br Med J 1986;292:188-90.
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XXIV, No. 2, April-June
1999
INWiT
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large print book.
HRP releases series of large print books for the elderly or visually impaired
The Journal of the American
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Registered Nurses, Inc.