Abstract
Aims:
We aim to identify the educational needs and feasible educational modalities for specialist nurses working with ophthalmic patients in a tertiary eye centre in Singapore.
Design:
This was a mixed-method study utilising paper-based surveys and focus groups with nurses working at a tertiary eye centre in Singapore.
Participants:
One hundred nurses were invited to respond to the survey, with a response rate of 91%. Two focus groups with a total of 19 nurses were facilitated.
Methods:
Participants completed a modified Hennessy–Hicks survey. Among these participants 19 were invited to participate in a focus group. Descriptive statistical analysis was performed on the survey results. Focus groups were analysed using the inductive thematic analysis procedure described by Braun and Clarke.
Findings:
The participants in this study reported a need for ophthalmic-specific education programmes, more training in patient education and a need to broaden clinical exposure and experience.
Conclusion:
For ophthalmic nursing, where the workforce and patient population are considered relatively small, and postgraduate programmes are limited, the need to develop local education strategies to meet workforce needs has emerged.
Introduction
Ophthalmic nursing is a small and highly specialised field of nursing that has undergone significant and rapid change in the past two decades. Improvements in technology have seen a shift from episodic inpatient care with an acute orientation to ambulatory care for most ophthalmic procedures. The majority of pre-registration nursing programmes prepare graduates for practice in a range of settings including outpatients, the community and acute inpatient care. However, in many pre-registration nursing curriculums, the competing demands of ‘essential’ content have resulted in an overburdened curriculum focusing on acute inpatient care. There is often little time in this curriculum to address the needs of specialty areas such as ophthalmic nursing, with an assumption that if graduates enter these specialities, the employing organisation will provide specialist education and training.
In addition, the transfer of nurse education into the tertiary sector has disadvantaged small specialties such as ophthalmic nursing, as the numbers of nurses wanting to enrol in specialist courses may fall below the numbers required by a university for financial viability. Previously, specialist hospitals, such as Moorfields Eye Hospital in London, were accredited to offer in-house ophthalmic nursing education programmes, for example, the ENB 346 qualification. Nurses undertaking these programmes generally worked in a salaried ‘student’ capacity at the hospital while studying and gained both theoretical knowledge and practical experience. Despite these institutions only offering limited numbers of places, the result was that the majority of nurses working in ophthalmology tended to have a formal recognised specialist qualification. This is in contrast to ophthalmic nurses today, with many having ‘learnt on the job’ and through ad hoc attendance at professional development seminars. 1 Globally, ophthalmic nurses have voiced concern at the lack of formalised education programmes available to them.1–4 Indeed, education, professional development and experience have all been acknowledged as being essential for clinical decision making. 5 Despite these concerns, there is a dearth of information about the educational and training needs of the ophthalmic nursing workforce, with only two major studies being published, both in the United Kingdom, in the past two decades.1,2,6 However, these studies, and an additional study in New Zealand comparing advanced practice roles in ophthalmic nursing, identified a lack of formalised professional development opportunities and the need for more consistent training for ophthalmic nurses.2,7
Ageing populations globally have resulted in an increase in the incidence of eye diseases. The economic burden of eye disease and visual impairment in the United States is estimated to cost $139 billion annually. 8 Data relating to the epidemiology of eye disease in Asia concurs with this estimated growth in eye disease throughout Asia. 9 This increase in eye disease will therefore demand more ophthalmic-trained nurses to provide services at both tertiary and primary levels.
This paper presents the findings from a study which explored the educational needs of registered and enrolled nurses delivering ophthalmic nursing care in a major tertiary eye centre in Singapore. In addition, the study aimed to identify feasible educational modalities and programme content.
Methods
This descriptive research study used a mixed-methods approach to collect diverse types of data that best described an understanding of the research problem. 10 The study included a survey combined with semi-structured, face-to-face focus group interviews, conducted using a pre-prepared interview guide.
Data collection
For this study, 100 participants were invited to complete the modified Hennessy–Hicks survey during a 1-week period in 2014. Response rate was 91%.
The survey used a modified Hennessy–Hicks survey. This is a validated survey that identifies and prioritises training needs.11–13 The instrument has five sub-sections, which facilitates the collection of training needs in broad categories and allows comparison between categories. The instrument has been used across a number of sub-specialty areas in nursing, and has been used to identify training needs as well as to evaluate the effectiveness of training. 14 The modified Hennessy–Hicks survey has been validated across cultures, including Asia.15–18 Licensed to the World Health Organisation, 15 this tool is a psychometrically valid training needs assessment instrument that can identify occupational roles and the educational and training needs of the respondents. Results from the survey informed the questions used in the focus groups.
Two focus groups (n=19) were conducted with nursing staff purposively selected from across all areas of the institution including outpatient clinics, day surgery and operating theatres. Focus groups lasted 1 hour and were conducted by the researcher. Focus groups were conducted in a neutral setting to facilitate open discussion and dialogue providing an in-depth understanding of the perceptions of education and training. A semi-structured interview process using an interview guide guided discussion. This process involved the researcher developing a set of key questions to guide the session (Table 1); however, there is considerable flexibility that allows for additional topics to be discussed. 19
Interview guide.
Throughout the group interviews, and also at the end, the researcher verified verbally the participants’ statements to ensure an accurate account, ensuring that the study findings reflected the participants’ own experiences. The level of data saturation was determined by the main researcher. Nineteen participants were engaged in the focus group discussions.
Data analysis was carried out by two researchers. The transcripts were independently coded by the researchers to ensure consistency in interpretation of the themes. The researchers then discussed findings and codings and integrated these with the survey data.
This study received an exemption from the Singhealth Centralised Institutional Review Board (R1133/35/2014); however, the tenets of the declaration of Helsinki were adhered to throughout the study and participant confidentiality was maintained at all times.
Data analysis
The Hennessy–Hicks survey measures 30 activities in five broad health-related categories: clinical, research, communication, administrative and management. The survey involves participants rating the importance of a range of skills, and the level to which they currently perform those tasks along a 7-point Likert scale. Comparison of the scores for importance and performance prioritises training needs. Ordinal-scale data from the surveys were analysed and reported using descriptive statistics to measure central tendency and variability. A frequency analysis was conducted that tabulated responses expressed as percentages (Table 2). The mean difference between variables of importance and confidence are presented in Table 3. Confidence related to individual belief in the ability to perform roles/tasks competently, while importance was how participants prioritised the role/task.
Confidence and importance ratings.
Summary of training needs assessment.
Focus group interviews were tape recorded and transcribed verbatim. The qualitative data were analysed using a thematic analysis process informed by the inductive thematic analysis procedure described by Braun and Clarke. 20 This validated, six-step process involves: (1) immersing oneself in the data and becoming familiar with the data; (2) generating initial codes; (3) searching for themes; (4) reviewing and refining themes; (5) defining and naming themes, and (6) producing a report. Initially, significant statements and phrases pertaining to perceptions of training and education were extracted from the transcript and repeating patterns across multiple responses from the focus groups were identified and coded. The identified patterns were then compared with the research question so that problems and opportunities for improvement could be further explored. The researcher aligned corresponding nurses’ survey data with each of the identified themes.
Integration of quantitative and qualitative data
The availability of both quantitative (survey) and qualitative (transcripts from focus groups) data resulted in a convergence coding matrix whereby results from each element of the study were coded and then examined for agreement, partial agreement or disagreement. This process of triangulation compels researchers to consider how results relate to each other.21–23
Results
The 91 participating nurses worked in three different clinical areas: outpatients, day ward and operating theatres. The clinical experience of participants ranged from three months to 22 years. Of the 91 participants, 74% (n=67) were Registered Nurses while 26% (n=24) were Enrolled Nurses. More than 30% of the cohort had obtained a tertiary degree; however, less than 5% possessed a postgraduate certificate or advanced diploma in ophthalmic nursing.
Integration of the questionnaire results with the qualitative data revealed four overarching themes: (i) ophthalmic nurse education and training; (ii) patient education and counselling skills; (iii) broaden clinical experience; and (iv) work–life balance.
Ophthalmic nurse education and training
The majority of the participants (39%) were keen to pursue advanced training in ophthalmic nursing while others preferred a specialty course in patient counselling or patient education (6%). Four nurses (5%) responded that they would like to upgrade from a diploma to a degree and four nurses (5%) were keen to pursue a master’s degree in nursing or healthcare.
Table 2 indicates that the majority of participants reported a lack of confidence in their ability to manage clinical risk and a lack of skills in assessing ophthalmic patients’ clinical needs; this appears to correlate to the lack of formalised education and training in ophthalmic nursing across the surveyed group. Although a basic eye programme was available periodically to staff, some participants deemed it inadequate in providing in-depth knowledge and skills. However, half of the participants had not attended the in-house basic ophthalmic nursing programme and expressed concerns regarding their current nursing skills and knowledge, uncertainty in handling patients’ enquiries and practice protocols. There was minimal training on pre-operative and post-operative ophthalmic care and a lack of preparation for skills and procedures.
I want to know more [about] procedures on day ward cases, for instance eye lid patient after the surgery …, postoperative care in outpatient, patient counselling, Counsel before preoperative what to do prepare the patients.
basic ophthalmic course in SNEC … no ophthalmic training ….no eye ward training…
Other participants, however, highlighted that attending the basic eye programme was useful.
I have been to the basic ophthalmic course. I found that it was very important and useful to me. It also gives you attachments to all around the clinic. It also provides interlink and improvement in the system.
In addition, the in-house programme provided no experience in inpatient care and management.
[I have done the] …basic ophthalmic course here but no formal ophthalmic training and no eye ward attachment
Other participants, however, highlighted that doing the basic eye programme was useful and felt that the attachments in different clinics was beneficial.
I have been to the basic ophthalmic course. I found that it was very important and useful to me. It also gives you attachments to all around the clinic.
One participant spoke of attending the basic eye course and the Advanced Diploma in Nursing (Ophthalmic) which was previously offered through Nanyang Polytechnic.
I have been to the basic ophthalmic course in 2011. It is a two weeks [sic] course. Then [in] 2012 I went for an Ophthalmic course and it was an eight month course.
Participants asserted that basic ophthalmic knowledge and skills taught in pre-registration programmes did not prepare them for work in an ophthalmic environment. On-the-job training and professional development sessions were identified as the main methods of learning.
…only attended skills labs that taught checking eye pupils (Glasgow coma scale).
….in school we only learnt anatomy of the eye.
I have never been to any of these courses but I do learn about Ophthalmic [sic] during our in-house training.
In NUS only one hour on ophthalmic nursing…only a few slides.
Concerns were also voiced over the inadequacy of the current orientation programme, which did not provide any ophthalmic nursing care or even cover basic ocular anatomy.
Table 3 identifies three ophthalmic clinical skills that were deemed significant in the survey as the mean difference between importance and confidence were greater than 1.0. These were (a) applying pharmacology to practice according to defined clinical guidelines; (b) assessing the patient’s clinical needs in an ophthalmic context, and (c) recognising and managing clinical risk. These skills relate to knowledge acquisition and the application of knowledge to practice.
The number of nurses lacking confidence in performing these skills was also significant. All participants disclosed a lack of confidence in recognising and managing clinical risk, and only two participants considered themselves confident in applying ocular pharmacology knowledge to practice. Only 10 of the participants were confident in assessing a patient’s clinical needs. Basic ophthalmic knowledge was perceived to be inadequate by the majority of the participants.
…maybe more on glaucoma topics, preoperative assessment can learn [sic]
Our nurses need more to know about the disease process and the treatment, management of the glaucoma and oculo-plastics cases.
…for me, skills lacking, skills in assessing patients [sic].
Our team needs more to know about the disease process and the treatment, management of the common cases.
There was a consensus among participants that they lacked the knowledge to adequately provide patient information.
For me will be the complications of surgery, I would like to learn more about assessment of pre-operative patients.
Patient education and counselling skills
There were only a few participants (n<5) who indicated confidence in either providing information to patients/caregivers or in planning and conducting health education and promotion with patients. Despite this, the ability to respond effectively to a patient’s questions and to provide adequate and relevant information through health education and health counselling was considered a major challenge for the majority of participants. Despite being deemed important for their roles, participants perceived they had minimal skills or confidence in providing patient education and counselling (Table 3).
Some patients come back and ask questions and it is actually sort of like educating patients like how are we going to deliver the knowledge to them.
Yes, we do counselling. As in like nurses they have the knowledge but they do not know how to express it out to the patients so they somehow they just ask them to bring the brochure back and ask them to read themselves. Sometimes we have the knowledge but we do not have the accurate time to actually deliver that to them.
Because like [in] recent months patient would call us and ask about things like the wounds and the stitches, how long it is going to take before we actually remove it. So this knowledge that I think that I am inadequate because I probably haven’t got the time to read it up about how long will it take for stitches to be removed and like blurriness.
Gain wider clinical exposure and experience
Only a few participants (7%) felt confident in their ability to understand clinical procedures and management of patients with ophthalmic conditions (Table 2). Participants agreed in general that broader clinical experience, with rotations across all areas in the specialty, would facilitate an understanding of general ophthalmology and assist them to develop their skills and knowledge base.
…would like to understand more flow and other areas.
….what would it be like for them in a clinic…actually I have no idea what is going on in a clinic (nurse from day surgical unit).
Work–life balance
Only 5.5% of participants were confident in managing their time (Table 2). There was concern among most participants that further study would impact on family commitments, with participants emphasising that they were too tired after work and so were not motivated to undertake courses in their own time.
I was offered to attend degree and nursing, but to [sic] some personal reasons I was not able to commit to that course yet.
There are [sic] some training that you have to participate, putting manpower aside. I think if we attend certain training, maybe it isn’t knowledge that will help us improve. Because last time I went there maybe it was because my background knowledge was not very good and I didn’t know what they were teaching us. That was my barrier. Thus I had to go back home to read up to know what is going on.
Training Program is after work – too tired [and] not motivate[d] to attend.
Discussion
In our study we set out to identify the educational needs and feasible educational modalities for specialist nurses working with ophthalmic patients in a tertiary eye centre in Singapore. Consistent with the literature,1,2,6 our findings suggest that the ophthalmic health care setting is frequently faced with the challenges of an ophthalmic nurse workforce with limited ophthalmic clinical knowledge and/or experience. Inexperienced nurses not only add to organisational strain but are also more likely to experience stress and burnout. 24 Our findings also identified a significant need for an ophthalmic-specific, accredited programme for ophthalmic nurses in Singapore. Indeed, it has been asserted that there is a growing demand for ophthalmic nursing skills and knowledge; there are, however, fewer opportunities to acquire them. 2 The majority of participants were not interested in undertaking a generic master’s degree with minimal ophthalmic content; participants rather preferred a programme of study that was specific to ophthalmic nursing. This is consistent with results of other global studies.1,4 The majority of programmes in existence globally are not specific to ophthalmic nursing, tending to be generic courses with electives in ophthalmology. 1 These programmes do not always meet the needs of the ophthalmic nursing workforce as they provide minimal subject content in ophthalmology. However, such courses of study do exist in the United Kingdom at the University of Hull 25 and City University London, 26 and in Australia at the University of Notre Dame Sydney. 27 The inclusion of basic ophthalmic knowledge in the orientation programme for new recruits would provide nurses new to the area with a basic understanding of the structure and function of the eye, pathophysiology of common eye diseases and ocular pharmacology. Although there is a dearth of literature discussing what is included in orientation programmes in specialty fields of nursing, it is known that new graduates function better when provided with knowledge, skills and preceptorship in their new work environments.28,29 Furthermore, comprehensive and relevant orientation programmes have been found to improve patient outcomes, decrease medical errors and retain staff.29–31 Strasser 32 asserts that the lack of an appropriate orientation programme can be very stressful for new employees and can result in long periods of low productivity.
Zhang et al. found that educational levels among nurses were significantly correlated with self-efficacy. 33 Moreover, nurses with high self-efficacy were found to be more confident 34 and exhibit more professional nursing behaviours. 35 Furthermore, a highly educated, degree-prepared nursing workforce is associated with lower fatal surgical outcomes, lower failures to rescue, lower overall mortality rates, shorter hospital stays and fewer readmissions.36–39
The provision of patient education and counselling is a fundamental skill in nursing. Although the participants in this study perceived that they lacked the confidence and knowledge in providing patient education, they were keen to become more proficient. However, they also acknowledged that their lack of general ophthalmic knowledge impacted their ability to provide adequate information. Lack of knowledge has not been cited in the literature as a reason that prevents nurses from providing patient education. The common barriers cited are lack of time, poor staffing and the patient’s readiness to receive information. 40
The nurses’ motivation to undertake continuing professional development activities arise from a range of different needs, the most common being the need to meet work-related performance indicators and registration requirements. 41 Undertaking either professional development courses or more structured educational programmes has been cited as impacting on work–life balance and affecting family life. 42 Indeed, time needed to attend educational activities and the financial costs are known barriers to participation.42,43 Similarly, in our study, we found that erosion of leisure time and financial costs were negatively associated with professional development, thus presenting challenging barriers to participation. Of the aforementioned available ophthalmic nursing courses, one is offered online (University of Hull) while the remaining two require in-class attendance. The latter appears to be the preferred method of study if it is undertaken full time; however, the ability to go overseas to study is not an option for everyone.
Limitations
This study has several limitations. It was a small-scale study conducted in only one organisation in one country, therefore results may not be generally applicable to other contexts.
Conclusions
It is inevitable that in the future, institutions and nurse managers will need to change how they plan, develop and monitor their nursing workforce. Building a sustainable ophthalmic nursing workforce that is appropriately trained and meets the needs of specialist ophthalmic institutions needs to be strategically planned. A continuing and urgent need for ophthalmic-specific education has to be the top priority for both experienced and inexperienced nurses working in ophthalmic environments if ophthalmic nurses are to provide the best possible care to patients.
It is easy to fall into a state of despondency about the future of ophthalmic nursing when considering some of the challenges we are facing. In order to move forward as a professional group, we must explore innovative ways of addressing these challenges and develop specialty ophthalmic nursing programmes at a local level to address the current gaps. Through these programmes, institutions may be able to “grow their own” nursing experts and meet future patient demands. Building a sustainable ophthalmic nursing workforce that is appropriately trained and meets the needs of specialist ophthalmic institutions requires strategic planning. Responding to educational needs is one step in building this future workforce.
Footnotes
Declaration of conflicting interests
None declared.
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.