VOL: 100, ISSUE: 01, PAGE NO: 40
Sue Watkinson, PhD, MSc, PGCEA, BA, RN, is senior lecturer, research studies, Thames Valley University, London
Eileen Scott, BSc, RN, RM, Higher Award in Nursing, DipN, is sister, Central Eye Service, Central Middlesex Hospital, North West London Hospitals Trust
Ophthalmic and general nurse practitioners are currently addressing the changing role of nursing practice.
Extending the role of the ophthalmic nurse practitioner can promote delivery of a more effective health care service and reduce waiting times. This is significant, because the predicted growth of the older population means that common ocular diseases such as age-related macular degeneration will increase the incidence of visual impairment. Owen et al (2003) estimate that there are currently 214,000 people in the UK with visual impairment caused by age-related macular degeneration. This number is expected to increase to 239,000 by the year 2011. Stanford (1998) points out that no matter how cost-effective a health system may appear, it must address patients’ needs and meet the standards necessary to optimise care.
Meeting patients’ needs is central to clinical governance. For patients with visual impairment, the role of clinical governance is to ensure that the right thing is done at the right time and that it is done well. This is the basis for delivering excellent clinical care (Department of Health, 1999). The fundamental principles of care apply across all areas of health care practice. It is the application of these principles that is important and challenging. This can be achieved in a variety of clinical settings: in hospital, in outpatients, in A&E, and in the community.
Moore and Miller (2003) point out that care for patients with visual impairment must be carefully individualised, while fostering normalisation. Effective communication and, most importantly, acknowledging the patient with visual impairment as a human being with the same range of needs and feelings as a person who has normal sight, may achieve this.
An awareness and understanding of the concept of individual needs and how best to address them are also essential. Maslow’s (1954) five-stage hierarchy of needs model (Fig 1) serves as a useful basis for considering these needs. The model is underpinned by the theory of human motivation, which has five classes of need arranged in hierarchical order from the most basic up to the highest level. Gratification of needs is the key concept of this theory. When a need is gratified at one particular level, the next highest need emerges. The following discussion demonstrates how this theory translates into practice in meeting the needs of both young and older patients with visual impairment.
Applying Maslow’s theory of needs
The significant biological and physiological needs of patients with visual impairment are those associated with eating and drinking. Because the degree of a person’s visual impairment will determine the degree of assistance required with eating and drinking, good practice involves ascertaining from the patient (after asking tactfully if help is required) his/her normal routine at mealtimes. For example, the patient can be asked where it is best for certain items such as cutlery, cup, glass, and plate to be placed. Eating can be made easier and more enjoyable if the type of food and its position on the plate can be identified. This can be done by using the ‘hands of the clock’ method, for example, meat at 12 o’clock, peas at six, potatoes at nine o’clock. Cutting up food into small, manageable portions before the meal, particularly for a child, may also be useful.
Overfilling of cups or glasses, especially with hot fluids, is best avoided so as to prevent any spilling and potential scalding of mouth and lips. The level of the liquid should always be indicated to the patient. With cool liquids this can be done by allowing the patient to feel for the level of the liquid by placing his or her index finger just inside the vessel. Hygiene is important where food is concerned, and facilities for handwashing should be provided both before and after a meal, because many patients will need to ‘feel’ their food. Patients with diabetic eye disease may be particularly anxious about managing the onset of a hypoglycaemic attack that has been precipitated by a poor correlation between dietary intake and prescribed diabetes therapy. Assessment of the patient’s current treatment and dietary needs is therefore essential. Patients with diabetic eye disease may inadvertently misinterpret blood test results, making it difficult to determine the dose of insulin they should take before their meal. Some patients also have problems with differentiating between blue and green colours while interpreting the results of a urine test.
According to Moore and Miller (2003), visual impairment in older people has been associated with falls that often result in fractures, dislocations, and lacerations. Limited mobility, and difficulties in carrying out the activities of living, are also associated with visual impairment. Undoubtedly, a patient with visual impairment experiences some degree of disorientation as a result of being placed in the strange environment of a hospital. Escorting the patient around the new environment as and when required will help to meet the need for safety, promote some orientation and instil a feeling of security. The patient must always be asked sensitively whether help is required and then be allowed to take the nurse’s arm or hand. The nurse should walk one step ahead, giving appropriate directions, and warn of any impending obstacles along the route. When approaching a door, the nurse should stand on the same side as the door handle, open the door, step through and hand the door handle to the patient, who then has control over closing the door. When negotiating a narrow space, the nurse’s arm should be placed behind his or her back and the patient asked to walk behind the nurse. When approaching stairs, the nurse should be one step ahead of the patient, giving instructions as to whether to step up or down. Nurses should take responsibility for instigating safety measures, such as good lighting, placing the bedside locker on the side most appropriate for the individual patient, and ensuring that the call bell is placed within easy reach. Appropriate supervision must also be provided when a patient needs to visit the toilet.
Moore and Miller (2003) document the fears and uncertainties about the future expressed by older men with macular degeneration. Inevitably, hospitalisation provokes such fears. The prospect of undergoing ophthalmic surgery, for example, the removal of a cataract, or retinal detachment surgery, means having to confront uncertainties and fears about the possibility of not being able to gain further useful vision, or even total loss of vision. There is evidence that well-informed individuals have less anxiety and depression and are better able to manage their health and treatment than those who are not informed (Partridge and Hill, 2000). Speedwell et al (2003) suggest that most parents would prefer to receive information about their child’s visual impairment soon after its diagnosis because they will be particularly involved with the child’s treatment and future education. Nurses who are able to instil a patient’s eye drops and ointment effectively, and, conversely, to supervise the patient’s technique for safe instillation of eye medication or any other drug, may help to relieve anxiety and provide some reassurance. It is vital that patients understand the implications of non-compliance with drop therapy. For example, a patient with chronic simple glaucoma may face further deterioration of vision, or even blindness, if treatment is not adhered to. Health promotion is thus a significant aspect of the nurse’s role.
First meetings with a patient with visual impairment are important because the goals are mutual and first impressions will influence the patient’s expectations. A compassionate and empathic approach is therefore instrumental in meeting the person’s expectations and in establishing a caring relationship based on mutual trust. Some older patients with visual impairment also have hearing deficits and mobility problems. Patience and good listening skills are essential when caring for them. These skills are especially important when communicating with non-English speaking patients from diverse cultural backgrounds. Admission and discharge procedures may take much longer with a patient with visual impairment than with one who is normally sighted, and the nurse can make a difference to a patient’s time in hospital by allowing adequate time for the overall planning of care and educating the patient to care for him or herself. This may mean modifying practice; for example, in the outpatient department, it is vital that the nurse not only calls out the patient’s name when he or she is about to be seen but also approaches the patient, so as to establish contact. In the absence of vision, touch is the next most important sense. Thus, when approaching a patient, nurses should introduce themselves by extending a warm, calm and welcoming greeting. Loveridge (2000) suggests that touch can assist in developing a therapeutic relationship.
When trying to orient patients to their new environment, it is helpful to show them the layout of the ward or unit by allowing them to ‘feel’ their way to areas such as the bathroom, toilets and social area. This means placing their hands in contact with the physical structures of the environment; for example, a wall or a piece of furniture. This will help not only their orientation but also their balance. More importantly, it helps to encourage some independence, which is conducive to promoting confidence and maintaining self-esteem. Similarly, introducing the patient to immediate neighbours will establish social orientation and acceptance. When a nurse approaches a patient to speak to him or her it is important to speak in a normal tone of voice, as this is non-threatening. Often there is a tendency to speak loudly just because the patient happens to have visual impairment.
When a procedure needs to be undertaken at the bedside, the nurse should give advance warning of approaching by starting to speak before reaching the bedside so as not to startle the patient. Similarly, a verbal indication when leaving the bedside minimises the embarrassment of the patient’s continuing a conversation in the nurse’s absence. Some patients feel that their visual impairment has threatened their identity, as they have had to make a number of psychological, emotional, and intellectual adjustments to their loss of sight. Helping them to regain some control over their condition, or the underlying systemic disease causing it, may be the way to help to restore their self-esteem and confidence. For example, patients who have diabetic retinopathy and who can monitor their own blood glucose levels and administer their insulin injections safely signal their re-empowerment as individuals.
Confronting progressive visual loss means having to become more self-aware and more knowledgeable about creating personal strategies for maintaining an acceptable lifestyle. Providing these patients with information about low-vision aids such as talking books, large-print reading materials, small hand-held magnifiers, and telescopic devices can facilitate their adaptation to visual loss and the utilisation of rehabilitation strategies. Similarly, helping patients to resume general social activities and skills, hobbies, and travelling, can facilitate the maintenance of family and peer contact. This often helps to prevent the onset of depression, a well-documented psychosocial implication of visual impairment. Indeed, recent visual loss is one factor that has been linked with difficulties in carrying out daily activities, diminished sense of well-being, and depression (Moore and Miller, 2003).
This stage refers to the need to find self-fulfilment and realise one’s potential. For the patient who has visual impairment this translates into being able to optimise the current level of vision so as to be able to continue to achieve personal growth and development and fulfil any personal aspirations. Visual impairment can result in a loss of status, responsibility and a sense of achievement. This can often disrupt roles and create economic demands and stress within the patient’s family (Moore and Miller, 2003). The need for continued personal growth and self-fulfilment therefore becomes significant. The nurse can help by encouraging the patient to view any potential problems caused by visual impairment as challenges and situations requiring solutions rather than as insurmountable problems. For example, patients with low vision who enjoy reading or need to continue to read extensively as part of their job or study could be informed that visual reading may be supplemented with speech output devices such as spoken computer programs and books on audiotape. In addition, providing the family with information about the functional implications of visual impairment will increase understanding of the behaviour and feelings of the family member with the visual loss. This will facilitate the individual’s continued personal growth, and is a basis for the realising of his or her potential.
Implications for practice
The application of a patient-centred model underpinned by the concept of needs has several implications for practice. If nurses are to meet the challenges of managing patients with visual impairment, they must be able to demonstrate in their planning and implementation of care that they have knowledge and skills in several particular areas. These are listed in Box 1.
Maslow’s five-stage hierarchy of needs model offers a means of raising awareness of the care requirements of both young and older patients with visual impairment. Using the model has highlighted the challenges involved when planning and managing their care. Meeting individual needs through effectively managed care may help to make a difference to patients with visual impairment. Effective communication is instrumental in achieving this, and remains the single most important aspect of nursing practice. Nurses who have a knowledge and understanding of ocular pathology and the nature of visual impairment may be able to provide the effective communication and care management skills required to meet the special needs of patients who have visual impairment, their families and significant others.
- This article has been double-blind peer-reviewed.