An outline of the training and assessment process for a nurse practitioner to carry out a form of laser peripheral iridotomy
Helen Gibbons, MSc, BA, PGDip, RGN, is research practitioner, City University London and Moorfields Eye Hospital; Rupert R.A. Bourne, FRCOphth, MD, BSc, is consultant ophthalmic surgeon, Hinchingbrooke Hospital, Moorfields Eye Hospital and Addenbrooke’s Hospital; and professor of ophthalmology, Anglia Ruskin University, Cambridge.
Gibbons, H., Bourne, R.R.A. (2009) Extending a nurse practitioner’s role to undertake advanced procedures. Nursing Times; 105: 40, xx-yy.
This article outlines an initiative to develop an ophthalmic nurse practitioner’s role to carry out YAG laser peripheral iridotomy. It details the training and competency assessment needed to extend this role, and the results of an initial audit. Advice for trusts planning similar projects is also given.
Keywords: Laser treatment, Ophthalmology, Nurse practitioner
This article has been double-blind peer reviewed.
- The procedure of YAG laser peripheral iridotomy can be safely carried out by an appropriately trained ophthalmic nurse in selected patients.
- Trusts considering similar initiatives involving specialist nurse practitioners should ensure: adequate time is set aside for training; patients are suitable for the nurse list; informed consent takes place; andaccurate record keeping is maintained.
An ophthalmic nurse practitioner was trained to carry out Nd: YAG (neodymium: yttrium-aluminium-garnet) laser iridotomy on suitable patients. The nurse already had 10 years’ experience of performing YAG laser capsulotomy, and the glaucoma consultant felt that performing laser iridotomy would be a natural extension to her role. It would not only add additional capacity (reduced waiting times and so on) to the provision of glaucoma care in the hospital, but also enhance the nurse’s job satisfaction and give her new knowledge and skills.
This article explains how the role was developed, the patient pathway, the training involved in such an initiative and the results of an audit based on patients treated during the training period. It is thought this is the first scheme of its kind in ophthalmology in the UK.
Growing concern in the late 1980s and early 1990s about junior doctors’ working hours led to the publication of the Calman report (Department of Health, 1991). This recommended that junior doctors’ hours be reduced from a maximum of 72 to a maximum of 56 hours per week. The DH (1997) New Deal document supported this report. These reports led to internal pressure in hospital trusts to maintain a high quality service without increasing resources to implement recommended changes.
The Calman report (DH, 1991) recommended that appropriately trained nurses could extend their roles to take on some tasks previously only carried out by doctors. Many trusts, including ours, considered creating such roles to fill the gaps caused by the reduction in junior doctor hours. Enhancing nurse practitioners’ skills promotes personal development and encourages career advancement. However, the skills and knowledge cannot be achieved without extra study and training, which can be time consuming, costly and require much personal motivation.
The Scope of Professional Practice gave clear guidelines to nurses wishing to expand their roles, and ensured they recognised that by doing this they were accountable for their own actions (United Kingdom Central Council For Nursing and Midwifery, 1992).
Some authors – such as Duffin (2003) - argued that extending nurses’ role is particularly useful during night and weekend shifts, as it means the focus of doctors’ workload can shift to more daytime activities.
Developing the role
In June 2007 a departmental meeting was organised to explore the feasibility of a nurse-led iridotomy service. The solution discussed was to extend the role performed by the nurse practitioner in post, who currently carried out around 80% of all YAG laser anterior and posterior capsulotomies. Once this was agreed by the department, the trust board needed to endorse the initiative. Gaining endorsement involved preparing a protocol encompassing all issues surrounding the performance of Nd: YAG laser iridotomy. This was followed by the setting of competency standards to ensure the nurse practitioner would be adequately trained and supported.
Trust indemnity was obtained to cover the practitioner against adverse incidents and to approve the new initiative.
With approval given theoretical and practical training could begin. The theoretical aspect involved a series of lectures by the glaucoma consultant responsible for training, and instruction on possible complications while undertaking the lasers and following treatment. A session was also carried out to ensure the practitioner was able to obtain informed consent. Consent is an important issue and the nurse practitioner uses a pre-filled form to ensure all patients are given the correct information relating to their procedure. They are also informed their treatment will be carried out by a nurse.
The working party devised strict protocols and patient care pathways that both the training consultant and the nurse practitioner felt were safe, reliable and workable. The patient information leaflet was updated, ensuring patients were fully informed that a nurse would be performing their treatment. It was anticipated there would be a reduction in the number of patients waiting for a YAG laser peripheral iridotomy, thereby allowing them more choice over their treatment date.
All patients who were referred for a nurse-led laser iridotomy were to have been seen initially by a glaucoma consultant and the gonioscopic findings confirmed. The consultant only referred patients who had blue/green/hazel irides (for whom less laser power is needed than for those with darker eyes) and those who had no other conditions that may increase the complexity of the procedure.
The nurse practitioner had already completed a one-day laser safety training course before taking up her role performing YAG capsulotomy. This is an annual course run by Addenbrooke’s Hospital in Cambridge, which gives up to date information on laser safety and local guideline rules.
The practical training was not carried out within a designated time span as the supervising consultant would determine when the nurse was competent to work independently. Patients with dark brown irides (which may require argon pre-treatment) were excluded from nurse training.
On the day of the laser procedure, patients were greeted by the nurse and the treatment was explained. Many patients were anxious about the procedure as people often feel apprehensive about having their eyes touched, and are often extremely fearful of blindness (Walsh, 2006). It is therefore essential to remain calm and professional.
Informed consent for the procedure was then obtained. Patients had been sent an information leaflet before arriving to give them the opportunity to think of any questions and discuss the treatment with family and carers. The nurse had already been assessed as competent in taking consent previously, but this was formally assessed by the training consultant to ensure he was happy that the information being given to the patient was appropriate and correct. While the NMC (2008) supports nurses taking consent for procedures they carry out, it warns that if patients do not receive enough information to make an informed choice they are unable to give informed consent.
The intraocular pressure was measured using Goldmann tonometry. One drop of apraclonidine 1% and one drop of pilocarpine 2% were instilled into the eye approximately 15 minutes before laser treatment. After treatment, one 250mg tablet of acetazolamide was given (providing this was not contraindicated) and intraocular pressures were rechecked one hour later. Patients were given dexamethasone 0.1% eye drops to instil hourly for 24 hours (daytime only) into the treated eye/s and then four times per day for seven days, to reduce any inflammation in the eye. No extra precautions were needed.
Patients were given a contact telephone number so they had easy access to a nurse post-operatively if they have any fears or concerns following treatment.
A follow up appointment was issued for seven days’ time to carry out a biomicroscopic examination of the eye and measure intraocular pressure to assess for complications.
Practical training involved initially observing the procedure, followed by close supervision by the training consultant. This started with identifying the position where the laser was to be placed on the iris, moving on to finishing the procedure once the first shot had been made, to finally completing the whole process under supervision, until the training consultant was confident of the nurse practitioner’s procedural skills.
The consultant felt the nurse would need to treat at least 10 eyes under supervision before being assessed. A record was kept of all patients’ details to facilitate audit. On the day of the assessment, the consultant examined the nurse’s ability to perform the procedure and her interaction with the patient in explaining the procedure and the process of taking consent.
After the assessment the consultant completed a record for the nurse and the trust’s management board, giving evidence of competence. It was agreed that the nurse’s procedural skills would be supervised annually or more often if necessary to ensure high quality care was maintained.
The laser clinic was set up to run weekly, at the same time as the specialist glaucoma clinic. The one week post-operative visit was set to coincide with the glaucoma clinic, where patients also saw the glaucoma consultant who performed a gonioscopy and measured intraocular pressure to establish the effect of the iridotomy and to plan further management.
A small patient safety audit has taken place since training started, to ensure the laser treatment was being performed safely and effectively and there were no adverse incidents involving patients treated by the nurse practitioner. The results were:
- Seventeen eyes were treated (14 patients);
- Patients’ ages ranged from 40 to 89 years;
- The most common indication for YAG iridotomy was primary angle closure, accounting for 10 of the eyes treated.
The total energy used to perform the YAG peripheral iridotomy, and intraocular pressure (IOP) measurements made before and after laser, are given in Figs 1 and 2.
Ideally minimal power should be used for an iridotomy. Indeed, the majority of eyes treated in this study were treated with a power in the range of 5-12 mJ, which indicates that the nurse practitioner was treating safely (although it must be noted that lightly pigmented irides were selected for this training period - these patients are less difficult to treat). Although a relatively small number of treated eyes are involved in this analysis, trends can be seen in Fig 2 showing lower IOPs measured an hour after laser iridotomy as a result of the ocular hypotensive effect of the pre-operative eye drops and the post-operative acetazolamide. IOPs measured a week after laser were relatively similar to the pre-operative pressure. However, some eyes had raised IOPs, presumably as a result of several factors that may include diurnal variability of IOP measurement, inter-observer IOP measurement variation, and raised IOP secondary to steroid treatment (“steroid responders”) (Breusegem, 2009).
All IOP measurements were within the range of 10-25mmHg, whether measured before or after laser treatment. The consultant did not judge the post-laser IOPs to pose a risk to patients in this particular cohort.
Fig 1. Total power of the laser iridotomy procedure used in each of the eyes in the laser training period
Fig 2. Intraocular pressure measurements of eyes treated by laser iridotomy in the laser training period before and after surgery
Although the nurse practitioner was well trained in performing a YAG capsulotomy and had confidence in her procedural skills, she had some anxieties before starting training as the iridotomy procedure seemed far more complex. Her main concern was around causing bleeding and poor positioning of the iridotomy. However, these fears were soon allayed as training proceeded.
Lack of time was frustrating and caused severe delays in teaching being delivered due to work pressures in other clinics. This was resolved by designating specific clinic slots on a monthly basis for training to take place.
Demand for YAG laser peripheral iridotomy procedures has increased within our unit due to improved recognition of angle closure in a specialist glaucoma clinic and among hospital and community based optometrists who have received training in this area.
This department has already previously demonstrated that a specially trained ophthalmic nurse can safely perform YAG laser capsulotomy, which has meant that regular weekly treatment sessions keep waiting lists within government guidelines. It also gives patients more choice on when they would like their treatment performed, so it is hoped the same will apply to those waiting for YAG laser peripheral iridotomy under the new system.
Case selection of suitable patients for the ophthalmic nurse practitioner to treat is important. This involves selecting eyes with lighter irides that do not need pre-treatment argon laser, and also excluding patients who may be more difficult to treat, such as those with tremor.
The glaucoma consultant made decisions on the management of individual patients on the basis of post-operative IOP and gonioscopic appearance, ensuring continuity of care and patient safety.
We acknowledge that the sample size of the audit is relatively small and a further audit involving larger cohorts is planned.
Performing YAG laser peripheral iridotomy provided another new and challenging role for the ophthalmic nurse practitioner at Hinchingbrooke Health Care Trust. The role offers new opportunities for ophthalmic nurses to provide a first class service for patients while advancing their knowledge and skills and increasing job satisfaction.
- Nd: YAG (neodymium: yttrium-aluminium-garnet) laser peripheral iridotomy is a commonly performed procedure for the treatment of acute angle closure and primary angle closure glaucoma.
- The procedure can prevent or halt the progress of glaucomatous optic neuropathy.
- Most iridotomies in our predominantly Caucasian population require minimal laser power and do not need pre-treatment with the argon laser (De Silva, 2007).
We would like to thank consultant ophthalmologist Lydia Chang for her help and support with training and the ophthalmology department’s nurses for their support.
Breusegem, C. et al(2009) Predictive value of a topical dexamethasone provocative test before intravitreal triamcinolone acetonide injection. Investigative Ophthalmology and Visual Science; 50: 2, 573-576.
Department of Health(1997) Junior Doctors’ Hours: The New Deal. London: DH.
Department of Health(1991) The Calman Report: Junior Doctors Hours - The New Deal. London: NHSME.
De Silva, D.J. et al (2007) Laser iridotomy in dark irides. British Journal of Ophthalmology; 91: 2, 222-5.
Duffin, C. (2003) Cover plans. Nursing Standard; 17: 18, 12-13.
NMC (2008) The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives. London: NMC. tinyurl.com/nmc-code
Walsh, M. (2006) Nurse Practitioners: Clinical Skills and Professional Issues. Edinburgh: Butterworth–Heinemann.
UKCC (1992) The Scope of Professional Practice. London: UKCC.