General principles

Chapter 3

Ophthalmic Nursing

Box 3.1 Summary of communication etiquette for managing the visually impaired.

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Make sure that you are in the patient’s field of vision when you approach them to avoid startling them.

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Communicate in a well-lit area and preferably in a quiet room.

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Take into account that a patient may have other hidden disabili- ties that you may not be aware of. For example, following a stroke, head injury or tumour, the patient may experience hemianopia or blindness and a loss of visual awareness as a result of damage to the optic nerve pathway to the brain. The resulting consequence of hemianopia is a loss of one half of the visual field in one or both eyes. There are different types of hemianopia depending on which areas of the brain are affected. Regardless of which type of hemianopia is present, it is important that you approach and communicate from the unaffected side of the patient or from the front.

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Do not shout or raise your voice. Remember the majority of patients are only visually impaired and have still retained all of their other faculties.

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Remember to speak slowly and clearly and to use non-verbal com- munication such as body language.

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Ensure that you say who you are when you begin to speak.

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Speak naturally and address the patient and not the carer.

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Where possible, find somewhere quite as noise can be a distraction for the patient.

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Before leaving the patient, always inform them of your intention.

Otherwise the patient will be left talking to himself.

procedures involving their eyes. It is therefore very important that, prior to any ophthalmic procedures, the patient is fully informed of the nature and process of the procedure. The explanation given must be clear and concise and must include all possible side-effects. Explanations must take into account the patient’s learning style and intellectual ability, his physical and emotional state and any sensory deficits. When undertaking an ophthalmic procedure to a child, explanation must be given in a tactful and sensitive manner and must take into account the child’s age, mental capability and other factors such as any pain or discomfort the child might be in. This requires the ophthalmic practitioner to be extra patient and to take into account the whole spectrum of the child’s and parents’ need, including the psychological and social aspects.

A successful outcome of the ophthalmic procedure will be guaranteed if co- operation is obtained from both parties and if any unnecessary trauma to the child and parents can be avoided.

Box 3.2 Summary of communication etiquette with multiple disabilities such as hearing impairment, aphasia or Alzheimer’s.

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If a patient is wearing a hearing aid, ensure that it is turned on and that it is in good working order.

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Stand in front of a patient or where a patient can see you.

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Ask the patient how he would like to communicate. Writing using black bold letters is one option. Some patients may prefer to seek the assistance of a signer. Use gestures if it is helpful or use visual objects such as pictures or diagrams to aid communication.

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Be patient and allow the patient plenty of time. Do not rush the patient as it may make him more agitated. Don’t second guess what the patient is trying to say. Allow him plenty of time to express his thoughts and feelings. Allow yourself plenty of time to communicate with your patient.

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If a patient has difficulty in understanding you, use different words to get your meaning across. Don’t attempt to repeat your questions or explanations using the same words.

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Only ask one question at a time to avoid confusion. Use key words and repeat them slowly.

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Avoid invading a patient’s personal space. If a patient becomes agi- tated, a light touch on the arm can be helpful to calm him down al- though, for some patients, touching can cause offence. Judge each situation and patient individually.

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Don’t give lengthy explanations. Always re-iterate and check for understanding, especially if a patient is stressed, tired or anxious.

Where appropriate, give written information as well. Any written information given should take into account an individual’s needs.

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If you are having difficulty in communicating with someone with mul- tiple disabilities, be honest and seek help from a more appropriate person.

Infection control

Infections in hospitals continue to hit the headlines, and the number of patients in British hospitals dying from so-called super-bug infections has reached more than 10,000 every year (National Health Statistics Office, 2007). The UK Gov- ernment has introduced a number of initiatives such asWinning ways: Working together to reduce healthcare-associated infections in England (2003) – and a series of action plans for cleaner hospitals and lower rates of infection. Despite these measures, infection rates continue to climb, and antibiotic-resistant bac- teria are now so well established that we may never get rid of them.

Ophthalmic patients not only have to contend with the possibility of suc- cumbing to methicillin-resistantStaphylococcus aureus (MRSA) and Clostrid- ium difficile (C. difficile), but also the possibility of extra-ocular and intra-ocular infection. Such infections can have a potentially devastating effect on the pa- tients and their carers. For this reason, the importance of hand washing before and after each patient contact cannot be overemphasised. Infection control also includes other measures such as employing single-use disposable items, correct decontamination and sterilisation of equipment; correct sharps and waste disposal; and observing standard precautions.

In order to further reduce the spread of infection, some hospitals and clin- ical practices have adopted the principles of Aseptic Non Touch Technique (ANTT) and incorporated it within ophthalmic procedures. The principle of ANTT aims to prevent micro-organisms on hands, equipment and surfaces from being introduced into any susceptible site via intravenous lines, urinary catheter or procedures such as cannulation, venepuncture, wound dressing and administration of intravenous or intra-cameral drugs.

Health and safety issues in ophthalmology

As with any area of medicine, health and safety within ophthalmology is of paramount importance. A system for improving standards of care and main- taining the health and safety of patients is addressed through clinical gover- nance. Clinical governance is a system that ensures that NHS organisations are accountable not only for meeting standards and improving clinical prac- tice, but also have systems in place to safeguard practice. According to Kelly (2005), effective clinical governance within ophthalmology must include the following:

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The continuous improvement of patient services and care should be based on the best available evidence.

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The management of patient should be patient-centred and should take into account the individual needs of a patient.

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Patients should be kept fully informed of their treatment and the manage- ment of their ophthalmic condition.

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Patients should be treated with dignity and their privacy must be respected.

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An up-to-date workforce and clinical supervision should be in place.

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There should be a no-blame culture, with the opportunity to learn from errors.

As detailed in Table 3.1, the National Patient Safety Agency (2004–2009) advocates seven steps to patient safety. (See also Department of Health, 2008b)

Other health and safety–related issues to take into account must also include the following:

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Correct site surgery;

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Decontamination and sterilisation of equipment;

Table 3.1 The National Patient Safety Agency’s (2004–2009) seven steps to patient safety.

Stages Patient safety

Examples of application to practice

Step 1 Build a safety culture Ensure safety systems are in place in your work place. For example, risk assessment, incident reporting, induction of workforce, medical alert reporting, root cause analysis of incidents, etc.

Step 2 Lead and support staff in patient safety

Training for new and existing medical devices

Step 3 Integrate risk management

Provide risk-assessment training, including how to assess risk

Yearly updates of risk manage- ment to all groups of staff Step 4 Promote reporting of

patient safety incidents

Encourage staff to report incidents

On-line reporting system to simplify reporting mechanisms Step 5 Involve and

communicate with patients and public

Prompt communication in the event of any mishaps and swifter response to complaints etc.

Step 6 Learn and share safety lessons

Publication and dissemination of lessons-learned bulletins Step 7 Implement solutions to

prevent harm

Appropriate protocols and polices in place and ensuring awareness of staff to the policies and procedures

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Medical devices training;

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Infection control;

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Health and safety in the operating theatre.

Maintenance of patient’s privacy and dignity

Privacy and dignity are two important aspects of care that all patients and carers are entitled to and are now seen as a high priority on the quality- improvement agenda. A patient’s privacy and dignity can be compromised through, for example, unnecessary interruptions such as telephone mes- sages, entering consulting rooms without knocking, gaping curtains and the- atre gowns and simply not closing the door of consultation rooms. Asking a

patient’s personal details or taking telephone messages in a crowded waiting room can also be problematic. It may not always be feasible to take patients away to a quieter and more private area, but privacy and dignity must be maintained in all consultations and treatments, and should be built into the care delivered to patients as well as in the environment in which care is being delivered.