A UK competence based framework for ophthalmic nursing
practice
Janet Marsden MSc BSc RGN OND
This is the second paper presented by Janet as keynote speaker at the
Australian Ophthalmic Nurses (AONA Vic) conference, October 2006,
Melbourne. One of the major reasons for inviting Janet to be the guest
speaker at this conference was the desire by state Ophthalmic Nursing
Special Interest Groups to form a National Ophthalmic Nursing
Association. Members from each state organisation and New Zealand
met after the conference and voted unanimously to make this a reality.
Competencies would be developed and it is the work of Janet and the
Ophthalmic Nursing Forum (UK) that has formed the basis for the work
which is now beginning with ophthalmic nurses nation wide. This model
is not restricted to ophthalmic nursing practice but can be used for any
specialty.
In the late 1990s, the Ophthalmic Nursing Forum of the Royal College of Nursing in the UK
started to consider the future of ophthalmic nursing and some of the problems it was likely to
face. Specifically, we considered how we could move practice forwards and show others outside
this ‘Cinderella speciality’ that ophthalmic nursing is more than just the instillation of eye drops!
This paper describes the process of development of an integrated career and competence
framework for ophthalmic nursing in the UK and the possibilities for its wider application.
Ophthalmic nursing in the UK has developed over the years into a nursing speciality at the
forefront of practice and role innovation which has made a significant contribution to reductions in
ophthalmic waiting lists and the streamlining and modernisation of ophthalmic services. Nursing
development in the speciality has not been without its problems however and some of the issues
identified by the forum as also occurred in other nursing specialities, while others were
particularly pertinent to our own.
Education
Ophthalmic nursing was traditionally one of a small number of specialist nursing qualifications
that could be undertaken before general training in the UK, commencing at the age of 17. This is
no longer the case but the origins of the specialty meant that for many years (until 1985/6),
ophthalmic nursing education was regulated separately from general nurse training by the
Ophthalmic Nursing Board (ONB). The ONB prescribed educational programmes, overseeing a
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national standard for ophthalmic nurse training through a panel of educationalists and managers
and through inspection and close links with practice areas.
The National Boards for the four countries of the UK then took over the responsibility for nurse
education and had the same remit, initially being fully prescriptive in relation to standards and
length of courses. When the colleges of nursing were incorporated into universities in the 1990s,
the boards shared responsibility for standards with individual universities who each had their own
regulations, leading to diversity in length, content and outcomes of courses. Changes in the
National Health Service (NHS) have also impacted on ophthalmic nurse education as
secondment of nurses to large ophthalmic centres is no longer a financially viable option. Theory
now tends to be taught at the educational centre while practice takes place in the student’s own
clinical area, often in their substantive, rather than a student role. This enables nurses to obtain
theoretical input but does not necessarily enable them to have a wide experience of ophthalmic
settings.
There are therefore, a variety of ophthalmic nursing courses available, often combined, because
of small ophthalmic nursing numbers, with other specialties such as ENT and head and neck and
provision is very patchy across the UK.
There are no national standards of education for
ophthalmic nurses and no common outcomes.
Roles and skills
Role titles across the UK have proliferated, with no common national idea of what role titles
actually mean or what the incumbent of a role can actually do. Titles such as ‘clinical nurse
specialist’, ‘specialist nurse’, ‘nurse practitioner’ and advanced practitioner are often used
interchangeably and although there are both national and international definitions of ‘nurse
practitioner’, many roles with this title do not fulfil any accepted criteria.
This results in a situation where it is not clear
from nurses’ role role titles what skills and
competences are needed for the role or used within it. This proves a problem for managers when
employing new staff, and for staff ity. Skill transfer is problematic, both because of the lack of
common outcomes in training and education and because of the lack of opportunity for the nurse
to have nationally accredited skills – how does a manager satisfy themselves that a particular
nurse, new to the area, is competent to undertake a particular role? Nurses are often asked to
repeat courses and re-prove their competence which is clearly a waste of time and resources for
all concerned.
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As a body of ophthalmic nurses we felt that we needed to question whether the current situation
was as it should be and whether the lack of national standards of education, the lack of
availability of ophthalmic nurse education the problems of competence accreditation and skills
transfer gave us the ophthalmic nurses we need.
We felt that one possible solution for a t least part of this problem, would be a national framework
for ophthalmic nursing practice with the agenda firmly led by ophthalmic nursing.
We also felt that whilst competence is strongly linked to education, it is clear that those
ophthalmic nurses who have not managed to access education but have many years of
experience and have developed high levels of competence, should not be disadvantaged by any
national framework and therefore, any framework should be competence rather than education or
qualification based.
Some work had already been done on this issue which gave us a very useful indicator of the way
to begin. Within the Royal College of Nursing (RCN), the Emergency Nursing Association had
already proposed a competence based framework and a Faculty of Emergency Nursing (FEN),
which could set national standards for emergency nursing competence and then validate
competence nationally. It seemed that this would be useful, if not essential path for us to travel.
Ophthalmic Nursing Forum work in this area began with initial discussions about the format of
such a framework and of the content of a core of generic ophthalmic nursing competencies.
Developing the framework
It was intended that the competence framework would consist of core competencies at different
levels of practice and then further competencies based on different specialisms within ophthalmic
nursing practice. Core competencies would be those, the vast majority of which should be
demonstrated by all ophthalmic nurses at each level.
The different levels of practice have become known, following the Emergency Nurses’ template
as levels W, X, Y and Z where the W level nurse is the nurse who is competent in the specialty –
the first point at which competence would be assessed
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TABLE 1
Levels W X and Y are the levels which have been developed initially for use by ophthalmic
nurses. These letters were attached to the levels of competence for convenience and to ensure
that there was no possible link to grading systems in use at the time the framework was
developed.
Level Z is a level which would be demonstrated by a new level of practitioner, the consultant
nurse There are as yet, only three consultant ophthalmic nurses in the UK and the final boundary
of nursing competence remains fluid as practice is likely to expand further and further in the
future.
The model of competence is shown in diagram 1
DIAGRAM 1
This diagram shows competence ever increasing and a ‘ring’ of core competencies (in heavy
black) at different levels of practice. In fact, a three dimensional diagram would work rather better
because this pictorial representation suggests that the volume of core competencies get larger as
nurses’ competence increases. This is obviously not the case as higher levels of competence
build on lower levels so, in fact, the volume of additional core competences reduce as
competence levels increase. The best way to imagine this would be as a pyramid of skills, with
most needing to be acquired at the lower levels and smaller amounts of new skills building on this
base of knowledge until the nurse reached the apex of the pyramid (a place not, as yet,
particularly well defined and likely to change with time!).
The core competences build on the lower levels and show progression in the various areas,
through the different levels (see table 2)
TABLE 2
The core competencies were written by the forum steering committee in consultation with other
ophthalmic nurses, prior to peer review. The other strand of the initial work was to try to work out
how to divide ophthalmic nursing to allow specialist competence to be recognised and a
competence framework written for the specialist areas. A significant amount of (sometimes
heated) discussion later, It was decided that, rather than specialist ophthalmic practice being
divided into ocular systems such as glaucoma, cataract etc, it would be divided into areas of
practice. We felt that over many years, ophthalmic nurses have tried to get away from labelling
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patients by their eye condition (the cataract in the bed by the door etc) and we would not wish to
take a step backwards. The specialist spheres of competence became therefore;
In patient care
A significant, although small, number of patients, either because of their ophthalmic condition, the
intervention proposed, or due to other medical or social factors, are still cared for as inpatients
and this must be recognised (and often is not) as a specialist area in itself.
Outpatient care
The majority of ophthalmic work takes place in outpatient departments. Ophthalmic nurses have a
major role to play not only in the education and care of patients in medical clinics and also in their
own, nurse led clinics within ophthalmic specialities and independently.
Peri-operative care
Many of our patients undergo surgical interventions. In this context, Perioperative care is intended
to mean that care undertaken within the theatre environment, and includes anaesthesia, surgery
and the immediate postoperative recovery period.
Children and young people
While the care of these two groups is different, they are both very different from adults and it is
hard to have definite demarcation in terms of age. It was felt to be too complex to separate
children from young people in this context and unlikely that ophthalmic nurses would be
specialists in looking after ‘young people’ only.
Adult and elderly
This is our main patient group and therefore an obvious specialist area. Consideration was given
to the different care needed by the very elderly. However, as with children and adolescents, the
demarcation lines between adults and the very elderly are blurred. It might also be felt, by more
elderly people that to be defined as something other than adult is insulting in the extreme and
could lead to the lack of consideration and consultation that is sometimes seen when working
with elderly patients
Day care
Day surgery is one of Ophthalmic Nursing’s largest specialist areas and one which is likely to
continue to grow. The whole patient’s episode is included here from pre-assessment to post
operative care
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Accident and Emergency
Whether it takes on the ward, in outpatients or in a dedicated unit, the care of patients with acute
problems is an obvious specialist area for ophthalmic nurses. The title A&E has generally been
superseded in the UK by ‘Emergency Care’ and it likely that this will change in the framework at
some point however, as most ophthalmic nurses and patients seem to refer to ophthalmic
emergency care settings as ‘Casualty’ a title at least 30 years out of date, titles seem to be much
easier to change than ‘hearts and minds’ and whatever we call this area of expertise, its
principles will remain the same!
Primary Care
While primary care may not be an obvious area of specialisation for many ophthalmic nurses, the
competence framework is not just for current organisations, but also with the future of ophthalmic
nursing in mind. Primary Care Trusts are the commissioners of services in the UK and we are
likely to see more work initiated in the primary care arena. With this in mind, this competence set
will enable ophthalmic nurses working in primary care settings to have their specialist skills
recognised
Low vision
This is another area of practice where ophthalmic nursing is not in a particularly well developed
form at present. The aging population does mean though, that there will be a much greater
demand on ophthalmic services from people with low vision and particularly those with
untreatable forms of age related macular degeneration. This specialist area therefore is one
which is also likely to expand in future
The model of competence, with the specialist spheres is illustrated in diagram 2
DIAGRAM 2
The process
Expert nurses in each of the specialist areas were identified and were approached to be ‘stream
leads’ , to take the process of specialist competence development forward. Without fail those who
were approached embraced the concept of the framework and agreed to lead a team through the
process.
All those nurses who had expressed an interest in competence development at the national
ophthalmic nursing conferences, and many others who were identified by a variety of means as
having an interest were invited to a ‘stakeholder’ meeting in March 2003. Nurses identified
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themselves with a particular specialist area and the stream leads began the process of
developing competencies. Once a first draft of the specialist competences was available,
reviewers, drawn from all area of ophthalmic practice commented on their relevance and fitness
for purpose. This process of refinement and iteration continued until that everyone was satisfied
that the competencies were as good as they were likely to get.
The competence framework was further refined to ensure that it was congruent with the
competencies and targets described in the Knowledge and Skills Framework (a model of
competence development newly introduced into the NHS and used as a development and
progression tool). This also ensured that the framework was in line with Agenda for change
(www.doh.gov.uk/agendaforchange.index.htm), the new grading framework in use within the NHS
The value for ophthalmic nursesIt is hoped that ophthalmic nurses will develop a
portfolio of evidence, which not only fulfils the requirements for the KSF but which also is mapped
against the Ophthalmic Nursing Forum’s competence framework. A portfolio mapped against a
nationally developed and accredited framework is high quality evidence of the nurse’s
competence in practice at a particular level. Evidence may take a myriad of different forms and
there is no doubt that educational programmes will be of use. While it is clear that educational
input is required and is crucial for the development of the underpinning knowledge and skills for
competence, such education will vary and the development of the competence framework
recognises this. Education on its own does not guarantee or prove competence and this
framework is designed to ensure that nurses can demonstrate competence rather than merely
educational attainment. Those nurses with a high level of skill and competence but without
formal qualifications are therefore able to have their expertise recognised.
Competence assessment and accreditation
It is hoped that eventually, ophthalmic nurses will be able to have portfolios assessed by a
national panel of expert ophthalmic assessors. This seems some way off though, so at present,
the portfolio mapped against the competence framework is likely to be examined at the nurse’s
yearly KSF review which will validate the evidence within it and allow the nurse to map progress
and attainment against the national Ophthalmic Nursing Forum competence framework.
It is clear that not all nurses will be able to achieve or demonstrate competence in every aspect
of the core or a particular specialist competence area. We do not all do the same thing, our
practice is diverse and constantly changing. There is likely to be a minimum achievement needed
to allow nurses to be considered competent at a particular level and as yet, this has not been
articulated but should be around 80% of the core. Ophthalmic Nurses would achieve all or nearly
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all of the core competencies at a particular level and then achieve competence in one or more of
the specialist areas. Ophthalmic nursing has some very expert nurses, but it is unlikely that many
nurses would achieve an expert level in all or even nearly all of the specialist areas! Each
ophthalmic nurse would achieve a map of competence which is unique to them and their practice.
General nursing competence
The RCN has also developed a set of generic competencies for nursing and when added to the
core and specialist competencies for ophthalmic nursing, each nurse can develop a portfolio of
evidence which exactly describes the nurses stage in his/her career
This is shown as ‘wedding cake’ model of competence development in diagram 3
DIAGRAM 3
Skills transfer
A portfolio of evidence, developed in line with a national framework and validated at KSF review
(or eventually perhaps, accredited nationally) is very good evidence of competence for
employers. Managers employing ophthalmic nurses will be able to tell, very easily, what skills an
ophthalmic nurse has and what competence level they have achieved. The ‘how do I know you
know’ question from a manager employing a new member of staff, will be much easier to answer
and therefore skills transfer and the acceptance of competence by the new employer is likely to
be facilitated.
Education
Educationalists have been involved at every stage in this process and as programmes of
education come up for revalidation, the competence framework is being used as a basis for
educational development, thus equipping ophthalmic nurses with the underpinning education and
skills which the ophthalmic nursing profession deem necessary for competence in the ophthalmic
arena.
This should ensure that, eventually, a national standard for courses will develop, and that
employers clinicians and educationalists will have a much better sense of what a nurse
completing a particular course of study will have achieved.
Benchmarking and role mapping
The RCN Ophthalmic Nursing Forum expects that the competence framework will allow us to
benchmark competence in ophthalmic nursing practice over the whole of the UK and beyond.
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The framework has been designed with the international diversity of healthcare systems in mind
and it can therefore be used in all ophthalmic health care settings, allowing an international
understanding of ophthalmic nursing practice.
The framework also enable individual roles to be mapped against, for example, Agenda for
Change/ KSF competencies and may allow ophthalmic nurses undertaking the same role to be
accredited by other systems, at the same level, over the whole of the UK and perhaps more
widely.
The process of developing the competence framework is complete….but only for now. We have
been proactive to an extent ion that competencies have been developed in areas where
ophthalmic nursing has little presence at present. We have no way of knowing exactly what the
future hols for our speciality so the framework must be dynamic, both reacting to changes in
practice and practice organisation, but also continuing to try to predict the future. This exciting
project has relevance to ophthalmic nursing wherever it is practiced, in the UK and throughout the
world. We have many more commonalities in our practice than we have differences and people
with eye problems have the same needs and requirements of us wherever we are.
The framework is available to all ophthalmic nurses and ophthalmic nursing organisations at
www.rcn.org.uk/publications and is called - Competencies: an integrated career and competency
framework for ophthalmic nursing
TABLE 1
Level
of
Relates to
Practice
V
The nurse who is new to the speciality, with nursing competence but little ophthalmic
nursing competence
W
The competent ophthalmic nurse (Under the supervision of an expert nurse)
X
The ophthalmic nurse who has developed further competence, probably specialising in
a particular area of practice - the experienced/proficient nurse (With the minimum
guidance and supervision of an expert nurse)
Y
the senior practitioner/expert nurse (Working autonomously)
Z
The consultant nurse and beyond – an ever expanding area
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TABLE 2
Level W Element of competence
 Has a comprehensive working knowledge of the anatomy and physiology of body systems in
relation to ophthalmic and related systems
 Demonstrates a basic understanding of healing processes
 Use knowledge of abnormal ocular pathology to anticipate effects on the person
 Demonstrates a basic knowledge of the pathophysiological presentations of conditions that are
common to one’s area of practice
 Able to recognise and describe signs of common conditions in one’s area of practice using a
limited range of terminology
Level X Element of competence
 Use a full range of nursing strategies to relieve the psychological and spiritual impact of
physical and emotional aspects of ocular pathology upon individuals, family, and supporters
 Assess, prioritise and plan care for patients presenting with a range of ophthalmic conditions
and trauma
 Is identified as and leads on aspects of Essence of Care/ Fundamentals of Care initiatives
within the department and /or other initiatives for developing practice expertise such as
National Service Frameworks
 Acts proactively as an educator and resource to other professionals within and outside the
ophthalmic setting
Level Y Element of competence
 Using expert knowledge, assess, prioritise, treat and safely refer or discharge a range of
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patients with ophthalmic problems
 Anticipate the effects of clinical diagnosis on the individual and family/ supporters, adjust care
to enhance well-being and respond appropriately
 Anticipate the likely course of the patient’s treatment process and use own specialist
knowledge to effect best outcome
 Initiate, supply, administer and evaluate effects of pharmacological interventions in line with
national and local policy and clinical guidelines
DIAGRAM 1
Core competence
Y
X
Expertise
W
V
Core Competencies
DIAGRAM 2
Core and specialist competence diagram
Z
Outpatients
Y
A&E
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Children &
young people
Peri-operative
X
DIAGRAM 3
Ophthalmic specialist
competence at Y
Ophthalmic core
competence at Y
Accreditation of competence at Y
Generic competence
at Y
Ophthalmic specialist competence at X
Ophthalmic core competence at X
Accreditation of competence at X
Generic competence at X
Ophthalmic specialist competence at W
Ophthalmic core competence at W
Accreditation of competence at W
Generic competence at W
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