An evaluation of optometric advanced skills within a UK tertiary based setting

Abstract

Introduction

Hospital-based optometrists are undertaking extended roles across ophthalmology that may require them to perform advanced skills (AS). Moorfields Eye Hospital (MEH) is the largest UK employer of hospital-based optometrists, it was sought to investigate which AS are being performed at this centre and how they align to the four pillars of advanced clinical practice (ACP).

Methods

An online survey was sent to MEH optometrists in May 2022 that asked about professional status, sub-specialties worked, qualifications, acquisition and validation of AS, research and leadership.

Results

Ninety-six optometrists with mean post-qualification experience was 16.2 years (SD 10.4) responded to the survey. There were 84 AS that covered clinical, leadership and research, with respondents achieving a mean of 11.8 (SD 10.3). Those with independent prescribing (IP) qualifications (n = 52) had a higher number of AS compared to non-IP optometrists (p = 0.03). There were 68 clinical AS across the sub-specialties (23 clinical AS were common in ≥2 sub-specialties), 49 out of 120 clinical AS could be performed by at least 60% of staff. Twenty-six optometrists identified with leadership, 56 had undertaken research/audit, 27 had published within a peer-reviewed journal and half of the time spent in active research was funded.

Conclusion

AS are being performed by optometrists within a tertiary eye hospital that supports ACP. IP optometrists had higher self-reported AS but current educational frameworks don’t accommodate for some AS. Targeted AS courses with competency-based sign-off may further support high-quality patient care. Further research is required on how advanced care practitioners can support workforce transformation.

Introduction

The UK currently spends £25 billion per year on ocular disease, there is expected to be a 40% increase in those affected by visual impairment by 2050 [1]. To manage this demand, 82% of ophthalmology units across the UK utilize non-medical healthcare professionals (HCPs) [2], this includes optometrists working in secondary and tertiary care.

UK scope of practice surveys have documented that the roles of hospital optometrists have developed considerably in the past two decades [3, 4]. The largest expansion has been in sub-specialty areas such as glaucoma, medical retina and emergency eye care, in addition to newer areas including uveitis and adnexal, which allows for a greater number of new skills to be developed [2, 4]. Alongside managing outpatient appointments within these sub-specialties, there are an increasing number of clinical procedures that optometrists are undertaking (e.g., selective laser trabeculoplasty), where it is essential that these are underpinned by a robust education and governance structure to support the safe provision of care for both patients and practitioners.

There are now several educational frameworks that provide ophthalmology training for HCPs [5–7]. Some of these underpin the roles, skills and qualifications for optometrists working within ophthalmology [4, 8]. The Ophthalmic Practitioner Training (OPT) framework [6] was developed in collaboration with a number of UK stakeholders to provide a universal standard of training for HCPs providing ophthalmic care. The highest level of OPT (level 3) forms a major part of the clinical pillar within the Master’s degree in Advanced Clinical Practice (ACP) [9]. Within the ACP curriculum, there are a variety of skills that require competency-based sign-off; however there are some skills that are not present in this framework, despite recommendations that HCPs receive training in these procedures [10] or through recent guidance [11]. With the demand to provide timely ophthalmic care being increased by the COVID-19 pandemic, which resulted in a reduction in outpatient activities [12], the attainment of advanced skills (AS) amongst HCPs would be advantageous to support new care pathways and workforce delivery.

Moorfields Eye Hospital (MEH) NHS Foundation Trust is the largest single employer of UK-based hospital optometrists. MEH currently employs over 160 optometrists who are working in multiple services and performing a variety of clinical skills. Considering that most UK HES departments have fewer than 10 whole-time equivalent staff [4], it is important to understand what AS and competencies MEH optometrists have and explore their relevance to the four pillars of ACP (clinical practice, education, research and leadership). Such information could support the timely development of the UK optometric workforce.

The aims of this service evaluation project (SEP) were to (i) investigate what AS relating to clinical, research, leadership and education roles were being performed and if relevant had undergone validation, (ii) what qualifications had been attained by optometrists, and (iii) to explore how AS could be supported through education that informs workforce strategy and alignment to advanced clinical practice.

Methods

A prospective SEP was conducted at MEH NHS Foundation Trust, City Road, United Kingdom between May and June 2022. This SEP was registered and approved by the MEH Clinical Audit and Assessment Committee on the 7th March 2022 (Project Number 1003) and it was confirmed that formal ethical approval was not required.

The SEP was performed in two stages, firstly a questionnaire was developed and sent to all MEH optometric service leads to complete. This asked what desirable AS and post-graduate qualifications were relevant for optometrists currently working in their service. Service leads included: Accident and Emergency, Urgent Care Clinics, External Disease, Adnexal, Uveitis, Medical Retina, Low Vision, Contact Lenses, Cataract, Paediatrics, Research and Education. For leadership, there was no service lead therefore the head of optometry was consulted who has extensive experience in this area. The skills that were listed were not part of the current mandatory requirements for General Optical Council (GOC) registration [13], nor essential skills that are required in their respective service.

Responses from service leads were collated, and a final questionnaire was developed that asked questions in the following areas:

1. Demographics

2. Professional status

3. Which services do they currently work in and for how many sessions

4. Relevant qualifications gained/working towards per service

5. What AS they can perform in the service they are currently working in

6. Which AS had been attained through external or internal validation per service

7. What AS are not being actively performed

8. Proportion of time spent in their job role with respect to research and leadership

9. Relevant training courses attended per service.

Once the questionnaire was finalized, an online survey tool (Smartsurvey, www.smartsurvey.com) was used to construct the survey (See Supplementary 1) that was tested before launch. The online survey link was disseminated via email to all GOC registered optometrists working within the optometry department. The email invitation and link explained the purpose and objectives of the survey and the fact that all responses were anonymous. The survey was open to responses between the 5th May 2022 and 1st July 2022. The database was compiled and maintained by the Moorfields Optometry Learning and Development Lead (AJ). Reminders to complete the survey were sent at 4, 6 and 7 weeks post initial release.

The analysis was conducted using SPSS software (v29.0, IBM Inc., USA), parametric and non-parametric tests were undertaken, where relevant. For all inferential statistical tests, a p-value of <0.05 was considered statistically significant.

Results

Respondent characteristics and accreditations

The survey was sent to 160 staff that were employed by MEH in May 2022, 96 responses were received (60% response rate) of which the majority were female (n = 71, 74%). Total years qualified from all respondents mean (SD) was 16.2 (10.4) years. Almost a third (31.2%) of those surveyed had a master’s or higher qualification and two-thirds (n = 64, 66.6%) were either registered independent prescribers or working towards this qualification. The highest number of any single College of Optometrists professional accredited certificate gained was the professional certificate in glaucoma (n = 50, 52%). Thirty-four respondents completed the NHS consent training programme, 32 National Institute for Health and Care Research Good Clinical Practice (NIHR GCP) training and there were four trained COVID vaccinators. Professional qualifications of respondents are summarized in Table 1.

Table 1.

Professional qualifications of survey respondents.

Qualification	Awarded	Undertaking
MSc/MOptom	21	–
PhD/doctorate	9	–
Member/fellow of the College of optometrists	80	–
Independent prescribing	52	12
Professional certificate in low vision	2	0
Higher certificate in low vision	1	0
Diploma in low vision	1	0
Professional certificate paediatrics	5	0
Higher certificate paediatrics	0	0
Higher certificate in contact lenses	2	2
Diploma in contact lenses	4	0
Professional certificate in glaucoma	50	0
Higher certificate in glaucoma	31	15
Diploma in glaucoma	6	19
Professional Certificate in Medical retina	17	0
Higher Certificate in medical retina	2	3

Sessions worked per service

The number of optometrists working in each service were; Accident and Emergency (A&E) (n = 13), Adnexal (n = 3), Cataract (n = 17), Clinical trials (n = 9), Contact Lenses (CL) (n = 38), Education (n = 11), External Disease (n = 30), Glaucoma (n = 57), Low Vision (LVA) (n = 18), Medical Retina (MR) (n = 37), Paediatrics (Paeds) (n = 38), Urgent Care Clinic (UCC) (n = 15) and Uveitis (n = 1). The total number of sessions that optometrists worked in a service for one session was 226 (73.1%), two sessions per service 51 (16.5%) and three or more was 32 (10.4%). Figure 1 details the number of optometrists working in each service and the number of sessions that they were allocated.

Fig. 1. Number of optometrists and sessions worked per service.

A&E Accident and Emergency, CL contact lenses, LVA low vision, MR medical retina, Paeds paediatrics, UCC urgent care clinics.

Advanced skills

There were 84 AS of which 68 were clinical, 5 research and 11 leadership. The mean number of AS that respondents reported performing in the course of their work was 11.8 (SD 10.3). Those who have gained the independent prescribing (IP) qualification reported performing a higher number of AS (14.4) compared to those without the qualification (9.0), reaching statistical significance (Independent t-test, t₈₂ = 2.30, p = 0.025). Gender and age did not affect the number of AS attained (both p > 0.05).

Advanced clinical skills

Out of the 68 clinical AS the most frequently reported included gonioscopy, corneal topography interpretation and binocular indirect ophthalmoscopy; Fig. 2 details the clinical AS and the number of optometrists that can perform each skill.

Fig. 2. Number of optometrists that can perform each clinical skill.

BCL bandage contact lens, DCR dacryocystorhinostomy, IOL intraocular lens, OCT optical coherence tomography, RGP rigid gas permeable, YAG yttrium–aluminium garnet.

Skills that were performed by one optometrist included chalazion removal, corneal gluing, cyst removal, laser suture lysis, myopia control, radiology interpretation, removal of aqueous shunt stent suture; no optometrists reported they could perform cannulation, cross-linking, fluorescein angiography procedure, intravitreal injections, lid laceration repair, laser retinopexy, pan-retinal photocoagulation and prism bar assessment.

Twenty-three AS were common to two or more services, which resulted in a total of 120 clinical AS across all clinical services with 49 AS (40.8%), 60% or more staff could perform (Supplementary Fig. 1). There were 13 AS where two or more services reported less than 60% of their staff employed in their service could perform that included: scleral indentation, ultrasound, blood glucose measurement, blood pressure measurement, performing and interpreting confocal microscopy, YAG capsulotomy, 3-mirror fundoscopy, cannulation, corneal gluing, corneal foreign body removal, fluorescein angiography interpretation, gonioscopy and suture removals.

Advanced clinical skills performance and accreditation

For each clinical service, the percentage (median and interquartile range [IQR]) of optometrists employed that could perform the relevant clinical AS were: A&E 69.2% (30.7–92.3%) (Fig. 3 details the percentage of staff that could perform AS in Accident and Emergency and were signed off), Cataract 47.1% (5.9–82.4%); Glaucoma 5.3% (2.6–11.4%), Paediatrics 15.8% (2.6–42.1%), LVA 37.9% (12.1–37.9%); External 48.3% (10.0–72.5%), UCC 53.3% (26.7–80.0), Medical Retina 2.7% (0–25%) and Contact Lenses 73.8% (IQR 45.8–90.5%) (Supplementary Figs. 2–9). Validation of clinical AS was relatively low for all services either through external or internal frameworks (median, IQR): Paediatrics 2.6% (0–42.1%), LVA 31.0% (12.1–41.4%), External 28.3% (7.5–36.7%), A&E 30.8% (15.4–38.5), UCC 26.7% (13.3–46.7%), Cataract 35.3% (5.9–47.1%), Medical Retina 1.4% (0–10.8%) and Glaucoma 3.5% (1.8–8.8%).

Fig. 3. Percentage of staff that could perform advanced skills in Accident and Emergency and were signed off.

OCT optical coherence tomography.

As only one optometrist reported working in the uveitis service and three in the adnexal, further analysis was not conducted for these sub-specialty areas. There were 5 skills out of 120 that were both performed and signed off by 60% of optometrists working in the relevant service.

Leadership

Twenty-six optometrists identified that leadership encompassed a proportion of their job role, with 14 (53.9%) reporting that this accounted for up to 20% of their employment and 21 (80.8%) up to 50%. 11 leadership skills were reportedly achieved that included knowledge of team building (16, 61.5%), strategy development (15, 57.7%), service/quality improvement (24, 92.1%), patient experience (21, 80.8%), driving innovation (10, 38.5%), collaborative practice (11, 42.3%), workforce management (18, 69.2%), operational planning (11, 42.3%), business planning/financial management (8, 30.8%), health and safety (9, 34.6%) and diversity and equality (10, 38.5%). Fourteen had undertaken leadership training such as the NHS Mary Seacole programme.

Research, audit and education

Fifty-six optometrists had reported they had undertaken research or been involved in an audit. A total of 279 papers in peer-reviewed journals were published by 27 optometrists either as the primary/senior author or as a co-author. From those who had published, 17 (63%) had a post-graduate research degree (e.g. MSc/PhD) and 18 had undertaken NIHR GCP training. 12 optometrists reported being currently research active, where they contributed to 220 (78.9%) of the total publication output, a median of 5.5 papers/staff member (IQR 1.3–28.8). Research skills included grant development/writing, developing applications for ethical approval, collecting participant consent, data collection/case-report form completion and statistical analysis. Those staff members who were involved in research/audit that could perform these skills ranged from 9 to 25%.

The total reported hours per week that staff undertook research and/or audit-related activities was 122 hours, where 60 hours were reported as being funded.

Eleven staff members identified with education roles, where nine members were allocated one dedicated education session. Three optometrists had achieved the fellowship accreditation with the Higher Education Academy and there were three that were working towards this. There was insufficient data to conduct inferential analysis as only one respondent completed the relevant fields related to courses attended or educational research published.

Discussion

In this SEP, optometrists at MEH reported performing a range of AS that were relevant to their respective services and were beyond the core competencies required for General Optical Council registration as an optometrist. It was identified that optometrists were working in a range of clinical services, which reflects the employment of HCPs within secondary and tertiary ophthalmology services across the UK [2, 4]. Gunn et al. [4], found an increase in the number of departments where optometrists hold IP qualifications, potentially facilitating an increase in autonomy for optometrists working in sub-speciality clinics. Whilst perceived autonomy was not explored in this SEP, the possession of this qualification was shown to significantly increase the number of AS they could undertake, this effect reaching statistical significance. Furthermore, none of the AS surveyed formed part of the entry requirements for optometric IP. Studies evaluating clinical decisions of IP optometrists in primary care found most cases could be managed to resolution without the need for further referral [14, 15], thus supporting the hypothesis that IP qualification promotes effective independent clinical decision-making. In addition, Todd et al. [16] found good agreement of IP optometrists to ophthalmologists within the hospital eye service which supports their ability to manage high-risk cases. The findings of our current work supports the hypothesis that the IP qualification encourages clinicians to undertake further professional development. As none of the advanced skills are covered in the IP nor undergraduate curriculum; acquisition of such skills could potentially support further optometric integration and provision of ophthalmic care in both primary and secondary/tertiary care.

The Royal College of Ophthalmologists Way Forward paper in glaucoma [5] predicted the number of people in the UK with glaucoma to increase by 44% from 2015 to 2035. As such, there have been several optometrist-led glaucoma pathways developed in recent years [17] in this area, however only 97 UK optometrists were found to have achieved the diploma in glaucoma offered by the College of Optometrists [8] that supports a range of independent clinical decision-making [18]. Within MEH, the glaucoma service has the highest number of optometrists employed with 57 of survey respondents working in this service, this being similar to the findings from a national survey by Gunn et al. [4]. Within MEH there are optometric-led glaucoma pathways that include both virtual and face-to-face clinics, these rapidly expanded as a result of the increasing demand brought by the COVID-19 pandemic. In these clinics, the ability to make autonomous decisions is required, the development of this skill being supported by a large number of staff members in these clinics undertaking the College of Optometrists diploma in glaucoma. With the recent updated NICE guidance recommending selective laser trabeculoplasty (SLT) as a first-line treatment for those with ocular hypertension and primary open-angle glaucoma [11], current numbers of optometrists undertaking this advanced skill remain low at both local and national level [3, 4]. Therefore, it may be anticipated that there will be a demand to train and upskill staff to perform this skill, but also for them to have the underpinning knowledge where this is supported by the OPT and College of Optometrists frameworks [2].

This survey found less than half of the advanced clinical skills across the sub-specialties could be performed by hospital-based optometrists and validation of these skills was found to be negligible. There could be several factors that may contribute to this, firstly the majority of optometrists are only employed one session per service. This would limit their exposure to patients within these sub-specialties and could present a barrier to undertaking further training. In contrast, ophthalmologists usually spend a significant period of consecutive time within a sub-specialty that has been integrated into formal training pathways, which allows them to develop and perform advanced procedures. Another barrier could be that the achievement of AS may be a low service priority when compared to performing essential skills, due to the resources that are required to enable such training. With increasing patient demand across ophthalmology, the requirement to train the non-medical workforce lies within current education frameworks that covers a number of essential skills and lead to the development of autonomous practitioners [2]. The Royal College of Ophthalmologists’ AMD strategy document, The Way Forward, [10] made recommendations for service providers to consider non-ophthalmologist injectors, however the competency required to provide this advanced skill is not present in any of the major education frameworks, the same being the case for SLT.

This work found that three of the four clinical sub-specialties from the OPT curriculum (glaucoma, medical retina and cataract) would support less than a third of the AS required by MEH optometric service leads. However, the ocular emergencies component from OPT aligned with fifteen of the twenty-two advanced clinical skills, where a number of these were common in external disease and urgent care clinics; these skills could also be adopted and may enhance current urgent primary eyecare services that have been reported by several authors [14, 15, 19]. Greenwood et al., suggested those delivering very specific tasks or procedures involve adherence to a standardized set of steps, ranging from low to high-risk procedures that require very specific education and defined protocols but probably not a masters level qualification [2]. This recommendation might also apply to the majority of AS questioned in the survey, where respondents have reportedly developed the ability to perform a number of skills without formal instruction, with the caveat that they have not uniformly received validation or sign-off due to the lack of appropriate protocols or frameworks. Whilst there may be clinicians who have been undertaking AS over a number of years without any issues, best practice of working to clinic protocols should be followed with associated formal sign-offs for significant AS.

The Department of Health & Social Care policy document, ‘The Future of United Kingdom Clinical Research Delivery: 2021 to 2022 implementation plan’ proposed the future of clinical research within the UK should encourage more clinical research across all healthcare settings and staff groups, in addition to embedding research into routine NHS care [20]. In this work, over half of all optometrists surveyed had been involved in research and audit, with half of this cohort having published in peer-reviewed journals or presented at a conference. This is an encouraging finding considering the number of barriers that optometrists face when wishing to undertake research that has been summarized by Taylor et al. [21]. Two-thirds of those who had disseminated research outcomes had a masters qualification or higher, with the ACP alignment to a masters qualification this could further support research activity. One pertinent barrier to research activity that was identified was the lack of funded time with approximately 50% of reported research time being reported as unfunded, equating to approximately £83, 000 of unpaid time over 1 year (assuming this was paid at Agenda for Change, band 7 with 5 years experience).

Transformation within the NHS to meet the demands of an ageing population requires leadership. A systematic review of nurses found that poor leadership led to nurses experiencing workplace bullying, burnout, stress and poor retention which in turn leads to poor morale and requires additional recruitment to replace those who have left [22]. This could also be very relevant for the optometric profession if there is poor workforce planning, especially if optometrists are entering new areas of practice that would counteract the investment in time and costs to develop them into their area of specialty. The NHS actively supports leadership development, offering a range of courses enhancing confidence and competence in healthcare staff [23], where leadership is also recognized as a core component of ACP. This work found that a quarter of staff identified with leadership as part of their job role, however it was found that attainment of leadership skills did not appear to be related to attending leadership courses nor the time spent undertaking leadership activities, despite half of respondents completing the relevant training. The NHS Leadership Academy [24] encourages leadership development up to director level, where it acknowledges the importance of developing and leading a culture of compassion and understanding over time [23]. Therefore, using skills to measure the quality or impact of leadership may be limited.

A major strength of this study was the number of respondents, representing a significant proportion of the optometric MEH workforce where these findings are applicable. The contemporary detail captured in the survey was also comprehensive and covered the four pillars of advanced practice. In addition, the two-stage approach where service leads first identified and came to a consensus on the necessary AS for each sub-specialty area, ensured the full range of AS needed for current roles in MEH were evaluated. Considering the majority of hospital-based departments employ significantly lower numbers, this survey provides insights into how HES optometry departments could support their workforce in terms of education and potential expansion into new services with substantial job plans to develop specialist roles. However, a limitation of this study was the number of respondents being relatively experienced practitioners based within a specialist tertiary setting, which would affect the generalizability of the findings where there may not be the scope to offer such specialized services/skills.

In conclusion, AS were reported for hospital-based optometrists actively working within ophthalmic sub-specialty clinics at MEH, where IP supports AS attainment. There was a relatively low proportion of AS being performed or signed off for nearly all services concerning the number employed per service. Over half of optometrists were involved in research, but half of the time spent on research was unfunded. It was identified from this work that the OPT framework may not cater to all the AS and there were a number of common skills in which targeted educational short courses with signoffs may benefit a number of ophthalmic sub-specialties and support autonomy. Further research is required to understand the requirements of ophthalmic sub-specialties regarding what AS are needed, so training and accreditation can be standardised nationally. Exploration of these areas could facilitate a national workforce strategy for optometrists to become specialists in their area with a career pathway that is suitably provisioned in advanced practice that can lead to high-quality patient care.

Summary

What was known before

• UK scope of practice surveys have documented that the roles of hospital optometrists have developed considerably in the past two decades alongside the skills they can perform.

• The Advanced Clinical Practice (ACP) framework that aligns with the Ophthalmic Practitioner Training curriculum aims to provide a universal standard of training for non-medical professionals providing ophthalmic care.

• Moorfields Eye Hospital NHS Foundation Trust is the largest single employer of UK-based hospital optometrists, it was sought to investigate what advanced skills are being performed and their relevance to the four pillars of ACP in this centre, such information could support the timely development of the UK optometric workforce.

What this study adds

• Advanced ophthalmic skills covering the pillars of ACP are undertaken by optometrists working within a tertiary eye hospital, however less than half of the surveyed clinical advanced skills were performed and half of research time is funded.

• Optometrists who could independently prescribe reported a higher number of advanced skills being performed; current national education frameworks may not cater to specific advanced skills.

• Targeted courses with competency-based sign-off and provisioned research time could further support advanced skills achievement and autonomous advanced clinical practice.

Author contributions

AJ: Conceptualization, planning; data acquisition; data analysis; transcripts. SA: survey development, PJM, VA and DS; critical appraisal.

Data availability

The datasets generated from the current study are not publicly available due to data use agreements with MEH. Requests for data will require approval from MEH and the signing of data access agreements; requests can be submitted to the corresponding author.

Competing interests

The authors declare no competing interests.

Supplementary information

The online version contains supplementary material available at 10.1038/s41433-023-02880-7.