Perceived eye care risk and safety issues identified by optometrists in Scotland: a focus group study

Abstract

Introduction

Evidence on the nature and scale of risk and safety concerns in optometry practice is very limited, especially compared with other primary care professions. In Scotland, many changes occurred in the profession during and because of the COVID-19 pandemic. The theme of risk and patient safety was, therefore, chosen as the priority focus for the 2022 mandatory national training programme, which optometrists providing General Ophthalmic Services in Scotland are required to undertake.

Aim

To explore and identify perceived current and future safety risks and how these might be mitigated in relation to professional optometry practice in Scotland.

Methods

Study participants were all registered General Optical Council members from nine of the 14 regional health boards in Scotland. Data were collected via three online focus groups over a 2-month period during 2021 with each comprising six to eight participants. Data were transcribed with permission and then subjected to a basic thematic analysis.

Results

16 optometrists participated in the study. Six principal themes were generated from the data analysis: (1) current overview and context (eg, perceived increased risk); (2) competency risks (eg, skills and knowledge to manage disease); (3) conduct risks (eg, behaviours of practitioners); (4) contextual risks (eg, environmental issues); (5) future risks (eg, technology) and (6) risk mitigations (eg, education and training).

Conclusions

Optometrists participating in this study expressed concerns that the level of perceived clinical risk in the Optometry profession is increasing, mainly related to technology, scope of practice, role development and changes in consumer demand. Multiple recommendations are made to minimise reported risks including education for new roles; increased focus on improving care quality; support to those involved in safety incidents and complaints; taking a systems approach to areas of high risk and sharing good practices.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Research into patient safety and exploring clinical and organisational risks in professional optometry practice is underdeveloped especially when compared with other healthcare settings.

WHAT THIS STUDY ADDS

• The findings generated provide evidence of reported safety and risk concerns perceived by experienced optometry professionals as well as suggestions for risk mitigations, particularly related to competency, professional conduct and organisational issues.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• The findings provide some insights for policy makers, educators and practitioners on reported safety and risk priorities in the optometry profession, with study outcomes informing the development and implementation of targeted patient safety and risk management education for the optometry profession.

Introduction

The safety of patient care is a serious public healthcare concern across all healthcare systems and is reportedly one of the leading causes of morbidity and mortality worldwide.¹ Evidence of the prevalence of patient safety incidents (circumstances where patients were harmed or could have been during their interactions with healthcare services) is well-established in acute hospital care—largely because much of the policy attention, and research and resource allocation, has focused in acute due to the perceived greater and more serious risks of harm in this sector. Here, it is estimated that around 10% of patients are unintentionally harmed, with approximately 50% of cases judged to be preventable.²

In response, a plethora of international and national regulations, policies, educational programmes and improvement initiatives have been developed and implemented over the previous two decades.^3–6 The WHO have initiated a 10-year strategic global action to improve patient safety and also have developed a well-established multidisciplinary curriculum on the topic.^{7 8} The patient safety issue is addressed by regulators as part of the expectations of good clinical practices and is also often included in undergraduate and post-training programmes across different professional groups. In the UK, for example, we also see the establishment of national patient safety programmes, while it is also integrated within the training curricula of professional bodies and Royal Colleges, often at the behest of clinical regulators.⁹

In the primary care professions, research into patient safety occurrences is gradually evolving but is not as extensive or rigorous as the many studies undertaken in secondary care.¹⁰ In general medical practice, a recent systematic review indicated that a safety incident may affect around 2%–3% of patients attending face-to-face consultations with clinicians.¹¹ Comparable safety incident estimates appear to be lacking for community pharmacy and primary care dentistry due to the dearth of dedicated research, but each profession has begun to study aspects of the patient safety problem. For example, studies of medication incidents and safety culture in pharmacy are published, as well as professional agreement on some of the most serious types of patient safety incidents that can occur in primary care dentistry.^12–14

In the optometry profession, the professional body in the UK (College of Optometrists) has published guidance on keeping patients and staff free from harm that covers issues around the quality and safety of care, expected competencies, maintaining trust and communication and teamwork.¹⁵ However, very little empirical information on the nature of risk and safety concerns is known or published. In a nominal group technique study by researchers in Wales, optometrists were asked to consider eye-care related safety incidents that they had experience of or they thought could occur.¹⁶ Incidents related to diagnoses incidents (eg, related to clinical decision-making) were reported to be infrequent but potentially the most severe, with administration related incidents perceived the most frequently occurring (eg, delayed or missed referrals). A group of Australian researchers concluded that rates of burnout among optometrists were higher compared with the general population and other health professionals.¹⁷ In a mixed-methods study by the UK General Optical Council (GOC) to explore risk perceptions and experiences of their registrants, practitioners deemed areas of practice around independent prescribing, detection and management of ocular disease and making appropriate referrals to hold the greatest level of risk.¹⁸ The study highlighted that perceived contextual risks around time constraints, working as a locum and commercial pressures were considered as recurring themes and ‘most likely’ to occur in practice.

Against this background, the National Health Service (NHS) Education for Scotland (NES; box 1) optometry team was also aware of the many changes in the profession during and because of the COVID-19 pandemic and therefore the theme of risk and patient safety was chosen as the focus for the 2022 mandatory training programme, which optometrists providing General Ophthalmic Services in Scotland are required to undertake.¹⁹

Box 1. About National Health Service (NHS) Education for Scotland (NES) and NES Optometry.

NES is an education and training body and a national health board within the NHS in Scotland. It is responsible for developing and delivering healthcare education and training for the NHS, health and social care sector and other public bodies. NES has a Scotland-wide role in undergraduate, postgraduate and continuing professional development.

NES Optometry exists to up-skill community eyecare teams, who provide NHS-funded care under the General Ophthalmic Services terms of service, to enable them to provide high-quality eyecare and to improve the ocular health of patients throughout Scotland.

To inform and support the design and focus of the training programme, this preliminary research study was undertaken. The main study aim was to explore and identify the perceived current and future risks and how these might be mitigated in relation to professional optometry practice in Scotland.

Methods

Definition of risk

For the purposes of the research, the definition of risk outlined to participants is aligned with the three-level categorisation out in the GOC report of competency, conduct and contextual risk²⁰:

• Competency risks: risks from practitioners lacking the necessary skills or knowledge to diagnose and manage disease and conditions or to use appropriate equipment.

• Conduct risks: risks stemming from the behaviour of practitioners either through negligence or inappropriate behaviour.

• Contextual risks: features of the environment in which the practitioner operates that may increase the scope for risk or influence the severity or likelihood of clinical and competency risks.

Rapid search and review of literature

A rapid, comprehensive search and review of empirical and ‘grey’ literature was undertaken to identify any key papers to inform the study context and design. The main electronic databases searched over a 15-year period from 1 January 2008 to 31 December 2022 were: PubMed, Medline, SCOPUS, PsycINFO, CINHAL and Google Scholar. The GOC report and a small sample of published articles of relevance related to risk and patient safety were uncovered. The literature review identified a gap in specific research relating to optometry and risk. Compared with other healthcare professions, the data are very much limited to published work by GOC. The 2019 GOC Risk in the Optical professions report (18) found that, in comparison to other healthcare professions, the roles of optometrists involve lower levels of risk to patients and the public. However, anecdotally, a consensus among practitioners that the level of risk in optical professions is changing required further exploration.

Study participants and setting

Study participants, who were all registered members of the GOC, were voluntarily recruited by invitational email using the NES Optometry organisational database of practising optometrists providing independent contractor services to the NHS in Scotland across 14 regional (territorial) health boards. The list contains 1551 practitioners, of whom 33 noted their interest in participating in the study. An invitation was extended to each of those practitioners.

Data collection

The primary method for obtaining data was online focus groups—a qualitative research method whereby a trained facilitator conducts a collective interview of typically between 6 and 10 participants from similar backgrounds and/or similar demographic characteristics of relevance to the study.²¹ They were deemed the most appropriate method of data collection as they are useful for exploring perceptions, attitudes and experiences, while enabling participants to debate and challenge each other and clarify their views. The focus groups were facilitated by DA an experienced educator, researcher and healthcare professional and co-hosted by JG, the NES Optometry specialist lead. A topic guide was developed and applied to explore the issues at hand without leading the discussion (online supplemental material 1).

Three focus groups were conducted over 2 months during the spring of 2021. The online platform Zoom was used to facilitate the group interviews, and each session was recorded with consent, transcribed and analysed. Focus groups consisted of six to eight people in attendance. Each session lasted around 90 min, and we were satisfied that all delegates had the opportunity to participate. Views were also collated using Jam board (an electronic flipchart) and recorded.

Data analysis, interpretation and validation

Data were subject to a thematic analysis²² and were deductively categorised using the a priori three-level risk categorisation framework with the addition of themed data related to risk mitigation strategies. The initial coding and generation of categories and themes was undertaken by DA, and these were checked and re-checked by one other researcher (PB) with any disagreements on theme generation resolved through discussion. The two researchers collectively agreed on the selection of quotations that best support the findings related to each of the themes.

Results

A total of 16 optometrist participants attended three online focus groups. A breakdown of professional and demographic data is outlined in table 1.

Table 1.

Breakdown of professional and demographic data of study participants (n=16)

Health board location	Number of optometrists (n)
Ayrshire and Arran	1
Borders	1
Fife	1
Grampian	1
Greater Glasgow and Clyde	4
Highland	1
Lanarkshire	1
Lothian	3
Tayside	3

Decade qualified	Number of optometrists (n)
1970s	2
1980s	4
1990s	2
2000s	5
2010s	2
Independent prescriber	9
Non-independent prescriber	6

Six principal themes were generated from the focus group data analysis.

Current overview and context

The perceived levels of current risks varied across the participants. Many highlighted the need for more awareness of known risk factors and education to identify and mitigate the risks. While many agreed with the previous consensus from GOC about the clinical and organisational risks being lower than in other healthcare professions, the majority were clear that these risk areas had increased significantly in previous years. They cited the greater use of complex technology and expanded roles in prescribing and treatment which, in turn, escalated the risks to ensuring safer patient care. Additionally, the COVID-19 pandemic provided both opportunities and new threats, including the need for a more consistent and robust approach to new ways of working involving the use of technology.

The ‘First Port of Call’ responsibility represents a reframing of the community optometrist’s remit, intended to promote the understanding that patients’ with ocular complaints should present to an optometrist in the first instance. The main purpose is to reduce the burden on other primary and secondary care colleagues, since many of these complaints can be safely managed by community optometry practices. First port of call was a common theme which provoked much comment and debate. While the initiative was generally welcomed and seen as a driver for improvement in patient care and treatment, multiple barriers and challenges were identified and discussed, which could be categorised in all three areas of risk that is, competency linked to scope of practice, conduct linked to communications and behaviours and context linked to the environment, technology and systems.

The logistics around providing 24-hour optometry cover and communication to patients and indeed between healthcare professionals may cause confusion and uncertainty. Some optometrists were concerned about duplication or overlap with other acute or emergency services such as minor injuries and emergency departments.

First Port of Call, …difficult to manage particularly in a small practice… Focus Group 1 Participant

Competency risks

Several participants noted the high-profile legal case of Honey Rose* where a qualified optometrist was convicted of gross negligence manslaughter.²³ Although the conviction was later overturned on appeal, the incident remained a source of concern and anxiety for participants. A common competency risk identified was related to missed diagnoses and a failure to detect disease. Although this was generally thought to be a low risk and unlikely to occur, it was felt that if there was a failing then the consequences would be significant for patients and the practitioners.

A further emerging theme was the risk to patients related to optometrists who were qualified as independent prescribers of medicines. There was clear concern and worry from participants about the increased pressure in prescribing and the need to ensure full and accurate record keeping and that clinical decision making was recorded in a robust and transparent manner. However, there was agreement that time pressures and inadequately designed work systems sometimes made this challenging for practitioners.

When safety and other incidents do occur, participants agreed that the profession should be encouraged to record and report any ‘near misses’ or adverse events. However, many felt they were not well equipped for this aspect of their role and welcomed the mandatory training in 2022 related to risk and patient safety.

All participants welcomed education and training, however several voiced concerns about elements of professional development being unsympathetic to the varying abilities of practitioners, from novice to expert. More specifically, in an enhanced role such as prescribing or invasive treatments, ongoing mentorship, peer support and clinical audit were considered necessary following the theoretical input.

…scope of professional practice has to be matched by training and interaction with secondary care Focus Group 3 participant

Conduct risks

Risks derived from conduct issues most often result from miscommunication or inappropriate behaviours. Incivility or inappropriate professional behaviour was discussed as a risk by participants. Concerns around the risks associated with delegating tasks to support staff, including visual field testing, fundus photography and contact lens insertion and removal were highlighted. Participants noted interactions between optometrists and patients, as well as between optometrists and colleagues or other healthcare professionals, all carried risk through poor or inadequate communication.

Other issues such as lack of information given or unnecessary delays may lead to challenging conversations with patients and occasionally patients may decide to raise a complaint.

Delegates reported challenges in responding to patient expectations, particularly during the pandemic: for example, patients referred by GPs for minor injuries who had high expectations to be seen urgently.

Professional behaviours were highlighted by practitioners in relation to maintaining a balance between business needs and delivery of high-quality care. Again, the risks here are to patient safety and to the well-being of the individual optometrists and colleagues.

Managing a concern or a complaint openly and honestly and awareness of the Duty of Candour legislation was a common theme. The literature suggests that many complaints arise due to issues with communication, behaviour and attitudes. The Scottish Public Services Ombudsman (SPSO) Annual Report 2021 indicates the importance of learning and improvement from complaints and encourages staff within the public sector to be proactive in seeking resolution at the earliest opportunity.

However, for individual practitioners to respond effectively to complaints, it is important they have the knowledge, skills and confidence to do so. Another SPSO publication Making Complaints Count for Everyone 2017 confirms the importance of staff being supported through the process to prevent practitioners becoming overly defensive in their future practice.

A number of practitioners mentioned their lack of knowledge about the Duty of Candour and wanted to raise awareness through more focused education and training, including systems and human factors science.

We need a culture of being open and honest, sharing mistakes and discussing with peers Focus Group 2 Participant

Practitioners going beyond the scope of their practice or competence, increased risk of undermining public confidence in the profession Focus Group 3 Participant

Contextual risks

The environment optometrists are working in plays a key part in the degree of risk perceived. The variation in risk between working in a rural practice compared with a hospital clinic is apparent. There are many variables which influence the environment: the current changes to ways of working, amended policies around patient contact and interactions, new technology such as video and phone consultations, have all elevated the degree of concerns and may result in increased risks to both patients and to the well-being of practitioners.

Participants discussed the use of technology and access to remote consultation as both an opportunity and a threat. Variations across Scotland were highlighted and could result in ‘a postcode lottery’ of clinical care. Recall and referral systems were discussed by participants who identified this as a potential high-risk area. There was significant variation across Scotland and appeared to be no defined or recognised good practice. Despite many practices using sophisticated patient management systems, often there are no standard procedures for recalling patients if they did not attend an appointment. Similarly, follow-up visits or referrals to secondary care were mixed.

Lone or working in isolation, specifically in remote and rural areas, was identified as being a risk to individual practitioners: opportunities for a broader range of patients, access to peer review, education and training was considered less available.

Crucial to the success of the newer ways of working is education and training. Education and training provided by NES optometry was considered to be a positive way of sustaining a workforce who were competent from registration through to enhanced and advanced roles.

The retail / clinical division is going to get greater and there will be some Optoms caught in the middle Focus Group 1 Participant

Future risks

Many of the themes identified relate to the rapid changes to care processes and systems due to the COVID-19 pandemic. Participants agreed that optometrists responded quickly and effectively to this complex and dynamic crisis situation; however, this may well have inadvertently contributed to the perception of increasing clinical risks by the profession. Participants also shared their concerns about time constraints and balancing the many conflicting requirements in their roles. Keeping up to date with technological advances and new equipment was identified as an opportunity for improved quality of care yet was also a source of stress for some practitioners. Changes in demographics and the shift to community care models are all playing their part in how optometry professionals gauge future working and hence consider future risks to practice.

…scope of professional practice has to be matched by training and interaction with secondary care… Focus Group 2 Participant

The profession becoming split between those wanting to extend clinical remit and those who do not… Focus Group 2 Participant

Risk mitigations

The optometry profession has undergone significant changes due to new and enhanced ways of working introduced as part of the response to the COVID-19 pandemic. The data generated by this study found those factors have increased the current and perceived risk to patient safety. Ways to mitigate risk can be a useful approach and participants were asked specifically to comment on how best to reduce risks. Table 2 summarises these views, which are set out below as part of the recommendations.

Table 2.

Risk categorisation and suggested mitigation strategies

Competence risk	Suggested mitigation
Missed diagnosis or failure in treatment	Education and training in risk and patient safety Ongoing requirement to demonstrate skills and expertise to remain registered
Independent prescribing	Education and training opportunities Peer support and review Clinical audit
Awareness of risk factors and mitigation	Education and training in risk and patient safety
Skills acquisition	Continuing professional development Peer support and review Clinical audit

Conduct risk	Mitigation
Poor or inadequate communication with patients and between professionals	Education and training in communication skills Increased awareness of complaints resolution and Duty of Candour
Professional behaviours	Mentoring and peer support Feedback and appraisal Clinical audit
Managing complaints	Peer support and review Education and training opportunities

Context risk	Mitigation
New ways of working including video and ‘phone consultations	Education and training in new technology and standards for practice Ongoing requirement to demonstrate skills and expertise to remain registered
Lone or working in isolation	Access to peer review Access to education and training opportunities Access to NES mandatory training
Variation in standards to recall and refer systems	Consider national standards/operating systems Clinical audit

NES, NHS Education for Scotland; NHS, National Health Service.

Education and training across all sectors of the profession will play a key role in acknowledging, recording and responding to risk. Particularly in relation to continuing professional development, ongoing access to high-quality educational opportunities from registration to advanced practice roles is paramount. GOC and NES were both applauded for their position in supporting individuals and the optometry profession. Specific education about risk management including complaints and adverse events is welcomed as is the NES approach to mandatory training. A continuing emphasis on learning and development in relation to leadership and professional behaviours will help to reduce conduct risks. Building on good practice and finding effective ways to disseminate new and innovative working should continue and again the NES mandatory training provides an effective way to manage this. Clinical audit, feedback and appraisal mechanisms were recognised as an important method of improving practice. Adopting robust approaches to mentoring and peer review was also considered a useful and productive way forward.

Discussion

We have introduced the perceptions of risk in optometric practice in Scotland: gathered as part of our focus group discussions, ahead of developing an educational resource around risk and patient safety in optometry. Aside from the ‘Risk in the Optical Professions’ paper, by the GOC (18) and a recent study by MacFarlane et al,¹⁶ research in this area is underdeveloped, especially in comparison to other primary care professions. Our findings make a small contribution to understanding in eye care safety in optometry practice. They also offer important and previously unreported insights from practitioners around suggestions to enhance current risk mitigation strategies and perceived future risks to safety that may need to be considered.

Within Scotland, there are a significant number of independent prescribing optometrists managing a variety of conditions within their community practices. Among those practitioners, there is of course variation in scope of practice, as well as confidence in managing certain conditions. While the expanding remit of the community optometrist is beneficial to patients, as well as reducing impact on other primary care professions and secondary care ophthalmology departments, practitioners within the focus groups shared a feeling of increasing risk in their role. It was highlighted that the wider practice team, and the system which practitioners work within, play an important role in the delivery of safe and effective patient care. Participants in the focus groups shared collective views that they, the optometrist, believed that the ultimate responsibility of any patients entering the practice resided with them, rather than the overall ‘system’ or practice they are working within. Concerns regarding the ability to oversee every patient interaction were raised.

The findings identified multiple concerns with patient safety and clinical risk issues in professional practice. These contribute to the development of targeted education to address the patient safety culture in community optometric practice: by increasing awareness of clinical risk, and how to manage it more effectively. The aim of this education was to support practitioners in reflecting more on risk in their own practice/work setting and introduce new theory and approaches that will help support a new culture around risk management in optometric practice as perceived and undertaken.

The move to ‘systems thinking’ is well described in a paper by Clarkson et al²⁴ which recognises healthcare is a highly complex and interacting system of people, equipment, processes and institutions working together. This ‘systems perspective’ of healthcare can reframe our understanding as to how care is understood, delivered and can be improved and help individuals and professions think differently about risk and patient safety. It is clear that integration of this approach would modernise and benefit quality, safety and risk initiatives and related education in the field of optometry.

A report by the Professional Standards Authority (2019) recognises there is no easy solution to complex safety issues and rather regulators, professional bodies, providers and education bodies need to work together. Specific training in risk management, including responding to complaints and adverse events, is welcomed as is the NES approach to mandatory training. A continuing emphasis on learning and development in relation to leadership and professional behaviours will help to reduce conduct risks. Building good practice and finding effective ways to disseminate new and innovative working should continue and again the NES mandatory training provides an effective way to manage this. Clinical audit, feedback and appraisal mechanisms were recognised as an important method of improving practice. Adopting robust approaches to mentoring and peer review was also considered a useful and productive way forward.

Strengths and limitations

Focus groups create a safe confidential space where individuals share their views in a dynamic structured conversation between participants. The focus groups offer powerful insights into people’s feelings and thoughts and thus a more detailed, nuanced and richer understanding of their perspectives on the research topics. We believe the experienced facilitators were able to manage the groups to enable these goals to be met. Limitations included the use of convenience sampling and a lack of professional representation from six regional health boards. The use of Zoom to conduct the focus groups may have inhibited the flow of discussion to a certain extent, however, many participants also contributed comments and ideas via the Chat function.

Conclusions

The optometry profession has undergone significant changes due to new and enhanced ways of working introduced as part of the response to the COVID-19 pandemic. The data generated by this study found those factors have increased the current and perceived risk to patient safety. GOC and NES were viewed positively for their position in supporting individuals and the optometry profession. Overall, further and deeper research is required to better understand the nature and management of risks in optometry practice. Exploring a targeted safety improvement programme, like those in other primary care professions, may also be beneficial.

Data availability statement

Data are available on reasonable request. The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Ethics statements

Patient consent for publication

Not applicable.

Ethics approval

Under UK research ethics arrangements, this study was considered to be service evaluation involving National Health Service staff and therefore does not require ethical review.