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Ophthalmic medical assistants
  1. BILL McDERMOTT
  1. Nurse manager/practitioner, Bristol Eye Hospital, Lower Maudlin Street, Bristol BS1 2LZ
    1. JANET MARSDEN, Senior lecturer, the Manchester Metropolitan University and chair, Royal College of Nursing, Ophthalmic Nursing Forum
      1. JOHN LEE, Consultant ophthalmic surgeon, Moorfields Eye Hospital, City Road, London EC1V 2PD
        1. M N JEFFREY,
        2. S K WEBBER
        1. Eye Department, Queen Alexandra Hospital, Portsmouth PO6 3LY

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          Editor,—It was with grave disappointment that I read the commentary in January’sBJO.1

          Webber and Jeffrey painted the picture of the ophthalmic medical assistant being the panacea for all ills in the ophthalmic world. The impression is given that the role had to be created because of the restrictive practices, rules, and working patterns of ophthalmic nurses.

          It is very sad that this must have been the situation in their unit.

          Let me take the opportunity to point out that up and down the country ophthalmic nurses are undertaking all the roles they describe and that, in collaboration with forward thinking nurse management, such roles can be created within the auspices of the nursing profession without having to invent a new profession. As a charge nurse, senior nurse, and nurse manager I have spent a lot of energy and time in collaboration with consultants who recognise the advantages of enhancing, developing, and creating roles for ophthalmic nurses for the improvement of service and patient care. These roles too have increased efficiency and built upon existing teamwork as well as the vast knowledge base that ophthalmic nurses already have. Attendance at any UK ophthalmic nursing conference would reveal exactly that.

          It may also be of interest to note that if it is appropriate for service development, nurse practitioners can be appointed to consultant firms or service teams. There are many examples of collaboration work with ophthalmic nurses and ophthalmologists where trust and mutual respect for each other’s contribution exists.

          It is a shame that some units are not able to achieve this within the framework of the existing professions. However, I would be more than willing to give examples of where it has been done.

          References

          Editor,—I was interested to read Webber and Jeffrey’s elaboration of the role of the ophthalmic medical assistant in the BJO and their translation of this role which is, as they state, quite prominent in the United States, into the UK health setting. The role which they describe seems to be suspiciously like that undertaken by many ophthalmic nurses in other centres in the United Kingdom. However, ophthalmic nurses do not merely carry out delegated “tasks”, but carry out holistic care within a nursing framework, having undertaken up to 4 years’ training and having proved their competence. It is true that although ophthalmic nurses understand the principles of refraction and motility testing, they rarely become more involved in these issues but tend to leave them to those professionals (optometrists and orthoptists) who have also had 3 or 4 years’ training and are registered practitioners.

          Nurses do, however, undertake their own outpatient clinics, run accident and emergency services, act as first assistant in theatre, assess patients for surgery, and discharge them afterwards; they also work with individual consultants in some areas. They also have a system of professional accountability and regulation which would appear completely lacking in the OMA role. Perhaps an incentive in the development of this role is the perception of the OMA as belonging somehow to his or her consultant (...one’s OMA) instead of someone in a complementary but not owned profession, and the possibility of enhanced medical power and control.

          There appears to be a subtle, underlying criticism of ophthalmic nurses within this commentary; “....communication can fail even in the best of teams...lead to missed or inappropriate admissions, suboptimal theatre timing, and other problems”. Later, the authors suggest that “less operating time is wasted through innapropriate theatre lists”. This also raise the possibility of the OMA as a “fall guy” for medical failures of communication. Ultimately, the person responsible for innapropriate theatre lists and wasted theatre time has to be the surgeon. This responsibility is for much more than just the act of surgery itself. The suggestion that the introduction of the OMA role will stop medical muddles and therefore increase the number of patients seen and operated on is purely speculative.

          More obvious problems with this role are easy to identify. Who will undertake the work when the OMA is sick or on holiday? What will they do if “their” consultant is away. There seems little chance of their acceptance by nursing staff and lack of communication between staff groups will lead to more failures in patient care. There is no career structure for OMAs no recognised training, and their standards will be those of “their” particular consultant which are technical/medical rather than holistic. The authors suggest that they may cost the same as nurses but they will not possess any of the flexibility of that workforce.

          This seems to herald the development of an unaccountable, unregulated personal servant with no formal training. Nurses can and do undertake these roles from a basis of accountable, registered, educated practice. That there is a need felt to employ informally trained, unqualified personnel in this area suggests a failure in communication and in the nursing and medical management of a developing service.

          References

          Editor,—I read the commentary by Webber and Jeffrey with interest, but some incredulity.

          There is little doubt that in a system such as that which obtains in the United States, where every service performed under the individual physician’s overall supervision may be billed, the ophthalmic medical assistant may well have a useful role. Indeed, I have recently heard the anatomically implausible term “physician extender” used by an American colleague to describe this type of relationship between ophthalmologist and assistant, in particular for staffing of distant outreach clinics.

          Could such a system take root in the United Kingdom? I rather doubt it.

          Firstly, where will they come from? It seems generally recognised that the shrinking supply of enthusiastic school leavers will have a serious effect on the recruitment of nurses, whatever the health secretary, Frank Dobson, may try to do to redress this, and this job hardly opens up the professional possibilities to which a nursing degree may lead.

          Secondly, will the public welcome a “practitioner” who is not a nurse, a doctor, or yet a member of one of the highly trained members of the professions supplementary to medicine? The cheerful assurance that the OMA “is not bound by restrictive rules and regulations” gives me, for one, considerable disquiet. Will the trust extend indemnity cover to an unqualified non-professional?

          Thirdly, will they stay? The career structure appears to have no prospect of promotion, so I suspect that anyone with a modicum of talent and intelligence will stay in the post for as short a time as possible before seeking a greater degree of challenge elsewhere, leaving behind those who have risen to their greatest achievable height. We are all familiar with this syndrome in the NHS managerial structure.

          Finally, my colleagues in our orthoptic and medical illustration departments are rather distressed to discover that they don’t exist, but have promised to be very brave and to apply for the very first OMA jobs as soon as they come along.

          References

          Reply

          Editor,—John Lee asks, from where will the OMAs come? Fielder et al, in their commentary in this issue (p 512), assume a very basic level of training for OMAs. This is not the case. At the moment all six OMAs in Portsmouth are highly experienced and trained ophthalmic nurses. We made the point in our commentary that they need not necessarily be from the nursing profession. Until such time (if ever) that a planned training scheme for OMAs is set up in the United Kingdom we would suggest that ophthalmic nurses are a good source for recruitment. While we share Mr Lee’s concerns about the shortage of trained nurses we would remind him that these members of staff are not being removed from the workplace.

          Fielder et al dismiss any comparison between the United Kingdom and the United States. The average patient in the USA is a much more informed and demanding individual than his/her counterpart in the UK. Do they really think that poorly qualified, untalented individuals would be permitted to work with such a demanding and litigious population? There are many people working within the NHS who are not highly qualified and yet who are accepted by the public. They carry out a limited range of important and worthwhile tasks. All trusts will indemnify people who have been trained to carry out specific tasks.

          A career structure could exist for OMAs. Mr Lee implies that anybody with ambition would want to leave their job. How is this different from any other healthcare professional? Not every person employed in patient care wishes to climb the NHS managerial ladder. As evidence of job satisfaction, we would inform him that all OMAs appointed in Portsmouth since the inception of the role in 1992 are still in post.

          Fielder et al claim that a group of OMAs, if given the opportunity, would form or join a professional organisation with rules and regulations. They point out that the first task of such a body would “inevitably” be to break down the close working relationship that an OMA and consultant may have. Their mistake is to assume that such a body would de facto be obstructive. This, of course, is a possibility, but also one of the reasons why we have introduced OMAs. The very essence of the role of the OMA is to provide continuity of care for patients. This is simply not the case in the majority of nursing environments.

          The work of the OMAs in our unit focuses on the surgical aspects of ophthalmology, but this needn’t be so in all units. Surgical waiting lists in ophthalmology are unacceptably long and they have become a government priority. Over 70% of all surgical procedures carried out in ophthalmology are cataract extractions. The service needs to be streamlined to be cost effective and to enable the maximum number of people to have surgery in as short a time as possible, while maintaining high standards of patient care. Fielderet al admit that the roles of the “team members [should] vary according to local needs and enthusiasm and prejudices”. This is exactly what the OMA post is designed to do, responding to a need in a department with a heavy surgical workload. They are rather dismissive in saying that the OMA system is inflexible and does not adapt speedily enough to meet the needs of modern ophthalmology. We wonder if any of them have ever worked with an OMA? The status quo is not an option and rather than dismissing the whole process, constructive criticism as to how it might be improved would be a more enlightened approach.

          It is of interest that Lee and Fielder are highly subspecialised ophthalmologists who do not carry out cataract surgery. We wonder how long it has been since either of these doctors have worked in a busy district general hospital? Ophthalmology will have increased demands made upon it by a more demanding public. At present we carry out only a third of the number of cataracts per 1000 population compared with the USA. The elderly population is increasing. It is our firm belief that a team of experienced OMAs can help with the ever increasing demands for efficiency and quality of care in ophthalmology.

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