Aim of Chapter 3

The aim of this chapter is to define a competency framework for optometrists with a specialist interest in glaucoma using a modified Delphi approach.

3.2 Methods

A panel of experts was selected and invited to participate using a convenience sampling technique. The panel was deliberately chosen to be multi-disciplinary and comprised 5 glaucoma sub-specialist ophthalmologists, 9 glaucoma specialist optometrists, and a researcher with extensive expertise in glaucoma. They were chosen to provide wide-ranging perspectives from ophthalmologists involved in glaucoma treatment, optometrists participating in hospital or community co-management of glaucoma and academics with extensive experience in the

postgraduate, post-registration education of optometrists. The process was facilitated by a smaller project steering group consisting of members of the Glaucoma Special Interest Group at City University London.

The first round of this Delphi process consisted of the panel members completing a questionnaire which was entirely web-based and hosted by a US provider of online surveys (Survey Monkey; http://www.surveymonkey.com; Oregon, USA). This online method ensured anonymity of the respondent and allowed respondents to express freely their opinions without being influenced by the views of others. To reduce the number of rounds in this modified process, the first survey consisted of draft competency statements generated by the project steering group. The group had taken existing competencies for the training of undergraduate and pre-registration optometrists as the baseline competency set, and then built upon these by adding additional statements relating to the diagnosis, monitoring and treatment of glaucoma.

The existing glaucoma-related competencies, obtained from the GOC (GOC, 2005), were:

• The ability to take an accurate history from patients with a range of optometric conditions.

• The ability to create and to keep clear, accurate and contemporaneous patient records.

• The ability to impart to patients an explanation of their physiological or pathological eye condition.

• An ability to understand the patient’s expectations and aspirations and manage empathetically situations where these cannot be met.

• The ability to communicate bad news to patients in an empathetic and understandable way.

• The ability to assess the external eye and adnexa.

• The ability to use a slit lamp.

• The ability to examine fundi using direct and indirect techniques.

• The ability to investigate visual fields and to analyse and interpret the results.

• An understanding of the special examination needs of patients with severe visual field defects.

• The ability to use a contact tonometer to measure intraocular pressure and analyse and interpret the results.

• The ability to evaluate glaucoma risk factors, to detect glaucoma and refer accordingly.

• The ability to make a judgement regarding referral and an understanding of referral pathways.

It was assumed by virtue of achieving registration that all optometrists in practice have acquired the competencies included in the General Optical Council Stage 2 Core Competencies for Optometry. It should be noted that all glaucomas were considered in this Delphi process. Twenty draft competencies were initially agreed by the project steering group as follows, presented under three headings:

1. History Taking/Record keeping

 The ability to take a comprehensive ophthalmic history in a patient with diagnosed or suspected glaucoma.

 The ability to maintain clear, accurate and contemporaneous clinical records of ophthalmic history, examination and results of clinical investigations in patients at risk of or suffering from glaucoma.

2. Examination/ Data interpretation

 The ability to carry out an appropriate examination of the anterior segment of the eye in a patient with diagnosed or suspected glaucoma and to interpret relevant clinical signs.

 The ability to perform the van Herick technique for the assessment of peripheral anterior chamber depth and to interpret the significance of the results.

 The ability to perform a gonioscopic examination of the anterior chamber angle and to identify anatomical structures, accurately grade the angle width and interpret the significance of clinical findings.

 The ability to perform an assessment of central corneal thickness using appropriate instrumentation and to interpret the significance of the results.

 The ability to recognise the signs and symptoms of a patient suffering from angle-closure glaucoma (or at risk of angle closure) and to refer the patient accordingly (including the instigation of emergency treatment if necessary).

 The ability to assess the optic nerve head by binocular indirect ophthalmoscopy and to detect the characteristic features of glaucomatous optic neuropathy.

 An understanding of supra-threshold perimetric techniques used in the assessment of a patient with suspected glaucoma including test strategies used, sources of error, interpretation of results and the recognition of glaucomatous field loss.

 An understanding of the use of threshold perimetric techniques used in the assessment of a patient with manifest glaucoma and the ability to detect the progression of disease.

 An understanding of the imaging techniques used to assess the optic nerve head and retinal nerve fibre layer and the ability to interpret the results of such investigations.

 The ability to differentially diagnose glaucoma through an interpretation and integration of the results of clinical examination and the results of any further investigative techniques.

 The ability to recognise the indications for treatment in glaucoma, the concept of target pressures and risk factors for disease progression.

 The ability to detect a change in clinical status (e.g. visual field status, intra-ocular pressure, assessment of anterior or posterior segments).

3. Management

 The ability to monitor the response to treatment and modify the management plan or consult a more experienced colleague or refer if necessary.

 An understanding of time frames for follow-up of patients with glaucoma taking into account target pressures and the risk of progression.

 Knowledge of the cautions, contraindications, interactions and side effects of anti-glaucoma medication.

 Knowledge of the surgical management of the glaucomas including indications for surgery, surgical techniques, complications and post-operative evaluation.

 An awareness of one’s own limitations and the ability to make clinical decisions based on the needs of the patient.

 The ability to operate within local protocols for the detection and/or management of glaucoma.

The full survey is included in Appendix 3.

The panel members were invited to rate each competency on a 9-point Likert scale ranging from “0 = non essential” to “9 = essential”, thus weighting the importance each member attaches to each enhanced skill or element of knowledge. Free-text boxes were provided to allow the panel members to add any comments, suggest modifications or re-wording and/or possible additional competencies. The survey was split into two distinct sections for two specialist optometric roles. The first related to those competencies that should be demonstrated by an optometrist involved in glaucoma diagnosis. NICE guidance describes this role as “diagnosis of OHT and suspect COAG status and preliminary identification of COAG”. The second section related to those competencies that should be possessed by an optometrist additionally involved in glaucoma monitoring and treatment. NICE defined this role as “healthcare professionals involved in the monitoring and treatment of people with OHT, suspected

COAG and established COAG”. The same draft competencies were included for each section, i.e. diagnosis and management.

The panel members were allowed 3 weeks to respond to the first questionnaire, after which the survey was closed and the results analysed. For each draft statement the mean rating was calculated, together with the mean percentage of respondents scoring the competency above 5 (the neutral point on the Likert scale). The project steering group reviewed the free-text comments and suggestions from panel members, which resulted in some modification of the competencies and the drafting and inclusion of some additional competencies. Following these changes, the panel members were again asked to rate, in the same way as in round 1, the now twenty-three competencies under the two sections of diagnosis and management. Prior to completing the round 2 questionnaire, they were provided with written feedback on the results of the first round. The full survey is included as Appendix 4.

The panel members were again allowed three weeks to respond, after which time the survey was closed and the results analysed as before. The Delphi process was followed by a face-to-face workshop to facilitate consensus on borderline competencies and to agree the final framework. Since the literature on the Delphi technique does not stipulate the level at which consensus is judged to have been reached, this was chosen arbitrarily by the steering group. Competencies with a mean score greater than 5 on the Likert scale and with more than a 2/3 majority (67%) scoring the statement ≥6 were included in the framework without further discussion at the workshop. Competencies were excluded from the framework if they had a mean score of <5 or if fewer than 67%

of respondents scored the competency greater than 5. All borderline competencies were considered at the workshop discussion and a consensus was reached on the day (2/3 majority) regarding their inclusion in or exclusion from the framework.

The competency framework that was agreed at the workshop was circulated to relevant stakeholders (including national bodies representing optometrists, ophthalmologists, general practitioners, nurses and orthoptists) during a 4-month consultation period, after which a final framework was published. The full framework is included as Appendix 5.

Ethical approval for these studies was granted by the City University School of Health Sciences Research and Ethics Committee and the research was carried out in

compliance with the Declaration of Helsinki http://www.wma.net/en/30publications/10policies/b3/index.html

3.3 Results