Ophthalmic nursing

An ophthalmic nurse is a nurse who has the education and expertise to provide holistic nursing care for people with a visual impairment or related conditions, temporary or permanent, wherever they may be. 

Marsden (2016), Shaw and Lee (2017) recognised the holistic knowledge, expertise, and complexity required to provide optimum ophthalmic nursing care, suggesting that nurses who are responsible for the care of the ophthalmic patient should ideally hold a first degree and a specialist ophthalmic qualification.

Ophthalmic nurses have unique skills relevant to their practice as adviser and promoter of eye health. They support the wellbeing of visually impaired people and those with eye conditions across the age spectrum. Ophthalmic nurses also practise in sub-specialist areas and  many are practising at an advanced level in clinical practice. In 2023, the RCN updated its definition of nursing, see: Definition and Principles of Nursing.

The primary aim of ophthalmic nursing care is to promote and to enhance a high standard of ocular health.

For further information about the ophthalmic nursing roles, see: Health Education England (HEE) Roles Explorer. The HEE Roles Explorer is hosted on the Future NHS platform platform. This is a membership only site and you can use your nhs.net account details to login. If you are already a member, enter your log in details and navigate to ‘workspaces’, search for ‘HEE Roles Explorer’ and click on ‘request to join’. If you are not already a member, you will be required to create an account before following the steps above. If you experience any issues, contact transformation@hee.nhs.uk. Once you are logged in, go to Explore roles and search for ‘Roles in Eye Care’. 

The nature of ophthalmic nursing is to provide specialist care to a defined group of people and is continually evolving to meet the needs of patients. It is a multifaceted and a complex speciality where nurses use their expertise to forge close relationships with patients (including their families/carers, and other healthcare professionals involved in their care) to support, maintain and enhance their eye health and wellbeing.

Ophthalmic nursing focuses on preventing ill health, maintaining and enhancing (where possible) ocular health, and this is encouraged and achieved through the continuing development of specialist skills, whilst promoting a positive therapeutic relationship with patients (and their families/carers).

Ophthalmic nurses are particularly aware that people live with sight impairments/loss in a range of health and social care settings, including acute care in the community or care homes. They should develop sound relationships to collaborate across health and social care, including voluntary groups and charities, to enhance care provision. Collaboration includes raising awareness of ocular health among healthcare colleagues and the wider community.

A key principle of knowledge and skills development is continuing to promote the person, not the condition. This includes developing a two-way relationship based on mutual trust that provides continuity of care. This in turn encourages shared decision making and enables the nurse to discuss the patient’s ideas, expectations and concerns when it comes to eye health (Burggarf et al, 2019).

To enhance this, ophthalmic nurses, draw on and make best use of the evidence-based resources available to them and are mindful of the positive value of collaborative working by signposting to other members of the wider multidisciplinary team. It is important to note that to fulfil their role effectively, wide knowledge base, will include, not only a sound physiology base, but the ability to effectively relate and impart information to patients, as well enabling informed decision making with patients around care choices. This will ensure nurses are working to incorporate current evidence-based literature and guidelines into their everyday practice.

The nature, value and scope of ophthalmic nursing aims to encourage nurses to engage in lifelong learning, ensuring the highest standards of care. Working together with service leads in both primary and secondary care, it creates an environment that sees the benefit of how education inspires nurses to participate in programmes such as the Ophthalmic Practitioner Training (RCOph, 2016, 2019). This in turn will enhance the knowledge skills and attitudes required to improve patient access to eye care (NHS, 2022). The nurse and the patient should work collaboratively to ensure that eye care is individualised, and patient empowerment is essential in healthcare (Marsden 2016).

The value of ophthalmic nursing has been identified through initiatives such as the national outpatient pathway (NHS England, 2022) and NHS Futures eye care hub (NHS England, 2019), which offer alternatives where the skills and expertise of ophthalmic nurses can be developed proactively in response to changing needs and service delivery. All nurses work to the standards in their code of conduct (NMC, 2018).

Adhering to these values ensures ophthalmic nurses are competent and confident to provide patient centred, evidence-based, and cost-effective care. This in turn is improves efficiency and clinical effectiveness for patient as well as the ophthalmic service. Demonstrating leadership skills is linked to quality of care and patient satisfaction, as well as better staff wellbeing and morale. 

The RCN Ophthalmic Nursing Forum believes in raising the profile of ophthalmic nurses by:

• encouraging all nurses working in ophthalmic nursing to find a voice through developing education
• to ensure all ophthalmic nurses see their own value and uniqueness in providing holistic care, and
• that all ophthalmic nurse are encourage to influence future practice, policy and guidance surrounding it by getting involved with the ONF and other national societies.

The scope of ophthalmic nursing continues to evolve as a consequence of drivers such as an ageing population (Raymond et al, 2021), a diminishing number of ophthalmologists currently within post (RCOphth, 2018), and the long-term costs of emerging treatments (Boxell et al, 2017; RCOphth, 2017). It also needs to keep pace with new treatments, including genetic eye conditions that may affect the population, in particular those with a learning disability. 

The psychosocial care of the ophthalmic  patients is very important in clinical practice (Williamson et al, 2023). The feelings of fear, anxiety, loneliness, depression and altered body image are real emotions experienced by the ophthalmic patients. Ophthalmic nurses should be educated to embrace the importance of psychosocial care as part of holistic, patient centred approach.

Ophthalmic nurses have a unique oversight of the patient pathway, acting as a link between health care professionals and third sector organisations. Recent data (Rattanasiriivilai and Shirodkar, 2021) indicates that 73 per cent of ophthalmic nurses take on more than one active role within their clinical practice, with over 59 per cent working autonomously in nurse-led clinics and in accident and emergency department as Enhanced or Advanced Nurse Practitioners.  

Ophthalmic nurses now support patients in both an interventional and educative capacity across an ever-increasing range of clinical pathways such as oculoplastics (Dunlop et al, 2020), cataract (Stanford & Ewing, 2020), wet Age-Related Macular Degeneration (AMD) (Gallagher, 2017; Mohamed et al, 2018), glaucoma management (Bubb et al, 2021), and YAG Laser capsulotomy (Moussa et al, 2022), as well as paediatrics. Furthermore, as more ophthalmic nurses continue to achieve master’s and doctoral level qualifications, the increased knowledge and expertise that such education provides, empowers nurses to act as change agents, contributing more fully to the shaping of health and social care policy, as well as carry out primary research to further advance the evidence base required for enhanced practice in this field. 

With the advent of remote monitoring using digital and technological solutions such as virtual clinics, digital hubs and apps, ophthalmic nurses who are usually based in secondary care, are presented with a unique opportunity to deliver person-centred care to patients in their own homes. 

Ophthalmic nurses should challenge their care patterns, in particular, with new and advancing technology and treatments. They should also consider how best to support the patients’ needs and expectations, (and those of their family) in the treatment of ophthalmic diseases, and always within the values of the NMC Code (NMC 2018). In this way, nurses can continue to expand their scope of practice whilst retaining the central values of nursing to support and empower those continuing to live with ophthalmic disease. 

Ophthalmic nurse education is essential to provide high quality and focused evidence-based care. Bespoke education will better enable nurses to articulate concerns, as well as having informed discussions about practice, when speaking to colleagues from the wider multidisciplinary team. Nurse education is lifelong and practice learning should always be underpinned by reflection. Before embarking on competencies and training in the workplace, nurses should have opportunities for practice in the ophthalmic care environment. This is reflected in the RCN Workforce standards (RCN, 2021) where continuing professional education and practice development is linked to safe staffing and patient care. 

For further information on developing as an advanced nurse practitioner in Ophthalmology, see: NHS England's What is advanced clinical practice? along with standards set by the RCN, and Ophthalmic Practitioner Training from the Royal College of Ophthalmologists.

The development of the multidisciplinary workforce is recognised as an imperative due to the increasing need for ophthalmic care (RCOph, 2021), and this recognises that ophthalmic nurses are essential and valuable members of the team. The Ophthalmic Practitioner Training (OPT) Programme provides education for a range of healthcare professionals, including postgraduate orthoptists, optometrists, ophthalmic nurses in secondary care to develop their skills in eye care.

The RCN Ophthalmic Nursing Forum worked collaboratively with the Royal College of Ophthalmologists, College of Optometrists, the British and Irish Orthoptists Society and Health Education England, to develop this curriculum. 

Before embarking on the OPT, nurses are recommended to undertake a nursing ophthalmic course (such as a PG Cert Clinical Ophthalmic practice or a university ophthalmic degree at Level 6 or at Level 7 or equivalent) RCOph, 2016), to ensure nurses have the necessary prerequisites to successfully complete the OPT and work within their scope of nursing practice. Level 3 of the OPT is for advanced nurse practitioner roles and the competencies should be aligned to a master’s level degree programme, which covers the pillars of advanced clinical practice (NHS, 2017). 

The Ophthalmic Nurse Career Pathway

Any registered nurse may develop an interest in ophthalmic nursing and have opportunities to work in the area. This can lead to enhanced levels of practice, in specialist ophthalmic areas and on to advanced levels of practice.

The RCN Ophthalmic Nursing Forum advocates that ophthalmic nurse education should be embedded in validated/accredited ophthalmic courses where students’ knowledge is formally assessed. 

Undergraduate nursing degrees leading to initial NMC registration offer limited exposure to ophthalmic theory or practice, and so post qualifying courses are essential and should be aligned to higher education institutions. There are a number of HEIs offering ophthalmic courses, including some online access. The RCN Ophthalmic Nursing Forum webpages provide links to some of these courses.

The RCN professional framework expands on the concepts of levels of practice, and is due to be launched at the end of 2023. 

Advanced Clinical Practice (ACP)

Advanced practice is a level of practice, rather than a type of practice, as is enhanced practice. It should be noted here that the terms Advanced Clinical Practice/Practitioner, and Advanced Nurse Practice/Practitioner are used interchangeably across practice areas and across the UK. This can be subject to service provision required, commission of services and/or local service requirements.

Advanced nurse practitioners are educated at master’s level and have been assessed as competent in practice using their expert clinical knowledge and skills. For further information, see: RCN Advanced practice standards, and NHS England's What is advanced clinical practice?

Continued professional development, supervision and audit of own practice is required to attain advanced clinical practice, as well as awareness of limitations and capabilities. They have the freedom and authority to act, making autonomous decisions in the assessment, diagnosis and treatment of patients.

The Nursing and Midwifery Council (2021), Royal College of Nursing (2018) and Health Education England (2021) are unanimous in their support that all advanced clinical practitioners should:

• have an active nursing and midwifery registration
• practice within the four pillars (education, clinical practice, management and leadership and research)
• have a job plan that demonstrates advanced clinical practicethat is equitable with other professional groups
• be educated to master’s level
• be an independent prescriber and
• meet NMC revalidation requirements.

The career pathway to advanced practice will vary in its achievement, but the above standards are recommended as a minimum for nurses to identify as advanced clinical practitioners. The RCN's Advanced Practice Standards (2021) provide further details about the expected standards for those nurses pursuing their career to advanced level practice.

Therefore, advanced practice brings the additional value of critical thinking and understanding, enhanced responsibility and autonomy and extended competency in their scope of practice when working with complexity, risk, uncertainty, and incomplete information. 

Nurses working in these roles bring enhanced professional judgement with regard to when to seek help and collaborate with other agencies. They also work in partnership with individuals, families and carers using a range of assessment methods (for example history taking; clinical assessment such as blood pressure, blood sugar monitoring, intravenous administration of medication, urinalysis; identifying risk factors; mental health, safeguarding, cognitive impairment or learning disability concerns) to positively impact individual patients' health.

Ophthalmic Nursing - Clinical Practice Education, Leadership and Management, and Research

Clinical Practice

Advanced practice roles have been developed in the following subspecialties. It is important to remember that these roles are dependent on the service needs of individual NHS Trusts as well as local service agreements. All nurses practicing at advanced level practice for all subspecialties should be prescribers and this should be reflected in the skills, they are competent and enabled to perform. There may be a cross-over of the remit of various roles and the skills can be used interchangeably between the subspecialties.

Accident and emergency	Accident and Emergency care nurses advanced skills include diagnostic assessment and management, including independent prescribing, of a range of ophthalmic conditions. This is a holistic role which can encompass aspects of all other sub specialities. The scope of the role will depend on local service requirements including whether the service is provided in Eye Clinics/Eye hospital or general emergency departments. Uveitis advanced nursing skills include advanced slit lamp skills, fundoscopy administering intravitreal implants or orbital floor injections for inflammatory conditions and cystoid macula oedema. The role also includes liaison with other medical specialities (for example rheumatology) to manage any systemic causes of their ocular condition.
Oculoplastic / Adnexal	Oculoplastic/Adnexal advanced nursing practice include minor surgery (Dunlop, 2010). Manage, prescribe, and administer injection botulinum toxin for rare diseases example blepharospasm, inflammatory eyelid and orbital disease with oral and intravenous steroid and biologics. Diagnosing and managing lacrimal disorders (Dunlop et al., 2020). In some setting temporal artery biopsies to diagnose giant cell arthritis are undertaken. The ACP diagnose eyelid lesions, prescribe, and arrange surgery via telemedicine consultation to reduce bottlenecks, improve service capacity and increase patient satisfaction (Kang et al., 2021)
Vitreo-retinal	Vitreo-retinal advanced nursing skills include undertaking fundoscopy and Yag laser. Their role includes managing new and long-term patients.
Uveitis	Uveitis advanced nursing skills include administering intravitreal implants or orbital floor injections for inflammatory conditions and cystoid macula. The role also includes liaison with other medical specialities (for example rheumatology) to manage any systemic causes of their ocular condition.
Corneal/external disease	Corneal/external disease nurses advanced practice scope includes collagen crosslinking for the treatment of keratoconus and undertaking confocal microscopy. Diagnosis of infectious organisms example fungus or acanthamoeba is undertaken using corneal scrape and staining techniques.
Medical retina	Medical retina nurses within this subspeciality administer intravitreal injections. (DaCosta, Hamilton, Nago et al., 2014; Mapani et al., 2021). In addition, fundoscopy, reading and interpretation of optical coherence tomography (OCT), fluorescein angiogram, indocyanine investigations to monitor patients. Diabetic eye screening is a previously documented role (Kirkwood; 2006).
Glaucoma	Glaucoma nurses provide diagnostic assessment and long-term management for patients Provide patient education, promoting concordance with treatment and selfcare (Gray, 2005). Clinical skills within this role may include gonioscopy, there is scope for developing skills in laser procedure, such as selective laser trabeculoplasty (SLT) (at the time of writing, ophthalmic nurses are considered appropriate non-medical professionals to deliver SLT, who may require different education needs and as a second stage approach. Visual Field (VF) and Optical coherence tomography (OCT) interpretation of results, fundoscopy, and examination of surgical patients are skills many glaucoma nurses practice
Cataract	Cataract advance role includes fundoscopy, skills in dense cataracts measurements - Accutome, Immersion or others  OCT interpretation, Biometry, consenting and prescribing medication following the assessment and management of post-operative patients. Stanford and Ewing (2020) have voiced the role has potential to increase capacity and access to cataract surgery. The ACP should apply professional conduct within the scope of extended practice and be responsible and accountable for acts and omission at this level of practice (NMC, 2018).

Education

Ophthalmic advanced nurse practitioners use critical thinking, complex decision making, and enhanced autonomy, underpinned by a master’s level qualification. In addition, ACP nurses are also registered non-medical prescribers who often teach and mentor learners, see:  NMC's Standards for prescribers.

The OPT programme (Ophthalmic Practitioner Training (2019) is work-based and underpinned by a common clinical competency framework) providing a structured approach to clinical skills acquisition.

MSc Advanced Clinical Practice modules are available in in Glaucoma, Medical Retina, Ophthalmic Emergencies and Cataract are available at some universities, see: RCN Ophthalmic Nursing Forum webpage for further details.

Leadership and management

Leadership and management are a key dimension of the role of the advanced nurse practitioners. In addition, using advanced skills in evidence-based practice will improve patient outcomes, be cost effective and meet patient needs and can shape healthcare reform (Wood, 2021). When developing leadership skills, the ophthalmic nurse should enhance their creative and critical thinking skills, which will in turn improve practice and benefit to patient care. The RCN affirms the importance of leadership within healthcare, linking it to patient mortality, quality of patient care and patient satisfaction, and better staff wellbeing and morale. See: RCN Leadership Skills for further information on developing leadership skills. 

Research

As a profession based on evidence, research affects every area of nursing practice, and is a cornerstone to enhancing practice. This may begin with audit of own practice, auditing specialist areas of practice and can include qualitative and quantitative research, which will enhance nursing care. Ophthalmic nurses should also be aware of ‘research findings’ in other fields of nursing and use relevant aspects of those findings when working with ophthalmic patients.

All practitioners are also required to conduct regular audits to ensure that their own practice and the service they provide is always contemporary and evidence based. The ophthalmic nurse should be an inspiration and source of knowledge for others, reflect on their own practice and use audit tools to assess effectiveness of their own practice Some of the areas that ophthalmic nursing research could contribute to, include improvements in health promotion and illness prevention programmes, infection prevention, symptom management, communication and the planning and organisation of care delivered by nurses are a testament to the power of research led by nurses. See: Making research matter: Chief Nursing Officer for England’s strategic plan for research.

Competency Frameworks relevant to ophthalmic nurses

A competency framework for Ophthalmic Nurses is due to be published in 2023. 

• A competency framework for Ophthalmic Nurses was due to be published in 2023 from Public Health England, and has been paused at present (NHSE 2024).  

The World Health Organisation (WHO, 2019) advocates the promotion of high-quality systems for eye care and the RCN Ophthalmic Nursing Forum considers the ophthalmic nursing workforce integral to those systems. WHO (2022) supports global health organisations to strategise eye care programmes, responding to increases in people requiring ophthalmic services and thus supporting and strengthening the value of effective ophthalmic patient care.

Nationally, the NHS, in 2022 set out priorities to improve patient access to eye care and advocates developing systems to promote patient flow and access to treatment. As part of a multidisciplinary team, ophthalmic nurses influence practice for the benefit of patients, nurses and the multidisciplinary team.

Within the workforce, ophthalmic nurses have an all-encompassing role, as clinician, technician, manager, educator and researcher. Ophthalmic nurses should aim to focus on holistic patient care, avoiding practice from a task related perspective. 

The RCN Ophthalmic Nursing Forum, (in alignment with the NHS Long Term Workforce Plan, 2023) considers that the ophthalmic nursing workforce should be empowered with lifelong learning to develop and support their role in terms of theory and practice so that they can work at every sphere of practice, from newly qualified registered nurse to advancing practice, including consultant level practice. 

The RCN Workforce Standards are clear that 'the nursing workforce is the most important factor in the provision of safe, effective, high quality compassionate, competent care in a timely, cost-effective and sustainable manner'. In order to articulate this, the RCN has developed a series of workforce standards to enhance safe practice, see: RCN Workforce Standards.

Eyes right: Older people and driving (RCN 2021)

Eyesight deteriorates gradually with age. This publication has been developed to assist nurses working with older people who present with eyesight issues. It includes details on eye health, visual impairment and ageing, highlights nurses’ responsibilities and signposts for further information.

Eyes right: helping non-ophthalmic health care professionals deliver quality care safely (RCN 2022)

A guide for all non-ophthalmic nursing staff in adult care settings, ranging from non-ophthalmic hospital settings to residential and nursing homes. Developed following a review of research literature and in conjunction with the advice of the RCN Ophthalmic Forum. 

• Ophthalmic nursing - references and further reading

Further support and information

• Glaucoma UK. Here to support people with glaucoma 
• Macular Society
• NHS England (2023) NHS Long Term Workforce Plan
• Nursing Times (2023) New 7Ps for nursing unveiled as part of CNO strategy
• Royal National Institute of Blind People (RNIB)

NHSE Decision making tools

• Cataracts: making a decision about cataracts
• Open-angle glaucoma: making a decision about open-angle glaucoma
• Wet age-related macular degeneration: making a decision about wet age-related macular degeneration