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The impact of a glaucoma nurse specialist role on glaucoma waiting lists.


The lengthy waiting times for first specialist appointments has been a concern in many speciality areas of practice particularly over the last decade, as the population ages and technology advances. Ophthalmology is an area that has seen significant increases in referral rates directly related to the aging population and advances in medical practice. Along with an increased number of referrals, is the Ministry of Health's (MoH) expectations of health service delivery which is clearly outlined by the Elective Services team in terms of access, assessment and treatment criteria and timeframes (Ministry of Health, 2001). As a consequence of increasing demand and finite resources, the deliverers of public health care have to explore alternatives to a totally medicine-led service. Literature reveals that skilled ophthalmic nurses, in the United Kingdom, are undertaking advanced nursing roles which are making an impact on waiting lists and patient outcomes in some ophthalmic subspecialties, glaucoma being one such area (Hume & Abbott, 1995; Martin, 1999; Mayer, Waterman, & Grabham, 2000).

A trial of a clinical nurse specialist role in a large New Zealand metropolitan hospital was funded via Elective Services for 12 months, with ongoing funding contingent on evidence of its success. The background of the role is considered along with its development, challenges and implementation and finally its impact on both patients and waiting lists. As with all new nursing roles there must be evidence of efficacy if the role is to be sustainable. Therefore, an audit on the implementation of this new role on the waiting lists and waiting times from referral to first specialist assessment was undertaken and is reported here.

The New Zealand Healthcare Context

Over the last two decades New Zealand, like all western countries, has experienced ever increasing pressure on health care service provision from increased public and health professional expectations, the media highlighting new technologies/ treatment options, an aging population and increasing demand for access to services (Blank, 1994; Davey & Duke, 2001). As a result we have seen a rapid escalation in the numbers of patients waiting for first specialist appointments in public health institutions. However, the Ministry of Health via the Elective Services team have developed patient care management guidelines, tools and referral guidelines for requesting hospital assessment, in order to assist primary care physicians to refer appropriately. They have set a specific target of six months that must be met for patients once accepted by hospitals for assessment and/ or treatment. For hospital-based medical staff triaging referrals into secondary and tertiary services, there are documented guidelines for Access Criteria for First Specialist Assessment (ACA) and Clinical Priority Assessment Criteria (CPAC) for 'scoring/rating' of patients requiring surgery (Ministry of Health, 2001).

Ophthalmology and Elective Services

The majority of patients referred to ophthalmic services are elderly with a large proportion having chronic conditions. This has impacted on the ability of ophthalmology departments to meet the stringent measurements for MoH timeframes. The ACA categorises ophthalmology patients into four categories with specific timeframes attached as seen in Table 1 (Ministry of Health, 2001).

Many large ophthalmology departments have implemented a timeframe of three months from referral to First Specialist Assessment for category 3 patients. This is outside the guidelines stated by Elective Services but it is deemed to be clinically appropriate. However, many departments still do not meet this extended assessment timeframe, often due to a lack of clinicians, medical and nursing. The Ministerial Taskforce on Nursing (1998) highlighted that nurses are often an underutilised resource and therefore opportunities may exist for nurses to extend their roles and to participate in planning and delivery of care (Raynel, 2002).


Aging is the most consistent risk factor for the development of all types of glaucoma except congenital glaucoma (European Glaucoma Society, 2003). Primary open angle glaucoma is a chronic condition that is slowly progressive. It is defined as an optic neuropathy with characteristic changes to the optic nerve in the absence of another ocular cause or congenital abnormality, and the angle of the anterior chamber is open (European Glaucoma Society). Approximately 80% of all glaucoma cases are attributed to primary open angle glaucoma and it is the commonest type of glaucoma in European countries and consequently they make up the greatest proportion of patients on the glaucoma waiting lists (Kroese & Burton, 2003). Studies in other western countries echo those undertaken in European countries (Attebo, Mitchell, Cumming, & Smith, 1997; Mitchell, Smith, & Attebo, 1996; Wensor, McCarty, & Stanislavsky, 1998).

Worldwide the number of patients with glaucoma is increasing in the over 65 age group (Quigley, 1996). There are no predictions available for New Zealand but it is reasonable to expect trends similar to other western countries. As primary open angle glaucoma is largely asymptomatic in the early stages patients are unaware of the disease and it therefore remains undetected (Quigley) hence it is sometimes referred to as 'the sneak thief of sight'. A routine examination by an optometrist accounts for approximately 70% of glaucoma referrals to hospital ophthalmic departments for glaucoma assessment (Kroese & Burton, 2003).

Advanced Nursing Roles

The introduction of advanced nursing roles and the establishment of nurse-led clinics have been increasing around the world and across clinical specialities (Garbett, 1996). In some areas this has been in response to lengthening waiting times from referral to specialist assessment, and evidence shows that the clinical nurse specialist has contributed to decreased lengths of waiting times (Davis, Bowman, & Shepherd, 2004; Mackie, 1996; Manchester, 2004; Sutcliffe, 1999). Clinical nurse specialists work within a nursing framework, are highly skilled providing assessment, diagnosis, education, patient management and participate in research in many specialty practice areas, including ophthalmology (Anderson & Hicks, 1986; Armstrong, 1999; Buzzell, 1997; Czuber-Dochan, Waterman, & Waterman, 2006).

Innovative Practice

In 2004 in response to a growing glaucoma waiting list and waiting times for first specialist assessment, the glaucoma clinical nurse specialist role was trialled at a large metropolitan hospital. This position was initially funded by Elective Services as an initiative to target waitlist management for a period of six months. If this role delivered the expected outcomes of reducing the waiting lists and waiting times, the expectation was that ongoing funding would be available from the District Health Board.

It was hoped that the glaucoma clinical nurse specialist role and clinic would reduce waiting times for glaucoma referrals (category 3 and 4 referrals) to the service. Other anticipated outcomes were that:

* patients identified with glaucoma could have treatment initiated earlier.

* patients with stable glaucoma or glaucoma suspects would attend nurse clinics, thus freeing up space in consultant clinics.

* the nurse would provide one-on-one patient education on the pathophysiology and management/ treatment regimes for glaucoma, thus aiding concordance with treatment regimes which can affect long term disease progression and visual outcomes.

It is essential that any advanced nursing practice role has the support from consultant medical staff for teaching and support in the clinical management of patients with glaucoma. This reflects a model of shared care for glaucoma that has been introduced in the European ophthalmic departments (Martin, 1999; Ormonde & McGhee, 2004). The establishment of the glaucoma nurse specialist role and clinic were well supported by ophthalmologists who specialise in glaucoma. The Charge Nurse of the ophthalmic outpatient clinic was seconded into the clinical nurse specialist position. This nurse had an interest in glaucoma having undertaken training in the assessment and diagnosis of glaucoma as part of post-graduate study.

It was expected that diagnostic outcomes from the clinical nurse specialist would generally fall into 3 groups: patients with definite glaucoma; those with suspected glaucoma but no definitive diagnosis made; or those with no identifiable disease or risk for the disease. Training for the role included history-taking and the general and specialist ophthalmic examination skills required to assess newly referred patients and to diagnose, exclude or manage glaucoma.

Selecting Patients

All referrals to the department initially triaged as category 3 or 4 by a consultant ophthalmologist were further reviewed by the clinical nurse specialist to identify patients who fell within the set criteria that had been defined for the nurse specialist clinic. This was important to ensure that patients were within the clinical nurse specialist's area of expertise (Heaney & Paxton, 1997; Manchester, 2004). This included patients with no previous history of glaucoma or any concurrent ophthalmic conditions. Other patients were referred to a consultant clinic. The initial review of the waiting list triaged 158 patients to the nurse specialist clinic, with the remaining 96 patients seen by a consultant ophthalmologist.

The role of the clinical nurse specialist was to assess all patients referred for first specialist assessment of glaucoma within the identified criteria and make a clinical decision as to the degree of risk for glaucoma. Based on the assessment the nurse specialist then referred patients to a consultant clinic; rebooked them to the nurse specialist clinic; or discharged them from the clinic. As this clinic was normally run in parallel with a glaucoma subspecialty ophthalmologist, there was consultant input available if required. Protocols were developed to guide decision-making when no consultant was available in clinics. In addition to assessing new patients, the nurse specialist also reviewed stable glaucoma or glaucoma suspect patients identified from the glaucoma sub-speciality clinics in an attempt to open up appointment slots for new patients who were triaged as requiring specialist ophthalmologist assessment for glaucoma.

Audit Results

An audit was undertaken in November 2004 to explore the impact of the new nurse specialist role in ophthalmology on the glaucoma waiting list. The audit aimed to assess the impact after a target of 300 new glaucoma patients from the waiting list had been seen by the clinical nurse specialist. The target was reached after 10 months. Patients were not identified in the audit therefore ethical approval was not required.

The audit assessed:

* the waiting list, pre and post introduction of the clinical nurse specialist role;

* patients' waiting times between referral for glaucoma assessment and first specialist assessment (either nurse specialist or ophthalmologist) pre and post introduction of clinical nurse specialist role;

* the percentage of patients seen by the clinical nurse specialist waiting outside the maximum Ministry of Health guidelines of six months;

Data were available from September 2002 and September 2003. Unfortunately in 2004 data were not available until November, 10 months after the introduction of the role. Between 2002 and 2003 the waiting list for glaucoma referrals increased from 109 to 282 patients, an increase of 61%. In the 14 months from September 2003 to November 2004 the waiting list had reduced by 78% to 60 patients waiting for glaucoma first specialist assessment. Within the first 10 months of the CNS role in glaucoma 300 new patients had been reviewed from the waiting list. The numbers on the glaucoma waiting list, over three consecutive years are shown in Figure 1.

In 2003 category 3 glaucoma patients were waiting 18 months for first specialist assessment and by November 2004 this had reduced to 11 months. In 2003 category 4 glaucoma patients were waiting 30 months from referral to first specialist assessment and by November 2004 this had reduced to 8 months. The decrease in waiting from referral to first specialist assessment could be attributed to the introduction of the clinical nurse specialist clinic in February 2004. However, the impact of the clinical nurse specialist role is less for category 3 glaucoma patients as they are more complex and therefore larger numbers are triaged to consultant clinics. There was still a scarcity of first specialist appointments in consultant clinics and this was reflected in the longer waiting times.

In the initial five month period of the clinical nurse specialist clinic 90% of the patients seen by the clinical nurse specialist had been waiting longer than the guidelines specify for first specialist assessment compared to only 20% of the patients seen in the second 5 month period. The number of patients meeting the elective service guidelines for first specialist assessment increased from 10% to 80% following the introduction of the glaucoma clinical nurse specialist role. The introduction of the clinical nurse specialist role has helped the ophthalmology department meet the elective service performance indicators expected by the MoH.


The impact of the clinical nurse specialist role on the waiting list is very clear but there are still anomalies within the system where patients who are triaged as more urgent, have to wait longer for first specialist assessment than those who could wait for longer periods without harm. The clinical nurse specialist clinic was introduced to assess patients who were referred with probable primary open angle glaucoma. As there are different types of glaucoma the more complicated were deemed to be outside the clinical nurse specialist's skill level and therefore required consultant input for management. In the future it may be possible to further increase the number of patients seen by the clinical nurse specialist clinic as skills develop. This would further reduce the patients who require consultant review and maximise the use of the new appointments available within the consultant clinics.

It is interesting to note that while this study did not investigate patients' attitudes to waiting times, a qualitative study by Burns, Barrett and Murdoch (2001) of 28 patients waiting for appointments for glaucoma assessment showed that generally this group of patients were unaware of the reason for referral and were not concerned with a six month wait. They felt that if their condition was serious they would have been seen earlier and they took the wait as reassurance that their condition was not serious when in fact the delay was due to pressure on the healthcare system. As outlined previously waiting times in glaucoma are extremely important to the patient's visual prognosis. Prior to this audit the number of patients on the waiting list and the length of time from referral to first specialist assessment had not been studied. It was important that having identified this risk to patient outcomes the clinical nurse specialist role was introduced to help manage the waiting list to minimise the risk of visual loss (Kroese & Burton, 2003).

While it is clear that in this ophthalmic setting, the introduction of a clinical nurse specialist role in glaucoma has had a positive impact on the service with respect to reduction of waiting times for first specialist assessment, there are other aspects of nurse led care that also need to be considered (Horrocks, Anderson, & Salisbury, 2002; Poulton, 1995; Pritchard & Kendrick, 2001; Shum et al., 2000). Clinical nurse specialists offer more than just an extra clinician; they also provide one-on-one education for the patient and family, a factor that should improve concordance with treatment regimes (Lee, 2006) and has the potential to reduce deterioration in the condition and consequently preserve vision. Increased patient concordance may lead to more stable glaucoma resulting in a decreased demand for outpatient visits. The clinical nurse specialist role clearly has the potential over time to contribute significantly to the cost effective utilisation of healthcare resource. This is an aspect of the role which has yet to be quantified and needs further research.

Patient satisfaction and improved concordance to medications in other nurse led services have been noted by Hill (1997) and Garbett (1996) and in primary care in particular, nurse led consultations have been evaluated as acceptable to most patients with many patients expressing levels of satisfaction over and above those of doctor led consultation (Horrocks et al., 2002; Kinnersley et al., 2000; Venning, Durie, Roland, Roberts, & Leese, 2000). Evaluation of nurse consultation in terms of clinical benefit, cost effectiveness and quality of care provided has been overwhelmingly positive and advanced practice roles are also acceptable to all members of the healthcare team (Marsden & Street, 2004). Further research is required to evaluate fully the impact of the CNS role in glaucoma on patient outcomes and patient satisfaction. Such evidence would strengthen the argument for advanced nursing roles to help manage growing waiting lists in the present health care environment.


Collaborative care for the management of patients on waiting lists is an effective strategy for reducing the number of patients waiting for first specialist assessment. The introduction of the glaucoma clinical nurse specialist at this ophthalmology department has had a marked effect on waiting lists and has facilitated the care of patients, both those who fall within the nurse specialist's area of practice and also for more complex patients as appointments in consultant clinics as freed up. A collaborative care approach between the glaucoma consultants and the clinical nurse specialist of glaucoma has seen benefits for patients in early assessment, diagnosis and management for POAG.

Development of further roles in ophthalmology, in order to effectively utilise the highly skilled nursing resource and optimise other finite health resources, requires forward thinking and planning as well as continuing support, both professional and financial, from the organisation in which the service is based. A passion for excellence in care and a commitment from the whole healthcare team to investigate new models of care is required to ensure success of new models.


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Carol Slight, NP (Ophthalmology), MN, Opthalmology Department, Auckland District Health Board

Janet Marsden, RN, MSc, Senior lecturer, Postgraduate Programme Leader, Manchester Metropolitan University, Manchester, UK

Susanne Raynel, RN, MA (Nsg), Research and Development Manager, Department of Ophthalmology, Faculty of Medical and Health Sciences, University of Auckland.
Table 1.
ACA Categories in Ophthalmology.

 Timeframe from
 referral to
 first specialist
Category assessment Examples of conditions

1 Within 24 hours Trauma, corneal ulcers, acute
2 Within 1 week Sudden vision loss, neoplasms,
3 Within 4 weeks Glaucoma suspects * (high risk),
 amblyopic conditions, orbital
4 Within 6 months Glaucoma suspects * (low risk),
 cataracts, keratoconus

* Glaucoma suspects are patients who have a suspicion of primary open
angle glaucoma but diagnosis is not definitive and they require
ongoing monitoring for signs of disease progression.
(Lee, A. (2006). The angle and aqueous. In J. Marsden (Ed.),
Ophthalmic care (pp. 420-460). Chichester, UK: Wiley.)

Figure 1. Waiting list number for glaucoma category 3 and 4 referrals.

Numbers of Waiting list

 Glaucoma 3 Glaucoma 4

2002 38 71
2003 129 153
2004 48 12

Note: Table made from bar graph.
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Author:Slight, Carol; Marsden, Janet; Raynel, Susanne
Publication:Nursing Praxis in New Zealand
Article Type:Report
Geographic Code:8NEWZ
Date:Mar 1, 2009
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