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What I have learned

“A fundamental part of our testing day”

Optometrist Madeline Hocking and professional services consultant at Visioncall Dr Scott Mackie discuss the domiciliary eye care company’s dementia-friendly training programme

01 Jan 2020 by Andrew McClean

Why did you undertake dementia-friendly training?

Madeline Hocking (MH): Working as a domiciliary optometrist is very different to High Street practice. When I joined Visioncall, I attended a course with Dr Scott Mackie. As well as dementia, he talked about more complex age-related ocular pathologies, gave guidance on referral pathways while working remotely and provided information on common drug side effects.

It is essential that as an optometrist who is going into somebody’s home that we respect their needs and demands, as well as understand why sometimes we may not get a welcoming reception. I had not learned about dementia at any other point in my career, so I needed to learn new skills before taking the role as a domiciliary optometrist.

Why was it important to undertake training?

MH: It is important to learn more about dementia as it is not something that we commonly encounter on the High Street. When working in residential and nursing homes, it becomes a fundamental part of our testing day. It is extremely difficult to understand and until you have experienced it first-hand, I don’t think you can really learn it. I have the upmost respect for the carers and nurses who look after people suffering with dementia on a daily basis because it can be extremely difficult and can make you feel vulnerable and upset at times.

What were the main learnings from the programme?

MH: It is essential that we work in the patient’s best interest and always make clinical judgements to the best of our ability, asking for help from clinical leads or fellow medical professionals by way of referral when necessary – just like you would on the High Street. The most important thing I have learned is that every day is different and everyday people can act and feel differently. Often singing or playing the piano in the lounge helps to engage patients to engage and relax. My repertoire of 1940 and 1950s songs has expanded greatly over the last year.

“It is essential that as an optometrist who is going into somebody’s home that we respect their needs and demands”

Optometrist Madeline Hocking

How did it change your approach in practice?

MH: I became a lot more patient. I understand that we have to work around the residents’ needs and if they need a break or have had enough, we need to stop and come back later if it is appropriate. Using different picture charts and matching games can get better results and encourage residents to participate. We often visit residents in their bedroom if they feel happier being seen in a familiar environment but tend to use a quiet lounge area to maximise privacy. I have learned not to trust an autorefractor so much, which has improved my skills greatly. My ophthalmoscope is my best friend and although I do not like the side effects of tropicamide, I have learned that the gain in results greatly outweighs the few seconds of upset from the patients. 
 

How has undertaking dementia-friendly training improved the level of patient care you provide? 

MH: I feel that I am an honest optometrist and a very caring person. I like to listen to stories and share experiences with the residents I meet each day. A little chat and a cup of tea helps most people feel at ease, which is essential when we often dilate and then shine bright lights in their eyes. If a patient ever becomes upset or distressed, my optical assistant helps to calm them down and reassures them that things are ok. If this doesn’t work, we stop. We will never see anybody who says, ‘no thank you,’ and are guided by the nurse’s advice. I understand more about dementia from the training provided. However, I feel like we will never understand the true extent of dementia and therefore can only work in the patient’s best interest.

What are the main considerations when providing eye care to a patient living with dementia?

MH: It is essential to fully explain every test we are doing and try to conduct a thorough history and symptoms report, just as you would in any High Street practice. Often, we need to gather medical information and history from a patient’s medical notes prior to the examination, which helps to make the record cards more accurate. It is important to explain all the results and discuss the findings with residents and their lead carers or family members if they are present and record the results not only on the general ophthalmic services forms, but in their medical care plan notes. Each resident we see should see better, live better and feel happy with the service which we provide.

“A little chat and a cup of tea helps most people feel at ease, which is essential when we often dilate and then shine bright lights in their eyes”

Optometrist Madeline Hocking

 

Why was a dementia friendly training programme developed by Visioncall?

Dr Scott Mackie (SM): We received feedback from our stakeholders including people with dementia, their families and carers on various aspects of the patient journey that were not satisfactory. This led us to develop an innovation hub at our support office and challenge our standard operating procedures to reflect our values of providing person-centred eye care and our belief that everyone is entitled to the fundamental right to sight. The challenge was to design a person-centred approach to discuss and resolve these issues, which were classified into pre-testing, testing and post-testing.

How did Visoncall develop the programme?

SM: We set up a focus group with all our key stakeholders. The optometrist and dispensing optician were regularly not allocated a carer or activities co-ordinator who knew the patient and if communication was poor or absent it was difficult or impossible to know if spectacles should be prescribed or not for assumed activities. This led us to perform an audit using our stakeholder group to identify all of the activities that patients undertook. These were summarised into 50 different activities. The challenge was then to allow the patient to communicate this information to us. This led us to develop activity cards using icons.  

The focus group recommended a report that could be easily interpreted. This allowed us to develop a patient passport on eye health. It contained pictorial information using easy to recognise icons under different subheadings. The challenge was to design an algorithm where vision and activities could be correlated. This was achieved using blurring of my eyes while performing certain tasks such as viewing the TV and working out the threshold required. 

An audit revealed that our dispensing opticians were demonstrating unconscious bias by recommending their favourite frames for the patients with dementia. The challenge was to design frames that patients preferred. Our Chosen by You initiative required us to run two separate focus groups with people living with dementia and their next of kin to help choose new frames. Surprisingly, they chose mainly bold colours, which in hindsight represented their loss of contrast and acquired colour vision defect that are both visual side effects from dementia and any co-morbidity, such as cataract. 

“We received feedback from our stakeholders including people with dementia, their families and carers on various aspects of the patient journey, which were not satisfactory”

Professional services consultant at Visioncall Dr Scott Mackie

Why is this training important to delivering the best eye care to patients?

SM: For people living with dementia, it is important to be regarded as an individual and to be treated with dignity and respect. The activity questionnaire we developed to facilitate communication between the patient and carer helps to achieve this standard by allowing the person with dementia to partake in activities that are important to them. This assessment allows the person freedom of choice and the ability to make their own decisions. This in turn allows the care staff to treat the person with dignity and respect, be as independent as possible and to be included in your community. The signage we developed helps achieve this standard by allowing the patient to live as independently as possible by choosing the correct spectacles to wear and facilitating orientation around the nursing home, which in turn allows inclusion in their community of peers.

Patients have the right to access a range of treatment, care and support. The patient passport allows the person with dementia to receive information in a jargon free format so they can make informed choices after thinking about the assessment. This gives the patient time to think about whether they want spectacles or not and supports any eye diseases identified that may cause distress. It allows the patient to contact the optician should they need further information. Our Chosen by You initiative grants access to care that is dementia-friendly.

It is important to have carers who are well supported and educated about dementia. We provide staff dementia care training and access to a doctor’s response to an enquiry using our online stakeholder online VC24. There are also podcasts on our website that assist in supporting the carer to understand how dementia can affect a person’s ability to see and why glasses are important to fulfil a good visual quality of life, which helps to achieve the this standard. Visioncall also has a leaflet that highlights its services, which is equally beneficial to both carer and the person with dementia using jargon free text.

“For people living with dementia, it is important to be regarded as an individual and to be treated with dignity and respect”

Professional services consultant at Visioncall Dr Scott Mackie

Are there any further plans to develop the programme and other areas of training?

SM: An exciting new development is the phased introduction of our digital platform IRIS, which will link this training, including electronic record cards. When we employ all new clinical and non-clinical staff members, we provide mandatory induction training which has this initiative at the centre of our model of patient centred eye care. This is to allow all staff members to understand our purpose to give all patients the fundamental right to sight. 

We conduct clinical audits on all patient-facing staff every 12 months and personal development plans are written for each employee to ensure our standards of practice are upheld. We continue to develop our stakeholder engagement so we can adapt our person-centred eye care through our monthly innovation hub meetings with our staff who visit care home managers to feedback any improvements or recommendations on our patient journey. 
   
Other areas of training that are currently under development are for patients with learning disabilities such as autism, Downs syndrome and other conditions that require the upskilling of both information and practical skills so our practitioners can provide bespoke person-centred care. 

Image credit: Shutterstock/Natee K Jindakum

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