|COMMUNITY EYE CARE
|Year : 1999 | Volume
| Issue : 1 | Page : 49-52
Refresher training and continuing education for para-medical ophthalmic assistants
BR Shamanna1, Sujata R Rao2, KC Premarajan3, S Saravanan3, RD Thulasiraj3, G Venkataswamy3
1 International Centre for Advancement of Rural Eye Care, L.V. Prasad Eye Institute, Hyderabad, India
2 Modern Eye Clinic and Nursing Home, Bangalore, India
3 Aravind Eye Hospital and Lions Aravind Institute of Community Ophthalmology, Madurai, India
R D Thulasiraj
Lions Aravind Institute of Community Ophthalmology, 1 Anna Nagar, Madurai - 625 020
Source of Support: None, Conflict of Interest: None
This paper describes a refresher training and continuing education programme in clinical and community ophthalmology for para-medical ophthalmic assistants (PMOAs) conducted by the Lions Aravind Institute of Community Ophthalmology. The course participants included 60 PMOAs working either in district hospitals, primary health centres or mobile units from the districts in Maharashtra. Each training programme was spread over 43 hours in 4 days and included lectures, practical demonstrations, and hands-on training in the outpatient, inpatient, and operation theatre of the training institution. Participants were given exposure to outreach activities in an eye camp and a satellite eye centre resembling a district hospital. The PMOAs found the training to be useful and it was seen that areas like patient counselling, instrument and equipment maintenance, and assistance in the operation theatre for newer surgical procedures which were lacking in the basic training were fulfilled in this training programme. Regional Institutes of Ophthalmology, upgraded medical colleges, and other eye-care institutions which have facilities and manpower could organise similar refresher and continuing education programmes for PMOAs so that they could be utilised more efficiently in the blindness-control activities in the country.
Keywords: Para-medical ophthalmic assistants, refresher training, continuing education
|How to cite this article:|
Shamanna B R, Rao SR, Premarajan K C, Saravanan S, Thulasiraj R D, Venkataswamy G. Refresher training and continuing education for para-medical ophthalmic assistants. Indian J Ophthalmol 1999;47:49-52
|How to cite this URL:|
Shamanna B R, Rao SR, Premarajan K C, Saravanan S, Thulasiraj R D, Venkataswamy G. Refresher training and continuing education for para-medical ophthalmic assistants. Indian J Ophthalmol [serial online] 1999 [cited 2019 Aug 22];47:49-52. Available from: http://www.ijo.in/text.asp?1999/47/1/49/22810
The National Programme for Control of Blindness (NPCB) conceived and created a category of paramedical personnel, the para-medical ophthalmic assistants (PMOA) to assist the Primary health centre (PHC) medical officer or ophthalmic surgeon in early detection of visual impairment and in other activities concerning control of blindness. Thirty seven training institutions in the country, including medical colleges, regional institutes, and other institutions have trained close to 3500 PMOAs as of 1994. Most private eye surgeons and voluntary organisations do not have trained ophthalmic assistants, and the little existing training varies considerably. Further, the government has stopped recruiting ophthalmic assistants and several of the training centres have closed. The crux of the problem is the gross inadequacy of qualified ophthalmic personnel and underutilisation of existing ones. It is estimated that the ophthalmologist to population ratio is 1:1,07,000 and the PMOA to population ratio is even smaller. The NPCB envisaged a ratio of one surgeon and one PMOA for 50,000 population. As the demand for trained personnel in the rural and underprivileged areas is very great, and with the paucity of trained personnel, efforts should be made to better utilise the existing ophthalmic assistants in PHCs through refresher training.
Maharashtra has been able to achieve the target number of cataract surgeries set by the state government each year (personal communication - Dr. L.H.Mishra, Directorate of Health Services, Mumbai, September 1995). It has nearly 600 PMOAs and is one of the states that utilises the PMOAs efficiently. In 1995, the government sent the district Ophthalmic surgeons (DOS) and district programme managers (DPM) in 3 batches to Lions Aravind Institute of Community Ophthalmology (LAICO), Madurai, Tamil Nadu for a training programme in community ophthalmology. During these sessions, the DOS unanimously felt the need to send their PMOAs to LAICO as PMOAs form an important component of the eye-care delivery team in the state.
Two refresher training and continuing education programmes were conducted for the 2 batches of 30 PMOAs each between September-October 1995.
The objectives of the training were:
- 1. To understand the roles and utility of PMOAs in eye-care delivery activities.
- 2. To redefine the roles and responsibilities of PMOAs after orientation to suit the needs of the state.
- 3. To update the skills with hands-on training in areas like refraction, clinical diagnosis, preoperative and postoperative patient care and recognition of postoperative complications.
- 4. To improve the ability to organise better outreach programmes.
- 5. To pay attention to quality of eye-care services in high-volume situations.
The expected outcomes were:
- 1. To develop a self-learning module with scope for periodic update.
- 2. Adequate motivation and skills update.
- 3. To provide high-quality care in high-volume situations.
The state government of Maharashtra decided to send 2 PMOAs from each district to LAICO for this course. The selection of the PMOAs was based on their experience and good working record. The selected PMOAs were briefed at Nasik and Aurangabad by DOSs and state health officials who attended the workshops on community ophthalmology at LAICO. These briefings related to the need and expectation of the training they would receive, and served as an orientation to the training programme.
A programme was developed with reference to the job responsibilities, training syllabus and recommendations of the DOS. Resource persons [Table - 1] were identified for each session from different areas of the hospital. The resource persons were briefed about the course and its objectives. Details of each session [Table - 2] were worked out including the methodology, duration, and venue.
Handouts listing the important points to be discussed during the various sessions were prepared for all sessions.
| Course Content|| |
The sessions were divided into outpatient, inpatient, operation theatre and outreach activities. All sessions were planned such that a lecture would be followed by the practical/ demonstration on the following day. For the practical sessions the PMOAs were divided into 4 groups.
At the beginning of the course, a pre-course evaluation form was given to the PMOAs to assess their knowledge with regards to their day-to-day working and job responsibilities. The nature of the questions were those which a PMOA was expected to know. At the end of the course a post-course evaluation was conducted. The same course evaluation sheet was again given to them. This gave us a picture of the utility of the course the PMOAs underwent.
A quiz was also conducted on the first day using 100 clinical slides which had to be identified. The slides were immediately shown again and the correct diagnosis with explanation and the treatment of the condition depicted in the slide was discussed.
As a major job responsibility of the PMOAs in a government set up is conducting outreach activities, a visit to a screening eye camp was arranged. Following this, a visit to Aravind Eye Hospital, Theni, which is similar to a district hospital in which the PMOAs work, was included as part of the training.
| Outpatient activities|| |
Under this broad category the following sessions were included; the relevant concepts were discussed and demonstrated.
- 1. Minimum standards in outpatient department. The concept of systematic screening; diagnosis and differential diagnosis of ophthalmic diseases by history and examination with minimum equipment.
- 2. Practice of general refraction. Identification of lenses including spherical, cylindrical and prisms; neutralisation; retinoscopy; dynamic and subjective verification in children, presbyopia and aphakia/ pseudophakia. Discussion and demonstration also included measurement of interpupillary distance, centring, decentring and transposition of lenses.
- 3. Contact lenses (CL) and low-vision aids (LVA). The various types of CL and LVA including fitting and dispensing techniques.
- 4. Squint and amblyopia. The management of squint by various methods, and prevention of amblyopia and its importance.
- 5. Intraocular pressure measurement, Lacrimal duct syringing, identification of gross defects in colour vision, measurement and recording the field of vision by manual and automated methods.
- 6. Medical record maintenance. The methodology of maintaining records and the minimum records required from the legal viewpoint.
| Inpatient activities|| |
- 1. Preoperative preparation. Admission procedures; preparation of the patient for surgery; and pre-operative instruction to patients.
- 2. Postoperative care. Instructions and counselling during discharge and systematic methods of postoperative examination and dressing in high-volume situations.
- 3. Postoperative complications. The common anterior segment complications following cataract surgery and their recognition. Common complications were demonstrated.
| Operation theatre activities|| |
- 1. Sterilisation of operation theatre and instruments. Sterilisation techniques for blunt and sharp instruments, linen, equipment in operation theatre, fumigation of operation theatre.
- 2. Technique of local anaesthesia. Methods of ciliary block and facial block.
- 3. Infection control. Lectures were given, supported by slides, on the common sources and organisms causing infection. Prevention of infection, especially endophthalmitis, was stressed.
- 4. Role of PMOAs in operation theatre. This included a visit to the block room and the operation theatre to observe the laying of the trolley, draping, taking the superior rectus suture, and writing operation notes.
| Outreach activities|| |
The schedule for outreach activities was designed in such a way that it covered areas related to camp organisation, logistic planning, camp management and publicity. The role of village awareness programme in blindness control, the role of aphakics in referring patients from their neighbourhood, and assessment of patient satisfaction was also shown to the PMOAs. Following this, a visit to a screening eye camp was arranged to give an opportunity to witness the activities of the village volunteers and interact with the aphakics who underwent surgery and assess their satisfaction levels.
The PMOAs also visited Aravind Eye Hospital, Theni, a 100-bed eye hospital located 75 kms west of Madurai.
The objectives were
- 1. To demonstrate the functioning of the different areas of the hospital which resemble a district hospital set up in terms of the level of services the PMOAs work in.
- 2. To demonstrate the rational utilisation of ophthalmic manpower, especially PMOAs, in the above set up.
Other areas like patient counselling, instrument maintenance, and preparation of eye pads and swabs were also included in the training programme.
| Results|| |
In our experience with the two training programmes we found that
- the PMOAs found the training extremely useful and the time duration adequate;
- they required continuous medical education to update their skills and knowledge; and
- they were motivated after the training, as they felt they could implement a part of what they had learnt.
Unfortunately, it was evident that their basic training was grossly incomplete as some sessions had to be dedicated to the basics. It is also possible that they had simply forgotten the basics as they had not been given the opportunity to apply their knowledge or skills or due to a lack of supervision.
It was also noticed during these training programmes that the PMOAs were good in certain areas including preoperative and postoperative care; recognition of postoperative complications; diagnosing common eye diseases; and in administration of local anaesthesia.
The PMOAs felt that areas in which further training was required were refraction, squint and amblyopia; contact lenses and low-vision aids; sterilisation techniques; infection control, and outreach (camp organisation).
| Discussion|| |
The programme of the two year basic training of the PMOAs includes 6 months institutional training in the recognised 37 training institutions identified for imparting this training followed by field practice for 6 months each at district hospital, PHC and mobile unit. At the end of the training, the trainee is expected to be able to render the following services:
- carry out eye-health education activities;
- assist medical officers/ophthalmic surgeon in estimation of refractive errors and treatment of common disorders of ocular motility; and
- carry out common ophthalmic diagnostic procedures.
Even though a job description exists for PMOAs at various levels, there seem to be some problems with their daily functioning. There appears to be considerable frustration among PMOAs posted at PHCs, particularly where no medical officer has had refresher training in ophthalmology and where the distance to the eye department is great and the PHC is rarely or never visited by an ophthalmic surgeon. The PMOA seems to function well when he or she is supervised daily by an ophthalmic surgeon or is functioning together with a medical officer with comprehensive refresher training or a diploma in ophthalmology. The establishment of a career system for PMOAs should be seriously considered, functioning as an incentive.
The Danish International Development Agency (DANIDA)-sponsored feasibility study5 team analysed the tasks of the PMOAs and found lot of variation in the quality of basic training and the quality of service provided by PMOAs when they are posted at the peripheral level and the utilisation of this cadre of manpower by the eye surgeons, mobile units, PHC medical officers and the district hospital. During the course of our training, we found this to be evident from the PMOAs who came for the training even though they belonged to the same state. The team also found that some PMOAs had received on-the-job training from the ophthalmic surgeon in eye camps. In some cases they had been given administrative work to facilitate patient flow in the camps or PHCs.
The team suggested remedies such as
- Review of curriculum, duration and basic training of PMOAs.
- Review and restructuring of manpower available at the PMOA training centres; teachers' training and reorientation of faculty members of the training centres to the needs of the blindness control programme.
The feasibility study also strongly recommended the refresher courses for PMOAs but they cautioned that such courses would only yield the expected results if the whole framework for their activities, their core tasks and additional tasks are adequately reviewed and the enabling factors for their functioning reconsidered. There were some performance gaps in core tasks of retinoscopy and refraction, primary eye-care and eye-camp work and operation theatre procedures for which they recommended short-term, practically oriented in-service refresher / continuing education of not less than 2 weeks' duration. Our experience with the training programmes seconded the above statements.
In Asia, one of the best-developed programmes for ophthalmic assistants is in Nepal. Selection is such that the candidate comes from the district where he would be based after the 3-year training. This training includes an initial intensive 3 months of theory followed by 2 years clinical experience in different hospitals and eye camps. The final 3 months of training is for the practice of refraction. Occasionally, exposure to other PMOA training programmes in neighbouring countries is arranged for these PMOAs where they are sent to learn skills of instrument maintenance and organisation of outreach activities. This programme is certified by the Ministry of Education, and a career ladder is available, parallel to, but separate from a career in conventional medicine. This is lacking in our programme. The PMOAs remain the backbone of the prevention of blindness programme in the rural areas of Nepal.
In conclusion, we suggest that in order to make the refresher training more suitable to the needs of India, the Regional Institutes of Ophthalmology and the upgraded medical colleges of the country could hold such training programmes for PMOAs at different locations in the country. Since the manpower and equipment required for such training programmes is available at these institutions, and as we have worked out the schedule for such a training, it would be convenient to hold these training programmes in areas where the PMOAs feel a need. In the National Society for Prevention of Blindness workshop, recommendations were made for supplementary or refresher training in equipment maintenance and minor repairs, optician training, orthoptics training, training in eye-camp activities, nursing activities and educational training. To a certain extent, we succeeded in doing this. This could make the job of the PMOAs more interesting and their skills could be put to better use in appropriate situations.
| References|| |
Ministry of Health and Family Welfare, Government of India. Training programme for ophthalmic assistants. In: Present Status of National Programme for Control of Blindness (NPCB). New Delhi: Government of India; 1992. p 47-61.
Venkataswamy G. Ophthalmic medical personnel in prevention of blindness programmes: their training and use. Workshop report; V General Assembly; Berlin. International Agency for Prevention of Blindness; 1994.
Kumar R. Ophthalmic manpower in India: need for a serious review. Int Ophthalmol
Goldschimdt E. Impact of NPCB. Proceedings of the workshop organised by the National Society for Prevention of Blindness; 15-17 March 1989; New Delhi.
Danish International Development Agency. Training of paramedical ophthalmic assistants in India: feasibility study. New Delhi: DANPCB; 1993.
Johnson GJ, Foster A. Training in community ophthalmology. Int Ophthalmol
[Table - 1], [Table - 2]