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Background: Competency standards for entry-level to the profession of optometry in Australia were first developed in 1993, revised in 1997 and expanded in 2000 to include therapeutic competency standards. The entry-level standards cover the competencies required by a person entering the profession without therapeutic endorsement of their registration. The therapeutic competency standards address the additional competencies required for therapeutic endorsement of registration. This paper presents a revised version of the universal (entry-level) and therapeutic competency standards for the profession of optometry in Australia in 2008.
Methods: Expert members of the profession and representatives from schools of optometry, registration boards in Australia, state divisions of Optometrists Association Australia and the New Zealand Association of Optometrists were consulted in the process of updating the standards.
Results: Three new elements of competency have been added to the standards. Twenty-three new performance criteria with associated indicators have been added. Some performance criteria from the earlier document have been combined. Substantial alterations were made to the presentation of indicators throughout the document. The updated entry-level (universal) and therapeutic competency standards were adopted on behalf of the profession by the National Council of Optometrists Association Australia in November 2008.
Discussion: Competency standards are used by Australian and New Zealand registration authorities for the purposes of registration and therapeutic endorsement of registration via the Optometry Council of Australia and New Zealand accreditation and assessment processes. They have also been used as the basis of the World Council of Optometry Global Competency-Based Model.
In 1989, the Australian Government began a process of economic reform that included a push for acceptance of a competency-based approach for determining entry into and movement within a profession or trade. The aims were to allow maximum use of skills in the community, increase labour market efficiencies and equity, offer a fairer method of testing overseas trained professionals and assist in mutual recognition arrangements between the states.1 The Government stated that competency standards for a particular profession belonged to the profession2 and would be modified only by that profession as required. Professions were able to develop competency standards for entry-level to their profession or at a more specialised level.1 In the 1990s, optometry was among a number of professions that developed entry-level competency standards (for example, nurses,3 dietitians,4 speech therapists5).
The competency standards were to list the skills, knowledge and attributes that a person needed to be able to perform the activities associated with a particular trade or occupation to a standard appropriate for the workplace.1 The term ‘attributes’ is used to indicate the personal qualities that underpin performance and, hence, competence. Attributes include capacities, skills, abilities and traits. Inevitably, to some extent such listings are open-ended as identifying and describing human attributes is not an exact science.
A ‘competent’ professional has the capacity to perform the range of professional roles and activities at the required standard of practice. The term ‘competence’ is a blanket term used to describe overall professional ability and links (or integrates) three key ideas: a practitioner's ‘capacity’, ‘performance’ and the ‘standard’ of the performance. These three notions are represented centrally in professional competency standards, where the term ‘standards’ is a convenient name for the overall structure that taken together comprises a detailed description of professional practice: units, elements, performance criteria and indicators.
Optometrists in Australia are the major providers of primary eye care and also provide eye care secondary to referrals from vision screening programs, other optometrists, general medical practitioners and other health and educational providers. In Australia, optometrists' clinical skills include case history taking, determination of refractive error, assessment of binocular vision and accommodation, assessment of the health of the ocular structures through the use of techniques such as ophthalmoscopy, slitlamp biomicroscopy and tonometry; visual field assessment; colour vision assessment; assessment of the basic neurology of the eyes and visual pathways, prescription and supply of spectacles, contact lenses and low vision aids; use of ophthalmic drugs to facilitate diagnostic procedures (anaesthetics in performing tonometry, mydriatics for internal examinations and cycloplegics for refractive and physiological investigations). Optometrists' skills include problem solving and case management; they advise patients with ocular conditions, recommend suitability for work activities and may refer patients for general medical, specialist optometric, specialist educational, ophthalmologic or other professional care. In recent years, legislation has been passed in all but one of the states and territories of Australia, allowing optometrists to use and prescribe topical ophthalmic medications to treat a range of eye diseases.
In optometry, entry-level is the point at which a person is able to be registered to practise optometry. Entry-level competency standards describing the skills and knowledge a person needed to be regarded as sufficiently qualified to be registered to practise optometry in Australia were first developed in 19937 and revised in 1997 to reflect the growing scope of the profession and to incorporate modifications prompted by experience in the application of the competencies.8
Specialised competencies were not developed until 2000,9 when it was recognised that with the prospect of legislation to allow therapeutic endorsement to optometric registration, there needed to be a mechanism in place to specify the skills and knowledge required for an optometrist to be able to prescribe therapeutic medications. Therapeutic competencies could not be regarded as entry-level competencies in Australia but would be regarded as skills possessed by optometrists who had undertaken additional study or gained the necessary knowledge and experience outside their undergraduate training sufficient to gain therapeutic licensing. It is expected that the therapeutic competencies will become entry-level competencies as optometric training in all states now includes training in the use of therapeutic drugs.
The entry-level (or universal) and therapeutic competency standards for optometry in Australia have been used by the Optometry Council of Australia and New Zealand in its processes to accredit the undergraduate optometry10 and post-graduate therapeutic courses in optometry in Australia and New Zealand and in the assessment of overseas trained optometrists seeking to practise optometry in Australia.11 The standards have also been used as the basis of the World Council of Optometry Global Competency-Based Model for the Scope of Practice in Optometry.12
To commence the process to review the competency standards, a literature survey was conducted to see which standards similar to competency standards were in place for optometry elsewhere in the world and for other health professions in Australia and to determine whether there were any areas addressed in these standards that were not contained in the 2000 Australian entry-level and therapeutic competencies.
The 2000 document was circulated to over 80 optometrists in the different states of Australia and members of optometrists registration boards for suggestions about how the standards needed to be altered to reflect current expectations for entry-level to the profession of optometry and the requirements for therapeutic endorsement. Responses were received from optometrists in academia, the state divisions, the registration boards, the New Zealand Association of Optometrists, members of the National Council of Optometrists Association Australia and individual optometrists. The resulting comments were incorporated into a master document that was then analysed and refined at a workshop comprising 12 optometrists and facilitated by Dr Paul Hager from the University of Technology Sydney.
Recommendations from the workshop were incorporated into a second master document and returned to workshop participants for further comment. Following this refinement, the standards were sent to state divisions of Optometrists Association Australia for further comment and refinement prior to presentation to the National Council of Optometrists Association Australia for adoption as association policy. It is estimated that the total number of optometrists who were given the opportunity to comment on the draft competencies exceeded 100, although the precise number is unknown.
A major issue that had been raised during the initial circulation of the standards for comment was the format in which the indicators had been presented in the 2000 competencies. In some instances indicators comprised structured sentences; in other places they comprised lists of equipment and techniques. One respondent suggested that ‘brevity is the way to go with these competencies, particularly the indicators, as any attempt to make them comprehensive will tend to highlight omissions and be more confusing to candidates if they start to treat these as a very specific syllabus’.
To address this issue a different format was adopted in the indicators where a phrase was used commencing with a noun, for example, ‘knowledge of . . .’ or ‘ability to . . .’ or ‘understanding of . . .’ or ‘recognition of . . .’
There were also comments on recategorising some therapeutic indicators to entry-level and reduction of the detail in the therapeutic standards so that there was consistency across the document in the degree of detail.
These modifications to the format of the indicators and other refinements detailed below were incorporated in the final document that is shown in Appendix 1. To differentiate Universal (entry-level) competencies from those specific to therapeutic competency standards, the Universal competencies are shown in black and the performance criteria and indicators specific to Therapeutic competencies are presented in blue.
In the revised standards, there are no new units of competency but three new elements of competency have been added. The first of the new elements addresses prognosis of disease (4.2). The contents of the element regarding treatment of ocular disease and injury (5.8) were distributed to other sections and replaced by a new element on the provision of legal certification. The third new element was on requirements for retention and destruction of patient records and other practice documentation (6.3).
Twenty-three new performance criteria with associated indicators have been added. In some instances performance criteria from the earlier document were combined, for example, 1.7.2 and 1.7.3 were combined into the new 1.7.2. Performance criteria 3.3.5 and 3.3.6 from the earlier version have been deleted and distributed to other competencies. The subsections of 5.5.1 in the previous version of the standards have been deleted and modified to act as indicators in 5.5.1. The modifications to the entry-level and therapeutic competency standards were not contentious.
The Universal (entry-level) and Therapeutic standards for optometry analyse professional practice into units, which are subdivided into elements for purposes of assessment, teaching et cetera. The order in which Units, Elements, Performance Criteria and Indicators are presented does not imply any degree of priority. The standards must be read holistically. This means several things.
Instances of actual practice often involve two or more elements simultaneously, for example, taking a case history, communicating with the patient, acting ethically et cetera. In practice, the individual elements are not discrete and independent. For assessment purposes this means that performance on several elements can be assessed simultaneously.
In the case of new, unusual or changing contexts, the standards may need to be interpreted or adapted to the situation. Such contextually-sensitive situational understanding requires informed professional judgement to comply with the spirit of the competency standards.
They are also holistic in the sense that competence is not directly observable. Rather, what is observable is performance on a series of relatively complex and demanding professional tasks. Competence is a global construct that is inferred from observed performance on a sufficiently representative range of tasks and activities.
At present, therapeutic competencies are still considered a second-tier competency as not all graduates from Australian schools of optometry have these competencies and therefore, they are not eligible for therapeutic licensing. By 2013, all optometry courses in Australia will produce graduates who will be entitled to automatic therapeutic licensing. Therapeutic competencies would then be regarded as entry-level requirements of the profession rather than a second-tier expertise.
The updated version of the entry-level and therapeutic competency standards was adopted in November 2008 by the National Council of Optometrists Association Australia for the profession as it exists in 2008. It is expected that both sets of standards will continue to be modified as the profession develops.