Competency-based training

The competency-based approach to medical training has become increasingly popular worldwide over the past 25 years. However, there is nothing particularly new in the concept of competency-based education, there having been arguments made for its introduction into the training of professionals for more than 60 years (Frank et al., 2010). The move towards adoption of the competency approach to optometry has progressed in parallel in a number of countries, including Canada and the United States, but much of the trailblazing work in this area occurred in Australia and New Zealand (Leung, 2002). The catalyst for this development in Australia was a bi-product of a raft of economic policies introduced in the late 1980s, and which included the introduction in 1989 of competency frameworks for entry into and movement within professions and trades (Kiely, 2009). There were several aims that underpinned this initiative. Some were generic across professions, such as the desire to maximise existing skills among the workforce in Australia. One of the major drivers behind these moves was of particular relevance both to medicine in general and to optometry: the desire to facilitate and better regulate the entry into Australia of those whose qualifications had been obtained in other countries (Kiely, 2009). Over the years many UK trained optometrists, for example, have taken their skills to Australia and New Zealand, so there was an obvious need to ensure that optometrists trained outside Australia possessed the necessary skills to practise in their adopted country.

A notable feature of the competency model of training is that a qualification is awarded by virtue of demonstration of competencies achieved rather than by a “time served”

approach in an educational setting. In medicine, the time-serving structure was exemplified by the “rotation” model used in the training of doctors. This model has increasingly been augmented with or superseded by a competency-based structure (Leung, 2002).

Within any competency-based approach the trainee makes progress by successfully demonstrating competence at a number of clearly defined outcomes. These discrete elements can be assessed in a much more objective way than the less defined components of traditional educational assessment processes, notably viva voce examinations and “one-off” assessments of practical skills on patients who may be of

varying degrees of difficulty. Benefits of the competency model include the scope for having more flexible training, which can be focused on the individual’s needs, and greater transparency in the assessment process.

Leung (2009) also identified some of the disadvantages of the competency approach.

For example, it can be difficult to identify all the competencies that encompass the entire scope of a worker’s role. Furthermore, even the advantages inherent in a competency-based assessment do not make it entirely free from subjectivity on the part of an examiner. Perhaps the greatest weakness of the approach is that breaking down any profession’s activities into a number of discrete elements can make it difficult to appreciate and make use of those connections between the separate tasks and their outcomes that can be crucial to the detection and management of disease. These disadvantages can be often be overcome by the introduction of “higher order competencies” and assessing performance (Diwarkar, 2002). Another possible disadvantage, for the professional in training, is that having to “tick off” competencies can be de-motivating and discourage critical thinking.

Nevertheless, the advantages of competency-based training have led to its widespread adoption in both medical and optometric training. In Australia, entry level competencies for optometry were first introduced in 1993 and these were revised in 1997 in the light of experience and to reflect the increasing scope of optometric practice (Kiely, 2009).

These developments influenced progress in other countries with long-established optometric professions. In Canada, for example, the Canadian Examiners in Optometry introduced competency-based performance standards in 2005, drawing heavily from the seminal work by their colleagues in Australia (Winslade, 2005). Optometry worldwide has embraced this trend, culminating in the publication in 2005 of a “Global competency-based model of scope of practice in optometry” (WCO, 2005).

It is interesting to track how the competency-based approach to training and assessment has been introduced to UK optometry. As recently as 10 years ago our optometric training post-university followed the traditional “time served” model. This was embodied in the “pre-registration year”, which trainee optometrists undertook following graduation from university with a BSc in Optometry, and which ended with the

“big bang” assessment known as the PQE (“Professional Qualifying Examination”) at the end of that year. This examination consisted of a series of viva-voce oral

examinations conducted by a range of examiners, plus the assessment of practical skills on patients who could present with varying degrees of difficulty. All the individual elements of the examination had to be passed to achieve registration. This structure was inevitably prone to subjectivity on the part of examiners and inequality of the challenge posed to the candidates taking the examination. The PQE was modified in the middle of the last decade, notably with the introduction of an element of practice-based assessment, but the big bang nature of the final examination was partially retained, with four elements that had to be passed individually. All this has now been replaced by the more flexible “Scheme for registration” which was piloted in 2008 and introduced fully in its present form in 2009 (College of Optometrists, 2010b). The pre-registration year has been replaced by the less rigidly defined “pre-pre-registration period”.

Stage 1 and Stage 2 work-based assessments have been introduced, in which trained assessors visit the trainees in their own practices and sign off competencies satisfactorily performed at each visit. The final examination adopts an OSCE model which tests a series of 14 competencies in 5-minute stations, which assess candidates’

abilities across the competency framework. The competencies themselves are regularly reviewed for currency and appropriateness by the General Optical Council (GOC), working in collaboration with the College of Optometrists, and involving more wide-ranging consultation with stakeholders (GOC, 2008c).

So far, this section has focused on “entry level” competencies for professions such as optometry. But there has been recognition in optometry that the expanding scope of the profession into more specialised areas, notably therapeutics, would require competency-based training for registered optometrists who wished to participate in these new disciplines. This recognition led to the next major development in competency-based training and assessment, which again occurred in Australia with the development of specialist competencies in therapeutics in 2000 to coincide with the introduction of legislation to permit optometrists to become involved in therapeutics (Kiely, 2009). UK optometry embraced the competency-based model for specialist practise with the development of its training for optometrists wishing to become optometrist prescribers. An important early stage in the development process was the formulation of the “Competency Framework for prescribing optometrists” (National Prescribing Centre and General Optical Council, 2004, Competency framework for prescribing optometrists. General Optical Council Stage 2 Core Competencies for Optometry, 2005) which fulfilled a number of purposes, notably to:

 “Inform the development of an outline curriculum to prepare optometrists to prescribe.

 Help ensure that optometrist prescribers possess all the relevant expertise to initially undertake supplementary prescribing and, eventually, independent prescribing.

 Help optometrist prescribers and their employers/managers identify gaps in knowledge and skills and therefore identify ongoing training and development needs.

 Inform the commissioning, development and provision of appropriate continuing education and training programmes for optometrist prescribers”.

There are obvious applications of the competency-based approach to the management by optometrists of patients with glaucoma and ocular hypertension. Indeed the bullet points above are directly applicable to glaucoma and OHT, with the substitution of

“detection and management of glaucoma and OHT” where appropriate for “prescribing”

etc. The first step in any competency-driven scheme is to develop the competency framework itself and this was the primary aim of this Chapter.