!-HERDIE EKSEMPLAAR pr,.G or~D:t:R
University Free State
';EEN OMSTANDI HEDE lJ1T DIE
wono 1111111 111111111111111111111111111111111111111111111111111111111111111111111111I:~IBLlOTE£K VERWYDER NIE 34300001318330
Universiteit Vrystaat
THE ~E[E[)5) AND OP~COR1fUN~l~E5)iFO~
PO~l =GRA[))UAre EDUCA 'f~OD\!Al ~[o)
rRA~N~NG PROGRAMMES FOR THE
OPTOME1~Y [P~OFESSION IN POST =
APARTHEID SOUTH AFRICA
by
STEFANUS JOHANNES KRIEL
lDossertatioll1l submitted HII1flUl l~fo~ment cf the requirements for
the d1egree
Magostell" OIl1l Hea~thlProfessiions Educat90n
(M.HPE)
in the
DiVISION OF EDUCATIONAL DEVELOPMENT
FACULTY OF HEALTH SCIENCES
AT THE UNIVERSITY OF THE FREE STATE
May 2003
Study leader: Prof. Dr M.M. Nel
Unlv.r.ttett von ,.1 1
OranJe-Vrv.toot
~f1fOHTEIN
I
1 3 FEB 2004 ,-' I
uovs IAIOL III ~
ii
DIECLAIRAlION
I hereby declare that the work which is submitted here is the result of my own
independent investigation. Where help was sought, it was acknowledged. I
further declare that this work is submitted for the first time at this
university/faculty towards an M.HPE degree in Health Professions Education
and that it has never been submitted to any other university/faculty for the
purpose of obtaining a degree.
.....4..<...~..·.,.·..7·..'·.1·..·......
S.J. KRIIEL
I hereby cede copyright of this product in favour of the University of the Free
State.
.....~.C.7.7.' ..1...................................
S.J. KRIEL .";j'"
iii
iv
ACKNOWlEDGEMIENTS
I wish to express sincere thanks to the following:
o My study leader, Prof. Marietjie M. Nel, Head of the Division of
Educational Development, Faculty of Health Sciences, University of
the Free State, for her guidance, assistance and expert advice
during the study.
o The late Prof. C.J.C. Nel, Dean, Faculty of Health Sciences,
University of the Free State, for allowing me the use of facilities and
his overall support.
G The staff of the Frik Scott Library and in particular Ms Rene du
Plessis, as well as Ms Elrita Grimsley of the Information Centre for
Higher Education at the Centre for Higher Education Studies and
Development, the University of the Free State, for assisting me in
my literature searches.
o Prof. Gina Joubert of the Department of Biostatistics, Faculty of
Health Sciences at the University of the Free State, for her
assistance in compiling the questionnaire and the processing of the
\ statistical data.
l
o The staff of the Division of Educational Development at the Faculty
of Health Sciences at the University of the Free State for their
administrative as well as technical assistance and their support.
o The respondents to my study, who made valuable inputs and
without whom this result would not have been possible.
v
o My wife, Fiona; my son, Steffen; Joyce Mazomba; and Liesl Viljoen
for their acceptance when I was elsewhere occupied, physically as
well as mentally.
o South African colleagues and friends who accepted that my social
life and conversation were often restricted as a result of my
preoccupation with this study.
o My partner, Fanie Kriel, and the staff in my practice in East London
for their loyalty and attending to the continued smooth operation of
my primary financial resource.
o American colleagues who were introduced to me via the New
England College of Optometry, Boston, for their friendship and
continued encouragement during the past ten years. Without their
support, the improvement in optometry skills in South Africa would
have taken much longer.
vi
rABLE Of CO~T[E~lS
Page
CHAPTER 1:
ORIENTATION TO THE STUDY
1.1 INTRODUCTIONANDBACKGROUND............ 1
1.2 RATIONALEOFTHISSTUDY ·· 4
1.3 STATEMENTOFTHEPROBLEM.................................... 11
1.4 GOALANDOBJECTIVES ·· ······ 12
1.5 METHODSANDPROCEDURE........................................ 13
1.6 SIGNIFICANCEANDVALUEOFTHESTUDY................... 15
1.7 SCOPEOFTHESTUDY ··· 17
1.8 ARRANGEMENTOFTHEDISSERTATION....................... 18
1.9 CONCLUSION ····.................. 19
CHAPTER 2:
FACTORS INFLUENCING THE DESIGN! OF OPTOMETRY
EDUCATION AND TRAINiNG PROGRAMMES
2.1 INTRODUCTION... 21
2.2 THEHISTORYOFTHEDEVELOPMENTOFTHE
I OPTOMETRYPROFESSION...... 23
~ 2.3 THETRANSFORMATIONOFTHEHEALTHCARE
SYSTEMINSOUTHAFRICAANDTHEEYECARE
NEEDSOFTHESOUTHAFRICANPOPULATION............... 25
2.3.1 Introduction.................................................................. 25
2.3.2 National and international perspectives...... 28
2.3.2.1 Vision 2020- TheRight to Sight....................... 30
2.3.2.2 TheNational Prevention of Blindness Campaign (Policy).... 32
2.3.3 Primary health care (PHC)............ 35
2.3.4 Statutory and professional aspects.............................. 38
vii
2.3.4.1 The Health Professions Council of South Africa
(HPCSA)...................................................................... 38
2.3.4.2 The South African Optometric Association (SAOA)......... 40
2.3.4.3 The South African Council on Optometric Education
(SACOE)...................................................................... 42
2.4 THE TRANSFORMATION OF EDUCATION AND
TRAINING IN SOUTH AFRICA......................................... 43
2.4.1 Introduction... 43
2.4.2 The roles of the Department of Healtlh (DoH) and of the
Department of Education {DoE)................................... .... 45
2.4.3 A programme-based approach in education and training... 46
2.4.4 Outcomes-based education and training (OBET). 49
2.4.5 The South African Qualifications Authority (SAQA) and the
National Qualifications Framework {NQF)........................ 56
2.4.6 Educational strategies for health sciences education......... 62
2.5 CONCLUSION... 70
CHAPTIER 3:
A SELECTIVE REV~EW OIFOPTOMETRIC EIDUCATION
3.1 INTRODUCTION... 71
3.2 OPTOMETRIC EDUCATION AND TRAINING IN
SOUTH AFRICA ········ 73
3.2.1 Introduction...... 73
3.2.2 Technikon Witwatersrand (TWR)... 80
3.2.3 University of the North {UNIN).. . 83
3.2.4 The University of Durban-Westville {UDW)...... 84
3.2.5 The Rand Afrikaans University {RAU)... 85
3.2.6 Cape Technikon {CT)................................................... 85
3.2.7 The University ofthe Free State {UFS)............................... 86
3.2.8 The Graduate Institute of Optometry {GIO)........................ 89
3.2.9 Summative remarks............ 92
3.3 OPTOMETRIC EDUCATION AND TRAINING IN
THE REST OF AFRICA..................................................... 95
3.3.1 Introduction... 95
viii
3.3.2 Ghana................ 97
3.3.3 Tanzania....................................... 98
3.3.4 Nigeriaand French-speakingAfrica.................................. 100
3.3.5 Summativeremarks on optometric education and
training in Africa ·..··..· 101
3.4 OPTOMETRICEDUCATIONANDTRAININGIN
THEUSAANDCANADA ·..·..· 102
3.4.1 Introduction...... 102
3.4.2 Programmesfor optometrie education and!training.......... 106
3.4.3 Summativeremarks ·· 110
3.5 OPTOMETRICEDUCATIONANDTRAININGINEUROPIE,
THEUNITEDKINGDOMANDAUSTRALIA...... ...... ...... 111
3.5.1 Introduction ·..·..·...... 111
3.5.2 Optometric education programmes in Australia,
the UnitedKingdom and Ea..orope..................................... 112
3.5.2.1Australia · ·.... 112
3.5.2.2TheUnitedKingdom...................................................... 117
3.5.2.3Europe ·.... 120
3.6 SUMMATIVEPERSPIECTIVE............................................. 124
3.7 CONCLUSION................................................................... 125
CHlAPTER 4:
CONTINUING PROFESSIONAL DEVELOPMENT (CIPID)IN
OPTOMIETRY
4.1 INTRODUCTION ···.. 127
4.2 RATIONALE · 128
4.3 CRITERIAFORCPOPROGRAMMES................................. 131
4.3.1 Convenience · 134
4.3.1.1Place................................................... 134
4.3.1.2Time................................. 135
4.3.1.3Pace............................................................................. 135
4.3.2 Relevance...................................................................... 136
4.3.3 Individualisation............................................................ 141
4.3.4 Self-assessment............................................................ 143
ix
4.3.5 Interest.......................................................................... 145
4.3.6 Speculation and systematic presentation........................... 147
4.3.6.1 Speculation ·.. ·.. ··..· 147
4.3.6.2 Systematic · · 148
4.4 TYPES OF CPD PROGRAMMES · 149
4.4.1 Formal programmes · · · 150
4.4.2 Informal CPD ··.. ·..·.. ·· 151
4.5 CPD IN SOUTHAFRiCA...... 151
4.5.1 Administration ·..·..····.. · 151
4.5.2 Categories of educational and developmental activities
and allocation of points.............................................. 152
4.5.2.1 Category 1: Organisational activities................... 153
4.5.2.2 Category 2: Small-group activities.... 153
4.5.2.3 Category 3: Individual activities...................................... 154
4.5.3 Deferment and non-compliance......................................... 156
4.5.4 Providers of CPO activities........................................... 156
4.5.5 Accreditors of CPD activities......... 157
4.6 THE HEALTH PROFESSIONS COUNCILOF SOUTH
AFRICA (HPCSA).................................... 157
4.6.1 Background................................................ 157
4.6.2 Registration with the HPCSA...................................... 158
4.6.3 Professional Boards · 159
4.7 DISCUSSION ·.......... 161
4.8 SUMMATIVE PERSPECTIVE............................................... 162
4.9 CONClUSION ·.. ·.. ·· · 164
CHAPTER 5:
RESEARCH METHODOLOGY
5.1 INTRODUCTION ··.. · · 169
5.2 THEORETICAL PERSPECTIVES ON THE RESEARCH
METHODOLOGY............................................................. 170
5.3 METHODSAND PROCEDURES......................................... 173
5.3.1 Literature review ·············· 173
5.3.2 The empirical study.......................................................... 175
x
5.4 RESEARCH DESIGN: EMPLOYING A NEEDS ANALYSIS
AS RESEARCH METHOD.................................................. 176
5.4.1 The questionnaire...... 176
5.4.2 The empirical study: Needs analysis................................. 178
5.5 THE PARTICIPANTS · 179
5.6 ETHICAL CONSIDERATIONS............................................ 182
5.7 ANALYSIS OF DATA........................................................ 182
5.8 CONCLUSION ·.... 182
CHAPTER 6:
RESUl T5, DATA ANALYSIS AND DISCUSSION OF
THE FINDINGS
6.1 INTRODUCTION · 180
6.2 RESULTS OF CATEGORY 1: PERSONAL INFORMATION..... 181
6.3 SUMMATIVE CONCLUSION ON CATEGORY 1: PERSONAL
INFORMATION............................................................... 198
6.4 MAIN FINDINGS OF THIS CATEGORY............................... 202
6.5 RESULTS OF CATEGORY 2: PROFESSIONAL
DEVELOPMENT............................................................ 203
6.6 SUMMATIVE CONCLUSION ON CATEGORY 2:
PROFESSIONAL DEVELOPMENT.................................... 237
6.7 MAIN FINDINGS OF THIS CATEGORY.............................. 240
i 6.8 RESULTS OF CATEGORY 3: POST -GRADUATIE/IPOST -DlIPLOMA
l STUDIES......................................................................... 2426.9 SUMMATIVE CONCLUSION ON CATEGORY 3: POST-
GRADUATE/POST-DIPLOMA STUDIES............................. 253
6.10 MAIN FINDINGS OF THIS CATEGORY............................... 256
6.11 RESULTS OF CATEGORY 4: FURTHER STUDIES TO OBTAIN
A FORMAL QUALlFICATION........................................... 257
6.12 SUMMATIVE CONCLUSION ON CATEGORY 4: FURTHER
STUDIES TO OBTAIN A FORMAL QUALlFICATION............. 278
6.13 MAIN FINDINGS OF THIS CATEGORY............................... 282
6.14 RESULTS OF CATEGORY 5: DETAILED INFORMATION
ON POST-GRADUATE/POST-DIPLOMA STUDIES............... 283
xi
6.15 SUMMATIVECONCLUSIONONCATEGORY5: DETAILED
INFORMATIONONPOST-GRADUATE/POST-DIPLOMA
STUDIES........................................................................ 295
6.16 MAINFINDINGSOFTHISCATEGORY............................. ... 298
6.17 RESULTSOFCATEGORY6: AWARENESSOFTHE
PUBLICNEED... 299
6.18 SUMMATIVECONCLUSIONONCATEGORY6: AWARENESS
OFTHEPUBLICNEED...... 351
6.19 MAINFINDINGSOFTHISCATEGORY................................ 362
CHAPTER 7:
SUMMATIVE PERSPECTiVE OF THE STUDY
7.1 INTRODUCTION ,. 363
7.1.1 Perspectives on Chapter 1..................... 363
7.1.2 Perspectives on Chapter 2................................................ 367
7.1.3 Perspectives on Chapter 3............ 371
7.1.4 Perspectives on Chapter 4...... 376
7.1.5 Perspectives on Chapter 5............ 384
7.1.6 Perspectives on Chapter 6 388
7.1.7 Perspectives on Chapter 7... 388
7.1.8 Perspectives on Chapter 8............................................... 389
7.1.9 Perspectives on Chapter 9............................................. ... 390
CHAPTER 8:
RECOMMENDATIONS ON POST-GRADUATE OPTOMETRIC
EDUCATiON IN SOUTH AFRiCA
8.1 INTRODUCTION..................... 391
8.1.1 Why post-graduate?.................................................... 392
8.1.2 Howwill this contribute to addressing the need?............... 394
8.1.3 Post-graduate education in optometry and its role in post-
apartheid South Africa......... 396
xii
8.2 PREMISES OF POST-GRADUATE OPTOMETRY
EDUCATION................................................................... 397
8.3 RECOMMENDATIONS ·····............... 399
8.3.1 Points of departure........ 401
8.3.2 Role-players...... 405
8.3.3 Recommendations with regard to post-graduate optometrlc
education and training ······ 410
8.3.3.1 Curriculum design, content and organisation 410
8.3.3.2 Teaching, training, learning and assessment...................... 412
8.3.3.3 Student progression and achievement............................... 414
8.3.3.4 Student support, development and guidance..................... 415
8.3.3.5 Aim, purpose and outcomes ·············· 415
8.3.3.6 Student and staff resources ·············· 416
8.3.3.7 Staff development and training.......................................... 417
8.3.3.8 Human and physical resources ················ 417
8.3.3.9 Governance and organisation........................................... 418
8.3.3.10 Quality assurance and enhancement............................... 419
8.3.4 Recommendations with regard to continuing professional
development (CPD).......................................................... 420
8.3.4.1 Recommendations concerning the CPO content and
design of programmes ·········· 420
8.3.4.2 Recommendations concerning the logistics of CPO............ 423
8.3.4.3 Recommendations concerning the marketing of CPO...... 423
8.3.5 Recommendations with regard to clinical competence... 423
SECTIONA: CLINICAL RESPONSIBILlTIIES..... 425
SECTIONB: PATIENTHISTORY ··········· 435
SECTIONC: PATIENTEXAMINATION 438
SECTIOND: DIAGNOSIS....... 447
SECTIONE: PATIENTMANAGEMENT..................................... 448
SECTIONF: RECORDINGOFCLINICALDATA....................... 469
8.4 SUMMATIVE PERSPECTIVE · 471
8.5 CONCLUSION ·· 480
xiii
CHAPTER 9:
SUMMARY OF CONCLUSIONS AND LIMITATIONS OF THE
STUDY
9.1 INTRODUCTION... 482
9.2 CONCLUSION................................................................. 482
9.3 LIMITATIONS OF THE STUDy ·. 484
9.4 RECOMMENDATION FOR FURTHER STUDIES 485
9.5 CONCLUSIVE REMARKS · 485
BIBLIOGRAPHY........................................................................ 487
SUMMARY................................................................................ 508
OPSOMMING... 514
APPENDIX A
APPENDIX B
APPENDIX C
APPENDIX D
APPENDIX E
xiv
l~STOFTABLES
Page
Table 2.1: Schematic presentation of the Natio01lal
Qualificatio01ls Framework (NQF) 58
Table 3.1: Some of' the major strengths and weaknesses
of underqraduate and post-graduate optometric
education and training in South Africa 94
Table 6.1: Demographic characteristics of respondents 183
Table 6.2(a): Qualification profile of the respondents 185
Table 6.2(b): Profile of institutions (which had been attended
by the respondents) offeri01lQqualifications 188
Table 6.3(a): Type of practice............................................................... 190
Table 6.3(b): locality of the practice 191
Table 6.4(a): Respondents who would IDIketo obtain a f'1L,JIII"ther
(higher) qualification in optometry 193
Table 6.4(b): Motivatio01l/reaSOD1osf' respondents who would
like to obtain a further (higher) qualification
i011 optometry '" 194
Table 6.4(c): Motivation/reasons given by respondents who
would not like to obtain a further (higher)
qualification in optometry 196
Table 6.5(a): Respondents' own perception as to whether
they were keeping abreast of developments in the
field of optometry practice 204
Table 6.5(1b): Respondents' ways of keeping abreast of
developments in the field of optometry 205
Table 6.6(a): Respondents' views on adequate opportunities
to stay informed in the field of optometry 207
xv
Table 6.6(b): Respondents' reasons for conflrminq that there
were sufficient opportunities to keep lntormed in
the field of optometry 208
Table 6.6(c): Respondents' reasens for statin1g that
opportunities to stay ill1lformed in the field of
optometry were not sufficient 2~0
Table 6.7(a): Respondents experiencing stumbling-blocks
in professional developmell1t.......................................... 2~2
Table 6.7(b): Stumblong-blocks experienced by respondents
in terms of their professional developmenL................ 213
Table 6.8: Factors which motivate respondents to engage
in continuing professional development (ePD) 215
Table 6.9(a): Respondents' perception as to whether current
ePD activities met their needs....................................... 2~7
Table 6.9(b): Respondents' reasons for statuD1lgthat current
professional development activities met their
needs................................................................................ 218
Table 6.9(c): Respondents' reasons for stating that current
professional development activities did not meet
their needs 220
Table 6.10: Respondents' ways of acquiring ePD points in
order to maintain a licence to practise 222
Table 6.11(a): epo activities preferred by respondents 224
Table 6.11(b): Respondents' reasons why they preferred to
participate in certain ePD activities 225
Table 6.12(a): Respondents' desire to specialise in an optometry
fieid................................................................................... 221
Table 6.12(b): The extent to which respondents agreed that formal
post-graduate qualifications should form. the basis
of such speciaiisation..................................................... 228
xvi
Table 6.12(c): Respondents' reasons why they felt that a formal
post-graduate qualification should form the basis
of specialisation 229
Table 6.12(d): Respondents' view that a formal post-graduate
qualification should not form the basis of
speclallsationv.. 230
Table 6.13(a): Respondents' agreement that formal qualifications
should represent expanded scope privileges 231
Table 6.13(b): Respondents' motivation as to why formal
qualifications should represent expanded
scope privileges, which recognise a broader
skills base 233
Table 6.13(c): Respondents' motivation as to why formal
qualifications should not represent expanded
scope privileges which recognise a broader
skills base........................................................................ 235
Table 6.14: Respondents who did investigate post-graduate
possibilities in optometry in South Africa 243
Table 6.15(a): Respondents who wished to embark 01111 post-
gradlLDate/post-diploma studies if the
opportunity arose............................................................ 244
Table 6.15(b): Respondents' motivation/reasons why they did
not pursue post-graduate/post-diploma studies
at present. 245
Table 6.16: Respondents' reasons why they wished to pursue
formal post-graduate studies in the future 247
Table 6.17: Positive responses to the offering of a
post-graduate programme.............................................. 249
Table 6.18: Respondents' preferred area to obtain a post-
graduate qualification in the field of optometry 250
xvii
Table 6.19: The inadequacies/shortfalls in the profes-
sional practice environment which respondents
experienced. 252
Table 6.20: formal study time schedules preferred by the
respondents........... 258
Table 6.2~: Course-structure (course type) preferred by
the respondents 259
Table 6.22: The respondents' ability to use onllne technology
as part of' the coursework delivery 260
Table 6.23: Respondents' availability to attend lectures 01111
campus for a short period of time 261
Table 6.24: Frequency of' respondents' ability to attend
lectures 262
Table 6.25(a): Indication of the repondents' preference with
regard to the place where the practical/clinical
sessions of the post-graduate course should
take place 263
Table 6.25(b): Respondents' motivation/reasons why the
practical/clinical sessions should be held in
these locations 264
Table 6.26{a): The percentage of respondents who preferred a
certain type/types or a comblnatlon of post-
graduate qualifications 265
Table 6.26{b): Other types of post-graduate qualifications that
respondents would like to obtain 266
Table 6.27(a): Respondents' awareness of post-graduate
opportunities in South Africa 268
Table 6.27(b): Respondents' views with regard to post-
graduate opportunities in South Africa which
fulfilled their needs 269
xviii
Table 6.27(c): Respondents' reasons as to wlhy post-graduate
opportunities in South Africa fulfilled their needs 270
Table 6.27(d): Respondents' reasons why post-graduate
opportunities onSouth Afroca did not fulfil
their needs 272
Table 6.28(a): Respondents' awareness of post-graduate studies
in other countries 273
Table 6.28(b): Respondents' views as to whether post-graduate
programmes onother countries fulfilled their
needs............................................................................... 274
Table 6.28(c): Respondents' views as to why post-graduate pro-
grammes in other countries fulfilled their needs 275
Table 6.28(d): Respondents' views as to why post-graduate
programmes onother countries did not fulfil their
needs 276
Table 6.29: Respondents' desore for international recoqnltlon
of South African programmes 277
Table 6.30(a): Respondents' preference with regard to tlhe
content of a post-graduate programme 284
Table 6.30(b): Other content suggestions with regard to post-
graduate programmes 286
Table 6.31: Respondents' recommendations on the duration
of a specialisation programme 288
Table 6.32: Respondents' preferred study mode 289
Table 6.33: Clinical/theory/research preference of the
respondents.... 291
Table 6.34: Preference for the inclusion of elective modules......... 292
Table 6.35(a): Responses to the broadening of scope of practice ..... 293
Table 6.35(1b): Respondents' reasons/motivation as.to why a post-
graduate programme should be aimed at broadening
the scope of practice 294
xix
Table 6.36(a): Respondents' detailed opinion 001title public's
needs regarding accessibility........................................ 300
Table 6.36(b): The respondents' detaued opinlon 001the public's
needs regardi01g affo rdability 302
Table 6.36(c): Respondents' detailed opinion 001 the public's
needs regarding equity ·· 304
Table 6.37(a): Respondents' detailed opinion on the public's
current needs regarding eye care with specific
reference to title management of ocular disease
in diabetes... 306
Table 6.37(1b): Respondents' detailed opinion 001 the public's
current needs regarding eye care with specific
reference to the management of ocular disease
in retinopathy 308
Table 6.37(c): Respondents' detailed opinion on the public's
current needs regarding eye care with specific
reference to the management of ocular disease
in glalLllcoma · 3~O
Table 6.37{d): Respondents' detailed opinion on the public's
current needs regarding eye care with specific
reference to the management of ocular disease in
cataract., 3~2
Table S.37(e): Respondents' detailed opinion on the public's
current needs regarding eye care with specific
reference to the management of ocular disease in
impaired (Iow) vision 3~4
Table S.38: Respondents' views on the role the optometrist
can play in the improvement of the standard
of care 316
Table 6.39: Respondents' view on the role post-graduate
education can play in eye care delivery and
standards 3~8
xx
Table 6.40(a): Respondents' perception of being part of the
community they served 320
Table 6.40(b): Respondents' reason/motivation why they saw
themselves as part of tlhe community they served 32~
Table 6.40{c): Respondents' reasons/motivation why they did not
see themselves as part of the community
they served ···........... 323
Table 6.41: Respondents' views on the role that the State should
play in the proviston of eye care.. 324
Table 6.42{a): Respondents' views/recommendations on the
number of optometrists that the State should
employ for the (whole) country 326
Table 6.42(b): Respondents' reasons for the recommended
number of State-employed optometrists 328
Table 6.43(a): Response to the suggestion of private/public
sector partnership to assist the State in addresslnq
the eye care needs in South Africa 330
Table 6.43(1b) Respondents' motivation for their beliefs that
the profession should develop a private/public
sector partnership to assist the State in addressing
the eye care needs of South Africans 331
Table 6.43(c): Respondents' motivation for their belief that the
profession should not develop a private/public
sector partnership to assist the State in addressing
the eye care needs of South Africans 333
Table 6.44(a): Responses to the introduction of compulsory
community service proposed for 2007.......................... 334
Table 6.44(b): Respondents' reasons why they were of the
opinion that compulsory community service is a
good idea. 336
xxi
Table 6.44(c): Respondents' reasons why they were of the opinion
that compulsory community service os not a good
idea 337
Table 6.44{c1): RespoB1ldell1ts'reasons why they were not sure
("Yes" and "No") as to whether 2007 (earmarked
for possible compulsory community service] was
a good Idea 339
Table 6.45: Respondents' views on the earlier implemen-
tation of' compulsory community servlee (earlier
than 2007) 340
Table 6.46(a): Responses to the suggestion that a National
Health Assurance Scheme is an option for
South Africa 341
Table 6.46(b): Respondents' motivation for the implementation
of a National Health Insurance Scheme in
South Africa... 342
Table 6.46(c): Respondents' motivation as to why a National
Health Insurance Scheme should not be
implemented onSouth Afll'ica.......................................... 344
Table 6.47(a): Responses to the question whether post-graduate
education would impact positively on the needs of
the public 345
Table 6.47{b): Respondents' reasons why a post-graduate edu-
cation would have a positive impact on the needs
of the pubiic..................................................................... 347
Table 6.47(c): Respondents' reasons why a post-graduate edu-
cation would not have a positive impact on the needs
of the public 349
xxii
usr Of IF~GURIES
Page
lFogure~.~: The diagram for the career ladder of the
optometrist. . ... . 8
Figure 2.~: Factors influencing the health care system
in South Africa and the eye care needs of the
South African populatioll1................. 27
Figure 2.2: Factors related to the transformation of
education and training.... 44
Figll,ue 3.~: The role of the GlO in post-graduate optometry
education in South! Africa (Master's level)......... 90
Fogure4.~: The relationship between the three com-
ponents of relevance ona CPO programme....... 139
Figure S.1: Graphic presentation of some of the aspects
of the main findings on Category ~: Personal
ill1lformatioll1l.................................................. 200
Figure 6.2: A graphic presentation of some of the aspects
of the main findings 0111 Category 2:
Professional development.......................... ... 238
fogure 6.3: A graphic presentation of some of the aspects
of the main findings 0811 Category 3:
Post-graduate/post-diploma studies............... 254
Figure 6.4: A graphic presentation of some of the aspects
of the main findings on Category 4:
Further studies to obtain a formal qualiflcation., 279
Figure S.5: A graphic presentation of some of the aspects
of the main findings on Category 5:
Detailed information on post-graduate/post-
diploma programmes..................................... 296
xxiii
Figure 6.6: A graphic presentation of some of the aspects
of the main findings on CategoD')'6:
Awareness of public need............................... 353
Figure 8.1: Polnts of departure witlh regard to the recommen-
dations on post-graduate education and tralnlnq. 400
lFigaJllJ8".e2: Role-players who influence recommendatlcns
with regard to optometric education and training. 404
Figure 8.3: A schematic OIIustration of the recommenda-
tions with regard to post-graduate optometric
education and training........ 409
figure 8.4: A proposed framework which can serve as a
point of departure for the development of post-
graduate education and training programmes in
optometl1)f..................................................... 473
xxiv
usr OF ACRO~YMS
ACOE Accreditation Council on Optometric Education
AHSCs Academic Health Service Complexes
ASCO Association of Schools and Colleges of Optometry
APL Acquired Prior Learning
CAS Certificate of Advanced Study
CCLRU Cornea and Contact Lens Research Unit
COE Continuing optometry education
CPD Continuing professional development
CRCERT Collaborative Research Centre for Eye Research and
Technology
CT Cape Technikon
DO Doctor of Optometry
DoE Department of Education
DoH Department of Health
DPAs Diagnostic pharmaceutical agents
EC European Community
ECOO European Council of Optometry and Optics
EEA European Economic Area
ETQAs Education and Training Quality Assurance bodies
FET Further education and training
GET General education and training
GlO Graduate Institute of Optometry
GOC General Optic Council
HET Higher education and training
HPCSA Health Professions Council of South Africa
IAPB International Agency for the Prevention of Blindness
MEDUNSA Medical University of South Africa
NEWENCO New England College of Optometry
NGOs Non-governmental organisations
NPPHCN National Progressive Primary Health Care Network
xxv
NQF National Qualifications Framework
NSBs National Standards Bodies
OAT Optometry Admission Test
OBET Outcomes-based education and training
OD Doctor of Optometry
OHTS Ocular Hypertension Treatment Study
00 Optometrists (previously Ophthalmic Optician)
PHC Primary health care
RAU Rand Afrikaans University
RPL Recognition of prior learning
RSA Republic of South Africa
SACOE The South African Council on Optometric Education
SADC Southern Africa Developing Countries
SAOA South African Optometric Association
SAQA South African Qualifications Authority
SERTEC Certifcation Council for Technikon Education
SGB Standards Generating Body
TPAs Therapeutic pharmaceutical agents
TWR Technikon Witwatersrand
UDW University of Durban-Westville
UFS University of the Free State
UK United Kingdom
UN IN University of the North
USA United States of America
UST University of Science and Technology
UWSO University of Waterloo School of Optometry
WCO World Council of Optometry
WHO World Health Organisation
lHE NEEDSAND OPPORlUN~l~ES fOR POSl~
GRADUAlE EDUCAr~ON AND lRA~N~NG
PROGRAMMES FOR THE OPTOMETRY
PROFESS~ON~NPOSr~APARTHE~DSOUTH AFR~CA
CHAPTER i
ORIENTATION TO THIESTUDY
1.1 INTRODUCTION AND BACKGROUND
It is an irrefutable fact that vision is a privilege which not everyone enjoys.
In some cases, permanent blindness is a fact of life which has to be
accepted, but in other cases something can be done about blindness and
related ocular complaints. That, in a nutshell, is the ultimate aim and
purpose of this study, namely to indicate that unnecessary suffering as far
as poor eye care and potentially blinding diseases are concerned, can
and should be eradicated.
In addition, "[g]ood health is basic to human welfare and a fundamental
objective of social and economic development" (The World Bank 1994: 1).
"Currently, the process of reevaluating our educational content
requirements in optometry seems particularly intense. Perhaps this is
related to our rapidly evolving scope of practice and legislative posture,
but other external pressures of societal reform, clinical innovation and
info-technology development certainly contribute to the process of
change" (Barker 1994:4).
2
One of the principles of the National Department of Health (DoH) set forth
in the White Paper for the Transformation of the Health System in South
Africa (RSA DoH 1997:38) is that education and training programmes
should be aimed at recruiting and developing personnel who are
competent to respond appropriately to the health needs of the people they
serve. Africa is considered the region in the world with the greatest need
for human resource development (RSA DoH 2000:33). Thus the time has
come for academic institutions to review their programmes in order to
adapt them and to make provision for the development of personnel who
can serve the health needs of the population better.
Currently higher education in South Africa, which includes education and
training for the health professions, is faced with many challenges. The
last decade of the previous century and the transition to a new millennium
involved some of the greatest political, socio-economic and technological
changes in the history of South Africa, in addition to creating new
opportunities and challenges for higher education internationally, as well
as in South Africa. Two of the major challenges are identified as:
o The need to ensure adequate access; and
e the need to maintain and enhance quality in both undergraduate and
post-graduate studies, as well as in research (Retief 1992:2).
In the education and training for health professions, many changes have
occurred. The focus has shifted from a hospital-based to a community-
based education and training with the emphasis 0':' primary care.
Institutions providing education and training are faced with a paradigm
shift from traditional content-based and teacher-centred methods to
outcomes-based and learner-centred methods and approaches (Harden,
Crosby & Davis 1999). Education and training now have to be delivered
within a programme-based, modular mode; diversification and access to
3
programmes have to be facilitated, while teaching and learning systems
have to be made more flexible to meet the criteria for qualifications laid
down by the South African Qualifications Authority (SAQA) (Strydom
1998).
As a result of the changes in higher education, including education for
health professions (among which count optometry education and training),
the changes in the socio-economic and political spheres in South Africa,
as well as the changing health needs of the population and international
trends in health sciences education and health care now demand of
institutions to reconsider the education and training professionals receive.
Institutions must ensure that programmes satisfy national and
international needs and demands. To ensure that programmes are on a
par with what the professional bodies overseeing and regulating the
professions require [with special reference to the optometry career ladder
(see Figure 1.1 on page 8) and continuing professional development
(CPO) to maintain competence], high quality programmes must be offered
and these programmes must be relevant to the needs of the people and
the times we live in. Apart from being relevant and applicable in South
Africa, programmes must also be comparable to what is offered elsewhere
in the world.
Optometry in South Africa developed from a British model based largely
on technical skills. As the profession developed world-wide, the accent
shifted to a biological model and education had to be adapted to address
the eye care needs of the broader society. In the apartheid era in South
Africa, these needs were mostly ignored, as whites dominated the
profession. At the same time there was little or no support from the Health
Policy, which excluded the profession from the public sector. Although
the medical profession enjoyed vast clinical opportunities afforded by the
disenfranchised groups, little was done to provide equity and quality in
4
health care delivery. The legacy of apartheid created marked differences
in health status, based on race (RSA DoH 1997: 123). This resulted in a
large number of blind people, mostly preventable, with cataract,
glaucoma, diabetic retinopathy and refractive errors being the major
contributing factors. Attention to these conditions, therefore, has become
extremely relevant, especially in Africa. In the quest to address these
problems, international affiliations need to be pursued in order to address
the unique needs of Africa at an internationally accepted standard.
1.2 RATIONALE Of THIS STUDY
The International Agency for the Prevention of Blindness (IAPB) was
established in 1975 as a co-ordinating umbrella organisation to lead an
international effort in mobilising resources for blindness prevention
activities. Its first major achievement was to promote the establishment of
a World Health Organisation (WHO) Programme for Prevention of
Blindness, with which it has remained strongly linked (IAPB s.a.a). The
Sixth General Assembly of the IAPB was held in Beijing, the People's
Republic of China, from 5-10 September 1999 (IAPB s.a.b). It was
attended by 600 participants and was a resounding success. The
scientific programme was structured to trigger off the Global Initiative for
the elimination of avoidable blindness by the year 2020 - Vision 2020 -
The Right to 'Sight (IAPB s.a.c.d).
The World Council of Optometry (WCO) has committed itself to expanding
the role of optometry in the global prevention of blindness activities. In
support of the WHO's Vision 2020: The Right to Sight campaign (IAPB
s.a.c.d), the weo drafted a resolution entitled the Global Vision Care
Campaign, which needs to be taken cognisance of in the education and
training of optometrists (Di Stefano 2001 ).
5
In essence, the rationale for reviewing the education and training
programmes of optometrists in South Africa can be found in this Global
Vision Care Campaign as expounded by Di Stefano (2001: 6-7). It reads
as follows:
'Recognizing the enormous burden that the loss of sight places on
the individuals, families and their communities, and affirming the World
Health Organization (WHO) global initiative for the elimination of
avoidable blindness by the year 2020; and
Affirming the challenges of health systems throughout the world
that have inadequate and unfairly distributed resources which threaten
to result in the potential doubling of blindness by 2020; and
Recognizing that the WHO VISION 2020: The Right to Sight
campaign offers an unprecedented opportunity. as a worldwide
partnership to marshal the resources and experience of a broad global
coalition of public and private nongovernmental organizations who are
dedicated to the shared goal of eliminating avoidable blindness by the
year 2020; and
Noting that there is an estimated 180 million individuals globally
who are visually impaired; that approximately 45 million are blind; that
9 out of 10 of the world's blind live in developing countries; and that 60
percent of these individuals live in India, China and sub-Saharan
Africa; and
Recognizing that a comprehensive program for the prevention of
blindness requires a community-based strategy that incorporates
attention to trachoma, blinding malnutrition, onchocerciasis, cataract,
ocular trauma, glaucoma, and diabetic retinopathy; and
Affirming the importance of expanding prevention of blindness
programs to include refractive errors and low vision, regocnizing that
uncorrected refractive errors are a significant source of avoidable
visual disability and functional blindness, especially in developing
6
countries; and that there are approximately 35 million persons needing
low vision services; and
Observing that a number of cost-effective models for the delivery of
vision care, which utilize new technologies and delivery paradigms,
offer the promise of significantly expanding access to vision care,
especially in underserved communities in both developed and
developing countries; and
Recognizing the value of mobilizing optometrists, ophthalmologists
and other types of vision care personnel; the critical importance of
forging strategic alliances among these professionals, their
organizations and the significant number of non-governmental
organizations working in the field of blindness prevention; and
Noting the global health challenge of addressing the significant
disparities in access to vision care, in both developed and developing
countries; and recognizing that APHA has addressed the issue of
"International Vision Care Cooperation" in complementary Resolution
8516, therefore
1. Recommends support of WHO's VISION 2020: the Right to Sight
global initiative for the elimination of avoidable blindness by
encouraging educational programs that increase awareness of the
broad societal impact of blindness and visual disability;
2. Suggests that eye care professional organizations promote
coordinated, primary care strategies that advance global
partnerships which transcend political boundaries and emphasize a
team approach;
3. Calls for targeted projects that address racial, ethnic and
geographic disparities in access to primary vision care'.
Of special importance as far as this study is concerned, is the first
recommendation cited above, namely that avoidable blindness should be
"eliminated by encouraging educational programs that increase
7
awareness of the broad societal impact of blindness and visual disability"
(Di Stefano 2001 :7).
Baldwin (1993:634) states that in many of the world's nations, optometry
hardly exists, because resources are neither sufficient to educate
optometrists, nor to fund their services. In others, tradition and co-
operation with other forces have rendered optometry incapable of change
that would expand its scope of services. In spite of this, however, in a
number of countries there is an accelerating trend towards the expansion
of education and the scope of practice. Baldwin (1993:634) furthermore
declares that "[o]ptometry is coming to be defined in those parts of the
globe as that independent primary health profession whose practitioners
are educated in vision and health sciences, and who meet standards that
qualify them to diagnose and treat visual problems and ocular disease".
Berman (1994: 15) states that optometry schools and colleges have as
their educational mission the responsibility of training students to become
primary eye care providers. This is a complex task and must be
undertaken in a manner consistent with changing societal and biomedical
variables, which include public policy; economic considerations;
technological advances; evolving health delivery systems; improved
understanding of disease management; and the public expectations of
quality vision care (Berman 1994: 15).
Yach and Tollman (1993:1048) maintain that the institutions providing
health professions education and training in the past have fallen far short
in providing the institutional backing and intellectual leadership so needed
to pioneer future directions in primary health care and community-based
health services. Baldwin (1993:634) states that the scope of the
optometric practice expands only after corresponding expansion in
optometric education. Thus far this goal of expanding optometry
8
education has been achieved only in a group of highly developed
countries in which optometry has long been an eye care provider, as well
as in countries in which socio-economic and political conditions are
improving, but where there is no significant source of tradition of primary
eye care of any scope (Baldwin 1993:634). The acceptance by the
Professional Board of Optometry of a career ladder in optometry in South
Africa opened the door for magister programmes, allowing practitioners to
develop clinical and speciality skills within the scope and parameters set
forth and regulated by the Professional Board for Optometry and
Dispensing Opticians. The accepted diagram for the career ladder for the
optometrist can be depicted as follows (Kriel 2001 a: 1-2):
FIGURE 1.1: THE DIAGRAM FOR THE CAREER lAIDDER OF THE
OPTOMETRIST
811
MaOpt:oma
(Certain Therapeutic privileges
and speciality skills)
B
sp'e~nsing
p.tlclan
The concept of the career ladder is founded in the principles of the
National Qualifications Framework (NQF). The main principle of horizontal
exits within vertical development is depicted here. The numbers 1 to 6
represent study years 1 to 6 of an integrated modular programme based
9
on outcomes. Besides certain primary core modules in the first two years
which mayor may not be shared with other professions in the health field,
the first recognised exit would be that of the dispensing optician after two
years of didactic exposure to acquire the National Diploma. These
candidates will need to complete a third or practical year.
The next exit is after year 4 when the Bachelor Degree or B. Tech.
Degree in Optometry is awarded. As from 2002 these graduates have
also enjoyed diagnostic privileges.
It is envisaged that the third exit will be a post-graduate diploma
representing certain therapeutic drug privileges, while the fourth exit, a
clinical Magister exit, will recognise certain speciality skills. It should be
noted that the Master's will effectively become Exit IV, as the post-
graduate diploma was developed after the original concept. However,
both "exits" were recognised by the Education Committee of the
Professional Board for Optometry and Dispensing Opticians. All the
above-mentioned qualifications are core to a Ph.D. at level 8 of the NQF.
In South Africa the National Prevention of Blindness Programme,
developed by the government, attempts to collate epidemiological data
I and implement a system by which these imbalances may be addressed.
l In the introduction to this programme (RSA DoH 2000:2), it is stated thatthe "current magnitude of visual disability in South Africa and its projected
exponential increase over the coming decades would have far-reaching
social, economic, and quality-of-life implications for affected individuals,
for their families, and for their communities". Such a disability is a barrier
to development. Within the eye team, the optometrist has been identified
as someone who, among others, should be able to diagnose and manage
all common eye diseases.
10
Although there are various areas in optometry education that are
inadequate, the area of diagnosis and management of ocular disease was
identified as a priority, measured against the immediate public need. The
Standards Generating Body (SGB) of the Professional Board will address
the shortfalls at undergraduate level; however, post-graduate education is
in need of renewal. Post-graduate programmes to date have been mainly
non-clinical, providing no vertical development opportunities in the
profession (RSA DoH 2000).
To develop clinical education and training beyond the bachelor's degree
within the career path of the optometrist, various courses have been
delivered in modular style. Among these certificate courses is the
Certificate of Advanced Study in ocular disease and pharmaceutical
application, offered by a United States of America (USA) institution.
South Africa has lost several practitioners due to the fact that further
studies have to be pursued in the United Kingdom (UK), the USA or
Australia. China provides an excellent example of what can be done in
this regard in a developing country. There an optometry training model is
used in which optometry students share their studies with medical
students for the first three years and only then do they specialise in
optometry (The New England College of Optometry Center for the
International Advancement of Optometry s.a.).
In South Africa, based on the current undergraduate training, there is a
need for a programme aimed at providing education and training to
learners in order to become competent to render a professional specialist
service in optometry and to contribute to the enhancement of the
discipline through research. Such a programme must afford professional
optometrists the opportunity to further their education and training in terms
of the optometry career ladder, and in the process gain certain therapeutic
privileges and acquire speciality skills. However, before a programme
11
with these aims can be developed, a needs analysis has to be done to
determine the needs and/or problems that should be addressed, namely
to identify gaps between current and desired outcomes; putting those
gaps or deficiencies in priority order; and developing strategies (the
programme that should be designed eventually) to rectify deficiencies and
bridge existing gaps.
1.3 STATEMENT OF THE PROBLlEM
The acceptance of a career ladder in optometry (see Figure 1.1) opened
the door for magister programmes, allowing practitioners to develop
clinical and speciality skills within the scope and parameters set forth and
regulated by the Professional Board for Optometry and Dispensing
Opticians.
The current magnitude of visual disability in South Africa, as well as its
projected exponential increase in coming decades, will have far-reaching
social, economic and quality-of-life implications for affected individuals,
their families and their communities. This is a barrier to development.
The knowledge and technology exist to make a difference to the lives of
thousands of South Africans. The elimination of avoidable blindness is
not only a social, but also a moral imperative (RSA DoH 2000:2).
The problem which was identified and addressed in this study, is that a
potential market of optometrists exists in South Africa. They wish to
pursue post-graduate studies; however, no suitable and clinical-relevant
programmes (opportunities) are offered to address their needs and to
afford them the opportunity to expand their scope and enhance their
knowledge and skills in order to make a more meaningful contribution to
the prevention of avoidable blindness in South Africa.
12
Blindness imposes a significant and largely unnecessary burden on
society, not only in terms of human suffering, but also financially (The
World Bank 1994). The economic burden of blindness in South Africa is
estimated at over 1 billion US$ per annum. According to the World Bank
(1994), blindness prevention interventions are among the most cost-
effective of all health interventions (RSA DoH 2000:3). As these
interventions lie at a speciality level, the training needs in post-graduate
optometry need to be investigated in order to identify possible solutions to
the public needs with regard to eye care and blindness prevention.
Consequently this study was undertaken, not only to obtain a better idea
of, but also to gain an insight with regard to the needs of and the
opportunities which exist for post-graduate education and training in
optometry in South Africa.
1.4 GOAL AND. OBJIECTIVES
The overall goal and objectives were outlined, namely to make a
contribution to eye care and the prevention of blindness, as well as to
make a meaningful contribution to education and training in optometry.
The aim was stated, namely to determine the needs of optometrists with
regard to optometric education and training and the opportunities existing
in South Africa, measured against the background of the needs of the
society (from the optometrists' perspective). Thereafter the objectives
were discussed, namely in the first place to enhance competence beyond
graduate level, thereby serving the eye care needs of the population of
South Africa in particular and of the whole of Africa in an indirect way
better. In the second place the objective was to make recommendations
concerning the delivery of relevant and applicable post-graduate studies
at Optometry Schools/Departments. All of these aspects were achieved
by conducting a literature study on optometry education and training in
order to collect information to serve as a background for the empirical
13
study, in addition to conducting an empirical study among optometrists by
means of a questionnaire survey to determine their needs in respect of
post-graduate studies, as well as obtaining the respondents' views
regarding existing opportunities in this regard (see Appendix C).
1.5 METHODS AND PROCEDURE
Research has been described as the "assumptions, techniques, methods
and procedures used to create knowledge by empirical and rational
means" (Sax 1979:355).
The study that was conducted can be described as a needs analysis (see
Appendix B: 1.7, 1.8). Needs analyses are not new in education - already
in 1975 English and Kaufman (in Wolmarans & Eksteen 1987: 1)
advocated a process "defining the ends of education, and then selecting
the means most promising to assist educators in reaching the 'promised
land"'. Inherent to a process of needs analysis are the following
procedures, namely gathering information regarding the nature, features
and scope of the problems; an analysis of the information, weighing up
various alternative options; and the choice of a justifiable strategy to
address the problems (Woimarans & Eksteen 1987:2).
This research took the form of a descriptive and an exploratory study as
described by Babbie and Mouton (2001 :304), comprising a literature
review and an empirical investigation. The literature study covered two
aspects, namely optometry education and training needs and possibilities,
as well as the eye care needs of populations, with special reference to the
South African situation. The empirical study entailed a questionnaire
survey carried out among optometry practitioners to determine what their
needs were in connection with post-graduate studies, as well as to
ascertain what possibilities are available in South Africa for post-graduate
14
studies in optometry. It should be noted that the target population for the
questionnaire did not comprise the total population of optometrists in
South Africa. The reason for this statement will be explained in 5.3 as
measured against the statement by Landman (1988:46). A quantitative
design was employed (cf. Babbie & Mouton 2001 :49-53). Open-ended
questions were, however, also included, giving this study a qualitative
dimension as well.
A comprehensive exposition of the methods and procedures which were
used with regard to the questionnaire and related aspects, is provided in
Chapter 5, entitled "Research Methodology". These aspects are briefly
touched upon here.
The questionnaire was compiled on the basis of the information gained
from the literature study. In addition, a pilot study was done to ensure
validity and reliability of the questionnaire (Landman 1988:80,96). With
regard to the pilot study, it has to be pointed out that a panel of three
experts - consisting of two optometrists and one educationist - were
consulted to obtain their expert opinion on the questionnaire. Points
which were taken into account were, for example, the following (cf. 5.3):
o The length of time it would take to complete the questionnaire, was
taken into consideration (i.e. 30 to 35 minutes or even 40 minutes in
the case of lengthy questions).
o The questions were tested against the criteria of being clear, easily
understandable and unambiguous.
o It was the aim of the researcher to make the format of the
questionnaire as user-friendly as possible (i.e. it had to be explicit,
accommodating and accessible). Respondents could either reply by
using electronic mail or they could return the questionnaires by
ordinary mail. Thus they were not restricted to a specific method.
15
The results were processed by the Department of Biostatistics of the
University of the Free State (UFS), while the open-ended questions were
processed manually and interpreted by the researcher. This report was
then drafted, containing the results of the survey, and recommendations
will be made here with regard to how the needs that have been identified
may be addressed, whether and how the possibilities that are available
can be built out, and how the need that exists for more opportunities can
be addressed in order to open the doors for optometrists for further
studies.
1.6 SIGNIFICANCE AND VALUE OF THE STUDY
In congruence with the WHO's Vision 2020: The Right to Sight (Di Stefano
2001) initiative and South Africa's Prevention of Blindness Programme
(RSA DoH 2000), educational programmes which increase awareness of
the broad societal impact of blindness and visual disability need to be
encouraged. The optometry profession faces new challenges, especially
in South Africa and in the whole of Africa. Taking note of the academic
challenges, optometric educators have to deal with issues such as
curricular enrichment, as well as opportunities for furthering knowledge
and skills in committing to a programme of educational reform and
renewal. The profession itself and optometry education and training are
undergoing significant changes, such as the expanding scope of practice;
advances in diagnostic and treatment methods; a new focus on primary
care; and the development of the optometry career ladder.
Against this background the needs of optometrists and the possibilities for
post-graduate studies in South Africa were identified, making it possible to
match these and determine the shortcomings that exist with regard to
possibilities for optometrists to reach the top of the career ladder of the
16
optometrist. As the Faculty of Health Sciences of the UFS already
registered a programme for a master's degree qualification in optometry
with the education authorities, the results of the study will play an
important role in addressing specific needs that were identified, as well as
to create opportunities that will be best suited to address the needs of
optometry post-graduate students, not only in pursuing formal post-
graduate studies, but also in ePD with a view to maintaining registration
with the professional board. In the final analysis, this study will ensure
that optometry post-graduate studies in South Africa will be embarked
upon in a scientific way and based on well-founded evidence. In this way
a relevant programme will be ensured. It will be recommended that this
study be followed up with a study aimed at developing the contents and
implementation, that is, a full curriculum, for such a Master's Programme
in Optometry.
Better education and training of optometrists - especially education and
training offered in South Africa based on and geared to the eye care
needs of the public - will make an important contribution to the well-being
of our broader population, especially that part of the population who
suffered negligence with regard to eye care in the apartheid era. The
whole of Africa, in fact, could benefit from the education and training of
optometrists who can help prevent blindness and make a contribution to
serving the eye care needs of the public better. Such education and
training will enhance the gatekeeper role of optometrists in the prevention
of blindness and will be to the economic advantage of the country.
This research product will, in addition, be able to serve as an important
reference document for education and training in optometry, especially
seen against the background of the fact that references and
documentation in the South African context are extremely limited.
17
1.7 SCOPE OF THE STUDY
This study was conducted within the field of Health Professions
Education. It is related to higher education and perspectives were gained
from that field of study as well. As the relevant health science for the
investigation is that of optometry, attention was paid to the demands made
on and the requirements of optometry education and training in South
Africa from the profession, as well as health care and higher education
authorities. International views and perspectives were taken cognisance
of too, as universities and technikons in South Africa educate and train
optometrists who must be acceptable internationally, as well as in South
Africa.
As this was a needs analysis to determine the needs of optometrists with
regard to post-graduate studies, as well as their opinion concerning the
needs and requirements of society as to eye care at a level that can only
be addressed by optometrists who have expanded their knowledge and
skills to a post-graduate level, the target population in the study was
limited to South African optometrists who had not as yet gained a clinical
and an applicable post-graduate degree-level qualification in optometry.
As reregistration is to become compulsory for optometrists in South Africa,
CPD with a view to maintaining an acceptable level of competence is also
linked and addressed briefly in this study.
It is recommended in this report that this study be followed by further
,
studies, designing a curriculum for post-graduate studies. Therefore, in
this study, the researcher concentrated on the needs which exist and the
opportunities which are already available to address these needs. It is
furthermore recommended that these needs and opportunities be
confirmed by a panel of experts according to the Delphi technique.
According to Clayton (1997:377), the Delphi technique is "a method which
18
is used to obtain the most reliable consensus of opinion of a group
through a series of intensive questionnaires interspersed with controlled
feedback". This method would therefore be eminently suitable, as the
opinion of a variety of experts all over South Africa would have been
obtained and their judgement determined (cf. Burns & Grove 1997:368).
Thereafter the next step will be the development of a Master's curriculum.
A model for attending to the needs falls outside the boundaries of the
current study, but recommendations in this regard will be made in
addition.
1.8 ARRANGEMENT OF THE DISSERTATION
In this chapter, Chapter 1, an orientation to the study has been provided;
the rationale behind the investigation has been explained; and the
problem which initiated the study has been elucidated. The goal and the
objectives of the study have been stated; the field that was covered has
been demarcated; and the methods of investigation have been briefly
discussed. The value which the study holds, is also pointed out.
Chapter 2 is a report of part of the literature study, namely the part that
deals with factors influencing the design of optometry education and
training programmes. The history of the optometry profession is related,
while the transformation of the health care system and the higher
education system, in which optometry education and training finds its
home in South Africa, is discussed.
In Chapter 3 the report of the literature study is continued, providing
information and perspectives on post-graduate optometry education and
training in South Africa, in Africa, as well as in some other countries.
Special attention is given to programmes that have been followed by
South African optometrists who wish to further their education and
19
training, in addition to the special needs these programmes address.
CPD in optometry comes under scrutiny in Chapter 4. CPD will play an
increasingly important role in optometry in South Africa in the future.
Therefore criteria for CPD programmes and the content of the
programmes are discussed, as well as the role these programmes can
and ought to play in improving eye care.
In Chapter 5 the research design, as well as the methods and techniques
followed, is explained. Theoretical aspects of research pertaining to this
study are discussed, a needs analysis as process is explained, and the
rationale for deciding on this method of investigation is provided. This
chapter contains a report of the course of the study and explains how the
data gathered by means of the questionnaire were processed.
In Chapter 6 the results of the study are reported and the data analysis,
as well as the findings of the investigation, is outlined and discussed.
In Chapter 7 a summative discussion of the study is provided.
In Chapter 8 recommendations on post-graduate optometric education in
South Africa are made. These recommendations are based on the
literature cited, as well as on the findings.
In Chapter 9 the conclusions are summarised and the limitations of the
study discussed.
1.9 CONCLUSION
Designing an education and training programme is a complex issue.
Increasing demands made on optometry as a health care service
20
necessitate the education and training of optometrists in South Africa to
be taken under scrutiny, especially in view of the dire need for more
specialist eye care in the efforts to eliminate preventable blindness in
Africa. The expansion of the scope of practice in optometry and the
career ladder which was accepted in South Africa for optometrists afford
them the opportunity not only to further their knowledge and skills, but
also to reach a level of specialist optometry services. Education and
training institutions thus have to respond to the needs of optometry
learners and develop programmes that will address the training needs of
optometry learners, especially with regard to post-graduate studies, where
specialist training finds its home. However, before such a programme can
be developed, the needs of optometrists regarding further education and
training need to be determined, as well as the opportunities that currently
exist in South Africa for such optometrists to satisfy these needs. The
study that is reported here was conducted with this in mind.
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CHAPTER 2
FACTORS INflUIENCING THIE DIESIGN Of OPTOMIETRY
!EDUCATION AND TRAINING PROGRAMMES
2.1 INTRODUCTION
As previously stated, change is one of the most noticeable and inevitable
characteristics of the new millennium. Furthermore, the whole world as
well as all aspects of daily life is subject to it. Health education and
training is no exception in this regard and thus it would be best to treat
these changes as challenges which have to be met in a straightforward
and unwavering manner while co-operating with others in the process of
learning. As already mentioned in Chapter 1, it is the aim of this study to
establish the needs that should be addressed in optometry education and
training in a time of change and new perspectives. In the process we
should, where applicable, follow the example of others to be successful
(cf. Kisil & Chaves 1995:13).
The importance of health care, not only in South Africa, but also world-
wide, is being increasingly emphasised. The reason for this is very aptly
l expressed in the words of Oswald (1996:37) when he states that,throughout the world, economic and political considerations are fuelling anactive, explicit and continuing debate concerning the purposes of health
care and the organisation of health care services. He adds that this
involves the identification of priorities for patients and services, as well as
a review of the competencies and attributes desired of those who are
trained in the health care sciences.
According to MacLeod (1996: 15), prominent trends in health care and
health profession education are characterised by specific changes, namely
a change from:
22
o independent decision-making to group decision-making;
o disciplinary isolation in education to interdisciplinary and
multiprofessional educational initiatives;
o physician-driven health care to multiprofessional balance;
o independence in care to co-operation and collaboration with multi-
disciplinary and multisectoral groups;
o specialist domination to a blended primary, secondary and tertiary care
team approach;
o primary institutional focus to a community-based balance;
o curative care to health promotion, as well as disease prevention; and
(il male dominance to gender equality.
South Africa does not exist in isolation, since the problems and challenges
which it experiences, resemble those of countries abroad. An example in
this regard is that, according to Olivier (1998:2), the critical outcomes
required in this country very closely resemble what is expected of
education and training in other countries. Health care practitioners will
require a number of specific enabling competencies and attributes if they
wish to remain effective and efficient. These they will already have to start
practising as undergraduates. According to Oswald (1996:39), these
characteristics are as follows:
o Being able to take responsibility for their own learning in order to
practise lifelong self-education.
o Possessing the skills to take advantage of sophisticated information
technology to ensure efficient updating of their knowledge.
Q Constantly re-evaluating their understanding, skills and attitudes, in
addition to having the characteristics of flexibility and self-awareness to
deal with choices and pressures.
o Possessing critical reasoning skills to evaluate evidence, as well as
being able to reject or accept solutions and suggestions.
23
o Being able to effectively operate as part of a team, as effective health
care depends on well-structured teams.
o Possessing a high level of communication skills; obtaining and giving
information; negotiating and counselling.
o A sound base in ethical decision-making. Without a firm grasp of
ethical principles, choices - far from being a liberating force - will lead
down paths towards inhumanity, inequality, irrationality and
exploitation.
Because of the continuous developments in the area of health care, a
constant evaluation of curricula is required to reflect the many changes
occurring in the philosophy, knowledge and practice of optometry.
In this chapter factors influencing the design of optometry education and
training programmes, as described in literature, will be taken under
scrutiny. The history of the optometry profession will also be attended to.
The transformation of the health care system in South Africa, as well as
the transformation of education and training in South Africa will be
discussed.
2.2 THE HISTORY OF THE DEVELOPMENT OF THE OPTOMETRY
PROFESSION
Baldwin (1992:634) paints the following picture with regard to the history of
the optometry profession: "Optometry's roots lie in sight testing and
delivery of spectacles. Competent performance of even these limited
functions requires skills and at least a rudimentary knowledge base.
Those who have also engaged in other pursuits - first astronomers, then
watchmakers, then physicians - from time to time have provided sight
testing and dispensing. However, only optometry can claim them
exclusively from their earliest application centuries ago. Independently
24
providing the means of improving visual acuity is the legacy that unites all
who call themselves optometrists today".
The history of optometry education has evolved as knowledge about vision
and its perceptual and multi system dependency are being discovered.
Initially most of this was technologically-driven as new spectacle and
contact lens materials and designs were placed on the market.
Applying new knowledge about products required little change to basic
undergraduate training, as background knowledge was adequate. New
technology also brought new non-invasive diagnostic instruments to the
workplace which required review of the ocular pathology knowledge base.
The regular interference with corneal physiology caused by the use of
contact lenses that can be worn for extended periods also required a
review of microbiology and ocular physiology.
As optometry found itself in a position where it had to educate patients on
an ever-increasing basis about pathophysiological changes in the eye and
the role of systemic disease, a new focus on the biological sciences and
various public health responsibilities became apparent.
This move into the eye health arena made optometry aware of the public
need for a health care professional that could see to routine eye
examinations and the management of various ocular abnormalities beyond
the supply of purely corrective devices only.
Today, areas of specialisation in the developed world exclude the
dispensing of spectacles as part of the daily task and certain universities
offer this subject as an elective. Optometry therefore almost came full
circle where the deregulation of the dispensing of spectacles is considered
with a new focus on the regulation of a new health care role.
25
The concept of visual acuity and refraction will be radically transformed in
the near future, as its measurement will become essentially objective and
not subjective. Similarly new technology will provide off the shelf and
surgical options for the correction of certain refractive errors.
These, as well as other technology-driven objective procedures, will entail
unique solutions for Africa's eye care problems and, because of its unique
background, optometry is placed in an ideal position to utilise these
advances in a new role as a health care provider as well as a public utility.
Although this study refers to post-apartheid South Africa, it is important to
note the history of optometry education in South Africa against the
background of the African continent. This aspect will be dealt with in the
next chapter (see 3.2.1).
It is interesting to note that European immigrants had introduced
optometry to Africa over several centuries and, by the early 1900s,
optometry was being practised in South Africa, as well as in a few
scattered African cities by European immigrants trained primarily in
England or Germany.
2.3 THE TRANSFORMATION OF THE HEALTH CARE SYSTEM IN
SOUTH AfRICA AND THE EYE CARE NEEDS OF THE SOUTH
AFRICAN POPULATION
2.3.1 lntroduction
The health of a nation is determined by many factors. Demographic,
socio-economic and environmental factors interact with individual
behaviour and health service interventions to result in a particular health
profile (Bradshaw 1997:s.p.). Health surveys carried out in South Africa
revealed numerous health problems (cf. RSA DoH 1999; Bradshaw 1997).
26
While attempts to extend basic primary care to all who need it will be
particularly important in the pursuance of the goal of the WHO's Health for
all in the 21st century, a more comprehensive approach, including more
preventive and health promotion initiatives, is needed in South Africa.
One of the initiatives for better eye care in South Africa is the Prevention of
Blindness Programme (RSA DoH 2000), which puts the focus on the
Vision 2020: The Right to Sight Campaign of the WHO (lAPS s.a.c,d).
The new millennium indeed brought many new initiatives and opportunities
to facilitate the development and enhancement of eye and vision care
world-wide. Two trends which have emerged nationally and internationally
with a notable impact on health policies and health care delivery, are the
primary health care approach and the community-based approach.
The above and other related factors influencing the health care system in
South Africa and the eye care needs of the South African population are
schematically presented in Figure 2.1.
,
FIGURE 2.1: FACTORS INFLUENCING THE HEALTH CARE SYSTEM IN SOUTH AFRICA AND THE EYE CARE
NEEDS OF THE SOUTH AFRICAN POPULATION
POLICY AND LEGISLATION
• The Reconstruction and Development Programme:
A Policy Framework (ANC 1994)
• White Paper for the Transformation of the Health
ROLE-PLAYERS System (RSADoH 1997) NATIONAL AND
INTERNATIONAL
• National Prevention of Blindness Programme (RSA PERSPECTIVES
DoH2000) N
-..j
• Etc.
; Medical Research ecunou
;. ~PSS/\ (formerly The Medical and
8::::-:!~~Council of SA)
• SAOA
• SACOE
28
2.3.2 National and international perspectives
The National Progressive Primary Health Care Network (NPPHCN) was
instrumental in putting health and related issues on the agenda for the first
democratic elections in South Africa in 1994. When the present
government came into power in 1994, these obstacles were addressed
and a set of policy objectives and principles to address the needs of all the
people of South Africa were drawn up on which the Unified National Health
System of South Africa was based (ANC 1994:43).
In 1997 the White Paper for the Transformation of the Health System of
South Africa was published by the Ministry of Health (RSA DoH 1997).
The object of the White Paper was said to be the presentation of a set of
objectives and principles upon which a unified national health system
could be built (RSA DoH 1997:2).
In the above-mentioned document it is stated, inter alia, that Academic
Health Service Complexes (AHSCs) are essential national resources, as
they play "an important role in educating and training health care workers;
caring for the ill; creating new knowledge; developing and assessing new
technologies and protocols; evaluating new drugs and drug usage; and
assisting in the monitoring and improvement of health care quality" (RSA
DoH 1997:91).
A number of principles as set out in the White Paper were adopted with a
view to enhancing the role of AHSCs in the development of health care in
South Africa (RSA DoH 1997:94). One of these is the principle which
states that "[t]he curricula of AHSCs will be revised to place greater
emphasis on the needs of the communities, in accordance with primary
health care principles" (RSA DoH 1997:94).
29
It becomes clear from this White Paper (RSA DoH 1997) that the main aim
of health promotion is to improve the health of all South Africans through
creating a social, political, economic and physical environment which helps
to make health choices easy. In its mission statement for the health
system of South Africa the following is stated by the Ministry of Health:
"To provide leadership and guidance to the National Health System in its
efforts to promote and monitor the health of all people in South Africa, and
to provide caring and effective services through a primary health care
approach" (RSA DoH 1997:13). It is further stated in. this White Paper
(RSA DoH 1997:94) that the types and numbers of graduate students
required in health professions; the appropriateness of their training; and
the extent of continuing education required should be established. It is in
respect of this goal of the health authorities that this research can, inter
alia, make a meaningful contribution.
In restructuring the health system of South Africa, the following goals were
set (RSA DoH 1997:7):
e To unify fragmented health services at all levels into a comprehensive
and integrated national health system;
o to promote equity, accessibility and utilisation of health services;
o to extend the availability and to ensure the appropriateness of health
services;
o to develop health promotion activities;
o to develop the human resources available to the health sector;
o to foster community participation across the health sector; and
o to improve health sector planning and the monitoring of health status
and services.
Poor health has a powerful effect on a region's economic progress.
According to The World Bank (1994: 1), productivity in some countries in
Africa could increase by up to 15% were illness and disability attacked
30
more strenuously. The harsh realities and desperate need for better eye
care are underscored by the following facts:
o 45 million people suffer from blindness.
o 180 million people have visual disabilities.
o 500 000 children go blind every year.
o 150 million people are afflicted with trachoma (Padilla 2000: 10).
Tens of millions of people around the world are classified as blind. They
can have their vision restored to the point where they could function and
lead productive lives ... with the help of optometry. The challenge to
optometry is to create an environment where optometric services reach
those in need wherever they are (Brisbin 2001 :3).
Two major initiatives in optometry in South Africa and elsewhere need to
be discussed here:
2.3.2.1 Vision 2020 - The Right to Sight
"Every five seconds one person in our world goes blind ...
and a child goes blind every minute" (IAPB s.a.d: 1 of 21).
In the Vision 2020 - Right to Sight Campaign document the following facts
about world blindness are supplied:
e An estimated 45 million people world-wide are blind.
e;) Every year, an additional one to two million people go blind.
ct More than two-thirds of this blindness is treatable and preventable.
Q A majority of the blind live in the poorest sections of the developing
world.
e Without proper intervention, the number of blind will increase to 75
million by 2020.
31
o Restoration of sight is one of the top most cost-effective interventions
in health care (IAPB s.a.d: 1 of 21).
Vision 2020 is a world-wide concerted effort designed to eliminate
avoidable blindness by the year 2020. This initiative was launched jointly
by the WHO and 20 international non-governmental organisations (NGOs)
involved in eye care and the prevention and management of blindness.
The programme is aimed at enabling all parties and organisations involved
in combating blindness to work in a focused and co-ordinated way to
achieve the common goal of eliminating preventable and treatable
blindness. Over the next two decades the programme will be taking steps
to prevent an estimated 100 million people from becoming blind (IAPB
S.a.c:1 of 8).
Vision 2020, in conjunction with the Global Initiative for the Elimination of
Avoidable Blindness of the WHO, is taking on the following responsibilities:
o To increase the awareness of blindness as a major public health issue.
o To control the major causes of blindness.
o To train ophthalmologists and other eye care personnel to provide
appropriate eye care.
o To create an infrastructure to manage the problem (IAPB s.a.c:1 of 8).
In its efforts to face these responsibilities, Vision 2020 focuses on creating
adequate eye care facilities, particularly in underprivileged areas, creating
a foundation of well-trained eye care workers, in addition to implementing
specific programmes to control the major causes of blindness (IAPB
s.a.d: 1 of 21).
The challenge which Vision 2020 faces, entails the fact that there are
nearly 45 million blind people and 135 million with low vision, comprising a
total of nearly 180 million people with some degree of visual impairment.
32
Blindness has an enormous personal, social and economic impact, limiting
the education and life choices of otherwise healthy people. Furthermore it
places a significant burden on families, communities, as well as social and
health services. Blindness is also associated with a lower life expectancy.
The direct global economic burden of blindness is estimated at US$25
billion and this figure could double or triple if the indirect costs are
considered (IAPB S.a.c: 1 of 8).
Ninety percent of the world's blind live in developing countries. In India
there are at least nine million blind people, six million in China and seven
million in Africa. This is indicative of the fact that people who live in
developing countries are ten times more likely to go blind than people who
live in the highly industrialised countries.
In this bleak picture the one ray of hope is that 80% of the world's
blindness is avoidable, and that treatments available for the prevention
and cure of blindness are among the most successful and cost-effective of
all health interventions (IAPB s.a.c:1 of 8). Specific activities on which the
initiative will concentrate, include intensified surgical interventions for
cataract, which - at present - accounts for half of all blindness; the
provision of spectacles, especially for school children; and the prevention
and treatment of nutritional deficiencies that lead to blindness in children
(IAPB s.a.d: 1 of 21).
2.3.2.2 TheNational Prevention of Blindness Campaign (Policy)
The South African National Prevention of Blindness Programme was
established in 1998. It was a development which resulted from the
National Cataract Programme. The Bureau for the Prevention of
Blindness (established in 1944) is a component of the South African
National Council for the Blind and has the task of taking eye care to rural
and underserved areas in the country. In 1994 the Bureau for the
33
Prevention of Blindness recognised the need for a national eye care plan.
A working group was established, comprising representatives from the
Department of Health, health professions and NGOs involved in eye care.
Based on recommendations made by the working group, the National
Cataract Programme was established in 1995. The programme was
operational till 1998, when it was agreed that the National Cataract
Programme should be expanded to become the National Blindness
Prevention Programme (RSA DoH 2000:2).
The National Prevention of Blindness Programme falls under the auspices
of the Directorate of Chronic Diseases, Disabilities and Geriatrics of the
National Department of Health in South Africa. This programme is a
component of the Vision 2020 programme of the WHO and is committed to
the elimination of avoidable blindness in South Africa by 2020. The aims
of the National Prevention of Blindness programme are the following:
o To provide support to Provincial Departments of Health and the
Southern Africa Developing Countries (SADC) in their prevention of
blindness programmes.
o To co-ordinate prevention of blindness programmes in South Africa.
o To protect and promote the rights of blind persons.
o To reduce the prevalence of blindness in the country from 0.75% to
0.50% by the year 2005 (RSA DoH 2000:5).
Among the resources required for this plan to be carried out successfully,
the following were identified:
CD Primary care level: At least one clinic nurse at each clinic or community
health centre trained in primary eye care.
e Secondary care level: At least one ophthalmic nurse per 100000 of the
population. One optometrist per 250 000 of the population.
34
o Tertiary care level: One ophthalmologisUophthalmic medical officer per
one million of the population (RSA DoH 2000:5).
In concurrence with the aims of the National Prevention of Blindness
Programme, the National DoH (RSA DoH 2000:5-6) stated that provincial
programmes should pursue the following aims:
o The provision of immediate access to primary eye care in the health
care clinics and community health centres.
o The provision of referral access to secondary and tertiary care.
I!) A reduction in the prevalence of blindness from 0.75% to 0.50% by the
year 2005.
Cataract surgery should be seen as the main thrust of the programme, and
other focus areas are glaucoma, childhood blindness, diabetic retinopathy,
and refractive errors and low vision.
The prevention of blindness will be addressed at four levels:
o Primary prevention consists of measures to prevent diseases, injuries,
or conditions which may result in complications, impairments or
disabilities. Such measures include health education, immunisation,
maternal and child health services, as well as safety promotion.
Prevention of corneal scarring from malnutrition, infection and trauma
is an important primary prevention activity in blindness prevention in
South Africa.
o Secondary prevention consists of early identification and intervention in
the treatment of diseases, injuries or conditions to prevent the
development of complications or impairments. Early detection and
treatment of diseases/conditions and injuries may prevent
complications, impairments and blindness. Glaucoma is a good
example.
35
o Tertiary prevention consists of measures to limit or reduce impairments
or disabilities. Cataract surgery is an important tertiary prevention
activity in blindness prevention in South Africa.
o Quaternary prevention consists of measurements to reduce the effect
of untreatable disease or disability. Blindness rehabilitation is an
important quaternary prevention activity in blindness prevention in
South Africa.
2.3.3 Primary health care (PHC)
World-wide a primary health care (PHC) philosophy has been developed
since the WHO stipulated in 1977 that governments should aim at
attaining an acceptable level of health for all their citizens in the Health for
all by 2000 declaration (WHO 1978). In South Africa this philosophy has
resulted in emancipated, pro-active legislation (RSA DoH 1997).
A PHC approach extends beyond the narrow, clinical sense of the term; it
is more than medicine. The impetus of the primary care movement partly
springs from the humanistic wish for access to, and continuity of care for
all, and partly from a pragmatic reality (Miller 1983: 1). PHC is defined
differently by different people, while primary care sites vary widely in
philosophy, organisation, as well as with regard to the health provider
roles. Thus there is no one primary care model (Miller 1983:6).
To explore the question: "What is primary care?" several perspectives
must be taken into account. Within society many different systems are
involved in activities directly affecting the health of people. Aspects such
as road and city planning, educational and welfare programmes,
agriculture and energy resources are all inextricably bound to the health
and disease status of individuals and groups (Parker 1974: 17). Certain
organisations and personpower configurations, however, combine to form
a health care system of a community, each with its own or a variety of
36
tasks and responsibilities. These subgroups are concerned with matters
such as planning or activities to protect people from hazards in the
environment, whilst others may be geared to educational and promotive
approaches to medicine and health care (Parker 1974: 18).
Personal health care is the most visible of these sub-groupings. In
general, personal health care can be divided into three functional levels,
namely a promary level, where basic services are rendered; a secondary
level, where ambulatory services of a specialised nature are rendered; and
the tertiary level, where highly complex and sophisticated services are
rendered in an institution. According to Parker (1974:18), this three-level
model of personal health care, although not a perfect fit in every respect,
may still be helpful in conceptually differentiating levels of care and can be
applied to divergent situations. This model is said to work so consistently,
because each level is natural, relating to the nature of health conditions,
health problems, and disease states to which every individual is subject
(Parker 1974: 18).
This model can also serve as a useful framework in defining the role of the
optometrist in the community and in designing outcomes for the present
situation in South Africa, once the needs to be addressed have been
established.
In order to achieve effective primary health care, it is said that the curricula
of AHSCs will have to be revised to place greater emphasis on the needs
of the communities, in accordance with primary health care principles
(RSA DoH 1997:94). Needs thus have to be defined and curricula should
be reviewed and adapted accordingly.
In the Government Gazette No. 17910 (RSA DoH 1997:13) it is stated
that: " ... health teams and workers at all levels should develop a caring
ethos and commit themselves to the improvement of the health status of
37
their communities. They should not only be responsible for the patients
who attend their facilities, but also have a sense of responsibility towards
the majority of the population in their catchment areas". This statement
puts a responsibility on training institutions to adapt their curricula to
ensure that they train students in accordance with these principles and
also to make sure that they come up to these expectations in the services
they render.
The aim of health promotion is to improve the health of all the people of
the country through creating a social, political, economic and physical
environment which is conducive to health. To achieve this, the following
objectives need to be pursued:
Q "To contribute to the development and achievement of a healthy nation,
national health goals and targets;
o to promote standards of excellence in health promotion practice,
drawing on both international and local experience;
e to promote and develop health promotion activity in government and
civil society; and
o to develop a skilled cadre of health promoters" (RSA DoH 1997: 108).
According to the DoH (RSA DoH 1997: 107), health promotion in South
Africa will be developed in accordance with the principles which underpin
the WHO's movement of Health for all in the 21st century, namely:
o "Equity: everyone should have similar opportunities to health and,
therefore, certain target groups will have to be prioritised, e.g. low-
income families, rural people and women.
o Empowerment and respect: health promotion activities should be
designed to increase and enhance the control that communities and
individuals have over their own health - in the process, traditional
values and beliefs will be respected.
38
o Participation: communities and individuals will be involved as respected
partners in the planning and implementation of health promotion
programmes.
o Intersectoral activity: multidisciplinary, inter-agency collaboration will be
undertaken wherever relevant and possible.
o Standards of practice: the highest standards of practice, incorporating
the above principles and based upon researched needs and adequate
evaluation, will be encouraged".
2.3.4 Statutory and professional aspects
In discussing the factors influencing education and training programmes in
health care, as well as in an effort to determine the needs and
opportunities that exist in South Africa for the education and training of
optometrists, the role of statutory and professional bodies should be
attended to, as health professionals have to register with these bodies and
therefore have to meet their requirements.
2.3.4.1 The Health Professions Council of South Africa
(HPCSA)
The Health Professions Council of South Africa (HPCSA), formerly the
Medical and Dental Council of South Africa, is a statutory body which has
continued the activities of the former health sciences councils of the
Republic and formerly independent Ciskei and Transkei. In addition, the
HPCSA regulates the health professions, including optometry, in South
Africa.
,, .
According to The Interim Medical and Dental Council of SA (1995:1-2), the
aims of the Council are as follows:
e "to assist in the promotion of health of the population of the Republic;
39
o to control and administer all matters in connection with the training of
persons in, and the methods of putting into practice this training, as
regards the diagnosis, treatment or prevention of physical or mental
defects, diseases or deficiencies in the human being;
o to promote liaison in the field of training in the Republic as well as
elsewhere, and to improve the standards of such training; and
o to advise the Minister on statutory amendments to support the
universal norms and values of the medical profession, with greater
emphasis on professional practice, democracy, transparency, equity,
accessibility and community involvement".
The function of the Council which is especially pertinent to this study in
optometry education and training, is the one which states:
o "Recognition of professional qualifications - Educationally the work
of the Council and the boards encompass the recognition of
qualifications for registration, laying down of minimum standards of
training, inspection of training, and conducting certain examinations"
(The Interim Medical and Dental Council of SA 1995:2).
As the Council regulates the profession, it also regulates, by implication,
education and training for the profession. It is clearly stated in its
documents that no person or educational institution may offer training to
qualify a person to be registered with the Council in any category unless
such training is approved by the Council (The Interim Medical and Dental
Council of SA 1995:3).
The compilation of new programmes, therefore, is not monitored by the
Council, but the Council will have to recognise the final professional
qualifications and approve the training courses (programmes) in order for
qualified optometrists to be able to register with the Council (The Interim
Medical and Dental Council of SA 1995:2).
40
2.3.4.2 The South African Optometric Association (SAOA)
On 31 March 1924 the South African Optometric Association (SAOA) was
founded by a group of 13 opticians in the boardroom of the Scientific and
Technical Club, Johannesburg. Initially it was known as The South African
Optical Association with its main action for the furtherance of the Optical
Profession in South Africa. According to Hamilton (1934: 18), "[t]he last
meeting of 1924 was held in August and through a gross
misunderstanding based on an accusation that the Association was
formed to make a ring in prices, the Association went into recess, and
consequently the minutes of that memorable August meeting in 1924 were
only passed as read on the fourteenth day of April, 1926".
In 1927 legal opinion confirmed that opticians were "considered to be
professional men". This opinion was requested as the Medical, Dental and
Pharmacy Bill served before Parliament at the time and in an interview
with the Medical and Dental Association, the Optical Association was
informed that Opticians were "left out of the controversy over this Bill". It
was not until 1974 that the profession was officially recognised in the
health legislation of South Africa. In July 1928, the SAOA became one of
the 25 founding members of the International Optical League, later to
become the World Council of Optometry or the WCO. In its 2001 review of
the constitution, the SAOA redefined what it stands for in the following
objectives:
o Representing optometrists with authority and credibility in all
matters concerning their interests in the health care arena.
o Promoting the integrity and image of the optometric profession.
o Providing optometrists with knowledge relevant to the demands of
their practice.
41
o Setting the minimum standards for the profession such as
qualifications, adherence to ethical standards, alignment to world
health standards and attendance of CPD programmes.
o Promoting education, research and academic excellence.
o Influencing the eye care environment to meet the needs and
expectations of the community by promoting improvements to
health care policy and legislation.
o Encouraging involvement in eye care promotion and education.
o Promoting trust, integrity, professional conduct efficiency and
goodwill within the profession.
o To support, improve and protect the status, rights, privileges and
interests of all members.
o To lobby the Government, the Council, and any relevant body for
the professions represented by the Association.
o To make and enforce ethical rules, regulations and By-Laws, while
attempting to resolve amicably issues between and among
members and the public via the Ombudsmen and the Disciplinary
Committee.
o To facilitate in the maintenance of standards of practice by
members to the public via CPD.
o To judiciously use all subscriptions, entrance fees, levies and
donations for the pursuance of the aims and objectives of the
Association, while also using funds entrusted for the furtherance of
Optometry by way of bursaries, research grants and subsidies.
o To be the guardian of the codes and tariff guidelines for members,
setting out the practice guidelines in all fields of practice.
42
o To strive to assist members in their ability to provide the
professional services to the public by way of projects and initiatives
that are co-ordinated nationally and marketed via the Association.
o To disseminate information to members in order to keep them up to
date with the latest developments in our industry.
o To act in an advisory capacity regarding member concerns and
requests where possible (SAOA 2000:1 of 2).
Today, the Association still enjoys vast support from the profession, as
some 80% of optometrists are members.
2.3.4.3 The South African Council on Optometric Education
(SACOE)
As the SAOA was initially responsible for optometric education in South
Africa, the Professional Board for Optometry relied on the education
committee of the SAOA for its educational input. This became an
increasingly cumbersome process when other institutions started
programmes and were not obliged to offer the SAOA external examination
in order to qualify students for entry into the profession. Representation on
this committee was a further problem and the committee started operating
as The Society of Optometric Educators so as to accommodate all role-
players in the field. This, however, proved to be too informal by its ad hoc
nature and the Board found itself again lacking input from the educators.
By 1996 an education committee was formed as a substructure of the
Board with representatives from all the institutions and private
practitioners.
The need for institutions to share a common forum remained, however,
and in January 1997 the SACOE was established, adopting the
constitution of the SAOA as a eo-opted education committee. Initial
43
meetings were well attended, but as the education committee of the Board
started to deliver results and became part of the regulatory process,
interest waned and today hardly any meetings are organised under the
SACOE banner.
Annual meetings of the African Optometric Educators are organised
directly between institutions and the SAOA may participate by sending a
representative. It is also this group that will from a subcommittee of the
WCO, based in Philidelphia.
2.4 THE TRANSFORMATION OIFEDUCATION AND TRAINING IN
SOUTH AIFRICA
2.4.1 Introduction
There are various factors related to the transformation of education and
training in general and of optometry in particular. In the next section these
factors will be discussed. First, however, a schematic presentation of
these factors will be provided in Figure 2.2:
FIGURE 2.2: FACTORS RELATED TO THE TRANSFORMATION OF EDUCATION AND TRAINING
POLICY AND LEGISLATION TRANSFORMATION OF EDUCATION AND TRAINING BODIES WHICH
NEPI (1992) • Programme-based approach influencing education
I' INFLUENCE
EDUCATION AND
Health Professions Act (RSA 1974) and training
• OBET outcomes TRAININGSAQA Act (RSA 1995) I
Education and Training V\lhite Paper Critical (essential) outcomes
(RSA DoE 1995) Specific outcomes • The DoE
NCHE Report (1996) - Career or vocational outcomes
I • The DoH
• SAQAandtheNQF
NQF Bill (SAQA 1997) Learning outcomes (knowledge and
V\lhite Paper for the Transformation of understanding; doing skills; attitudes and values) • NSBs
~
~
the Health System (RSA DoH 1997) • Establishment of the NQF resulting from SAQA • ETQAs
Draft White Paper on Higher Education legislation • TheNCHEI'
(RSA DoE 1997a) - Objectives • TheWHO
V\lhite Paper 3 on Higher Education _ Principles outlining specifications of qualifications • Etc.
Transformation (RSA DoE 1997c) _ Three major challenges facing SA higher education
Higher Education Act (RSA 1997) • Educational strategies for health sciences education
Green Paper on Further Education and - SPICES model (student-centred strategy;
Training (RSA DoE 1998) problem-based learning; integrated approach;
Regulations under the SAQA Act (Act community-based approach; elective strategy;
58 of 1995) (RSA 1998) systematically structured)
Etc. • Etc.
~-;;.;- --=,;;-~..,..::::.----::;.:::-::o~~~-~-~-~ ~';""".-"",:<""~--:=-,-: c_ ~~. "i.z, _ ~.~~-~-'!
45
2.4.2 The roles of the Department of Health (DoH) and of the
Department of Education (DoE)
It is difficult to decide which of these two Departments plays a more
prominent role in the health professions. Suffice to say that one
complements the other and that neither can exist and be meaningful
without the other. In a sense, they are therefore two sides of the same
COin.
"South Africa's transition from minority rule and apartheid to a
democratically elected government requires that all existing practices,
institutions, and values are viewed anew and rethought in terms of their
fitness for the new era. Higher education is a vitally important activity in
modern society. In South Africa today the challenge is to ensure that it
can succeed in stimulating, directing and using the creative and intellectual
energies of the entire population" (RSA DoE 1997a:9). It is essential to
mention, inter alia, a number of challenges and principles for higher
education as proposed in the Draft White Paper on Higher Education (RSA
DoE 1997a:9-14), namely that higher education needs to become more
responsive to societal needs and interests; institutions should become
more innovative in their teaching, research and delivery of services; and
conditions must be created to facilitate the adaptation and improvement of
higher education to enable it to contribute to the common good of society
through the production and application of knowledge, the building of
human capacity, and the provision of lifelong learning opportunities.
The Draft White Paper on Higher Education (RSA DoE 1997a) puts
forward certain conditions and requirements of the Department of
Education (DoE) which can be reached by means of curricula or
educational programmes. Developing or reviewing curricula is an
important aspect and - according to Lubisi, Wedekind, Parker and Guitig
46
(1997:7) - the following features should be attended to when curricula are
dealt with:
o Mutual respect for diverse religious and value systems, cultural and
language traditions.
o Multilingualism and informed choices regarding the language of
learning.
o Co-operation, civic responsibility and the ability to participate in all
aspects of society.
e An understanding of national, provincial, local and regional
developmental needs.
In a chapter on Human Resources in the South African Health Review
(Van Niekerk & Sanders 1997:s.a.), it is clearly stated that one of the main
issues in the health care policy is about where the responsibility for
training health care practitioners should reside - in the DoH, in the DoE, in
the Professional Council, or in a combination of these and other
stakeholders. SAQA has the statutory responsibility for determining all
standards in the education sector, including health sciences education.
As the education system in South Africa has undergone major changes in
recent times, it is clear now that it has become essential for education
institutions to adapt their curricula to ensure that they stay in line with
developments and satisfy requirements and guidelines.
2.4.3 A programme-based approach in education and training
Act 101 of 1997 - the now well-known Act on Higher Education (RSA
1997) - is asserted to be the end product of in-depth reflections,
arguments and discussions, as well as the ideas and inputs of a variety of
stakeholders in and experts on higher education in the RSA, in addition to
those of experts from other countries (Steyn 1999:3). Two sentences in
47
the preface to the Bill (RSA DoE 1997b:2) have specific relevance here. It
is stated that it is:
" ... desirable to:
establish a single, co-ordinated higher education system, which
promotes co-operative governance and provides for programme-
based higher education;
restructure and transform programmes and institutions to respond
better to the human resource and economic needs of the Republic
of South Africa".
This Act was preceded by the White Paper 3 on Higher Education
Transformation (RSA DoE 1997c) in which the challenges awaiting higher
education were listed. The White Paper stipulates the following: "The
programme-based approach, through ensuring greater articulation
between the different tiers in the higher education system, promoting
flexibility and diversification in the range of programmes offered and
fostering co-operation between institutions will result in structural changes
and a reconfiguration of the institutional landscape ..." (RSA DoE 1997a:
18).
According to Steyn (1999:4), the rationale for a programme-based
approach includes, inter alia, enhancing the meaning and coherence of the
training; countering content overload; eliminating unplanned overlapping
between subjects and courses; including fundamental, core and elective
modules, thereby promoting - among other things - lifelong learning skills;
indicating articulation with other programmes; equipping the learner for an
interwoven reality, i.e. the principle of the world being a set of interrelated
systems in which problem-solving contexts do not exist in isolation; and
staff members developing an entrepreneurial and team approach.
SAQA clearly outlines the six programme elements which should be
attended to, namely:
48
o Curriculum specialisation in one or more of the 12 organising fields.
o A planned combination of critical and specific outcomes.
o A demonstration of applied competence in learners.
o A basis for further learning, with the incorporation of credits as well as
entry and exit opportunities.
o Added value in terms of personal enrichment, provision of status,
recognition, enhancement of marketability, and employability.
o Advantages added to the community and economy - delivery of high-
level person-power, increased productivity and addressing inequalities
(SAQA 1997:15).
The modules in a programme have different functions in each learning
programme. Modules may contain fundamental, core or elective learning.
Fundamental learning is aimed at basic or generic (critical cross-field)
outcomes; core learning is aimed at the competencies which constitute the
core of the qualification, that is, the learning which is compulsory in
situations contextually relevant to the particular qualification; and electives
are selected additional credits at the specified level to ensure that the
purpose of the qualification is achieved. The idea of specialisation can
also be brought in here with competencies related to specialised areas, or
else competencies that broaden the core (RSA DoE 1998:39).
In a programme-based curriculum the academic disciplines are not taught
and learned because they form part of the scientific structure, but because
they facilitate specific learning outcomes which contribute to achieving the
outcomes of the programme. Concepts, theories, methods and knowledge
structures fulfil an instrumental role in realising specific competencies, and
are imbedded in such learning outcomes. Steyn (1999:8) states that
knowledge, skills and values/attitudes are an integrated part of the applied
competence.
49
The UFS accepted a programme-based, outcomes-based approach to
curriculum development (Steyn 1999:9). Therefore, as this research is
aimed at determining the needs to be addressed in an optometry
education and training programme, the philosophy underlying programme-
based and outcomes-based education and training needs to be attended
to.
2.4.4 Outcomes-based education and training (OBET)
In accordance with the regulations of the SAQA Act (Act 58 of 1995) (RSA
1995), education and training programmes should be outcomes-based.
Although it has been said that the movement to outcomes-based
education and training (OBET) in South Africa offers such an enormous
challenge to educators that it may be called a paradigm shift, the concept
is not entirely new. Good educators have always measured the value of
their instruction in terms of that with which the learners leave the teaching-
learning situation - in other words, instruction has been evaluated by
assessing the outcomes (Lubisi et al. 1997).
South Africa instituted a new education and training dispensation of which
SAQA, National Standards Bodies (NSBs) and Education and Training
Quality Assurance bodies (ETQAs) are the core role-players. The success
of an outcomes-based learning system depends on the development and
maintenance of education and training standards. Negating standards will
be detrimental to the system, as well as to the economic development of
the country as a whole. It is therefore important that those involved in
education, training and human resources development should understand
the ways in which traditional education and training approaches must be
capitalised in, while at the same time the ability to learn in various
situations is reinforced by building the capacity of learners with the aim to
promote lifelong learning (Olivier 1998:ix).
50
The point of departure of OBET is the proposed results of learning in terms
of knowledge, skills and values, rather than the content of that which has
to be studied, as the focus of OBET is on what learners know and can do.
The proposed outcomes have to be clearly stated, since "[t]he aim of such
explicitly stated outcomes is to direct the instructional and learning
process, while it also makes the appropriate evaluation of the process and,
ultimately, the outcomes possible" (Nel & Bezuidenhout 1998:20). In
addition, these authors define competence as " ... the capacity for
continuous performance within specified ranges and contexts resulting
from integration of a number of capabilities" (Nel & Bezuidenhout
1998:21 ).
OBET emphasises the relationship and interplay between the relevancy of
students' learning and the adequacy of their professional and career
preparation by specifying the outcomes or abilities critical for future
professional performance (Friedman Ben-David 1999:23). Determining
the needs of professional optometrists therefore is crucial for the
establishment of the outcomes for optometry education and training.
There are various kinds of outcomes, namely critical cross-field education
and training outcomes (briefly critical outcomes); specific outcomes; and
career outcomes. Critical (essential) outcomes are broad and people-
directed skills and competencies; specific outcomes refer to the more
clearly defined aspects of the educational process and are not only
context-related, but are also related to competence and skills in respect of
the concepts, methods, history and theory of a discipline (Lubisi et al.
1997: 11); while career outcomes empower people for a specific career
(Nel & Bezuidenhout 1998:21) (cf. Figure 2.2).
It was deemed necessary to take a closer look at critical outcomes, since
they have to inform the specific outcomes. In addition, the number of
credits required for fundamental knowledge - i.e. critical outcomes
51
knowledge - has to be specified when registering a programme with
SAQA. Therefore it was regarded as important to scrutinise these
outcomes to make an informed decision as to whether they should be
offered as such in, for example, an orientation module, but also to ensure
that they are imbedded in the other modules of an education and training
programme.
The South African Qualifications Authority: Regulations under the SAQA
Act (Act 58 of 1995) state that the critical outcomes include, but are not
limited to the following:
a) "Identifying and solving problems in which responses display that
responsible decisions using critical and creative thinking have been
made;
b) working effectively with others as a member of a team, group,
organisation, community;
c) organising and managing oneself and one's activities responsibly and
effectively;
d) collecting, analysing, organising and critically evaluating information;
e) communicating effectively using visual, mathematical and/or language
skills in the modes of oral and/or written persuasion;
f) using science and technology effectively and critically, showing
responsibility towards the environment and health of others;
g) demonstrating an understanding of the world as a set of related
systems by recognising that problem-solving contexts do not exist in
isolation;
h) contributing to the full personal development of each learner and the
social and economic development of society at large, by making it the
underlying intention of any programme of learning to make an
individual aware of:
i. reflecting on and exploring a variety of strategies to learn
more effectively;
52
ii. participating as responsible citizens in the life of local,
national and global communities;
iii. being culturally and aesthetically sensitive across a range of
social contexts;
iv. exploring education and career opportunities;
v. developing entrepreneurial opportunities" (RSA 1998:8).
Critical outcomes are working principles and as such they should direct
teaching, training and education practices, as well as the development of
learning programmes and materials (Lubisi et al. 1997: 11). All the specific
outcomes should therefore flow from these critical outcomes - hence their
importance in a needs analysis exercise such as this research (see
Appendix B; Instructional Technology Global Resource Network s.a.;
Instructional Technology 2000). Due to their generic nature, critical
outcomes should not be - and in this exercise were not - broken up into
more detailed level descriptors.
Since specific outcomes are context-specific, it is of crucial importance
that detail concerning the level of complexity, scope and learning context
should be included in the formulation thereof, otherwise assessment
cannot be fair, transparent and effective (Bezuidenhout 1999a: 1; Lubisi et
al. 1997: 13).
The third group of outcomes, namely career or vocational outcomes,
entails a description of the attributes of the qualified person.
Requirements of professional councils and the faculty or university
concerned should be reflected in these outcomes, as well as the critical
outcomes at the particular exit level and the specific outcomes required to
obtain the qualification (Bezuidenhout 1999a: 1).
According to Steyn (1999: 11), learning outcomes contain three integrated
elements, namely:
53
o Knowledge and understanding (knowledge of the content, concepts
and theories);
o doing (skills and abilities); and
o attitudes and values.
Examples in this regard are the following:
o Knowledge and understanding: Throughout the (optometry)
programme students should be encouraged to achieve outcomes on
the first three levels of the cognitive domain as described by Bloom
(1956). They will have to master new knowledge, interpret the
knowledge, and apply it in a problem-oriented situation. They should
be guided gradually to apply old and newly acquired knowledge to new
situations and to master new planning and management skills. This is
a deviation from traditional instructional methods.
e Doing (skills): Higher cognitive levels, such as analysis, synthesis and
evaluation (Bloom 1956) need to be applied with regard to basic and
clinical skills. Students' cognitive development should gradually be
incorporated into the instructional modules. They must learn to collect
and analyse, as well as convert knowledge into problem packages that
can be prioritised and applied as part of practical skills during
interventions, first in the classroom and then in a clinical or practical
situation.
o Attitudes and values: In an education and training programme, affective
development should take place together with cognitive and skills
development. Students need to be guided and supported, and through
the role models of the lecturers to be induced to become empathetic
professionals, willing to treat and manage clients/patients regardless of
their background or social standing in life. Respect for patients and
colleagues; recognition of patients' and human rights; an awareness of
54
moral and ethical responsibilities; and a positive attitude and outlook
are important (Bezuidenhout 1999a:2).
As outcomes play such a crucial role in education and training, attention
should be paid to the formulation thereof to ensure that the needs of the
learners will be addressed. A well-formulated outcome should in the first
place contain a verb which answers the question: "What will the learner be
able to do as a result of the learning?" In the second place, the outcome
should contain an object which answers the questions: "With what?" or "In
connection with what?" In the third place are questions related to
conditions/context, e.g.: "Under which conditions?"l"ln what context?"
(Bezuidenhout 1999a:2). An example in the above regard would be the
following sentence: Students will be able to prepare (action word) a patient
(object) for a physical examination (context).
An outcomes-:based approach to education and training has implications
for methodology. Specific outcomes may vary, but they must be
underpinned by critical outcomes. This means that the instruction and
learning must be directed towards understanding, as well as acquiring
abilities and skills, rather than memorising information. In this regard
Lubisi et al. (1997:26) point out that the ability to solve problems,
communicate effectively, work in groups, etc., cannot be developed except
by practising those activities and constantly refining performance in
response to assessment of progress.
More will be said in a later section on educational strategies and
methodology, but with particular reference to OBET the following should
receive attention in the development of an education and training
programme geared to addressing the needs of learners and the
communities they serve as a means to satisfy the well-founded
requirements of OBET. In determining the needs of optometrists with
55
regard to their education and training, attention will have to be paid to the
following aspects:
o An emphasis on activity-based learning, with opportunities for learners
to explore ideas and approaches to learning and to practise skills.
o Co-operative as well as individual learning contexts, in order that
learners can develop skills in working collaboratively in a group and
individually, as well as to develop the ability to recognise when each
mode is appropriate.
o An emphasis on formative evaluation, so that the importance of the
processes and developmental nature of learning as well as the end
product can be realised.
o An integration of theory and practice, and manual and mental learning
where practicable, as well as an integration of classroom learning and
application to the broader society (Lubisi et al. 1997:26).
It is clear that an outlook that emphasises acquisition of skills or
competencies is replacing that which has been based on the acquisition of
knowledge as the sole purpose of education. It is also clear that learners
can no longer cope in the traditional way with the amount of knowledge at
their disposal. The solution to such a dilemma is equipping learners with
skills that will enable them to be lifelong learners (Tisani 1998:48). The
passing of the SAQA Act (RSA 1995) as well as the establishment of the
NQF has effectively introduced an outcomes-based education and training
system and, by following the principles of this approach, it is hoped that
the findings of this research will be relevant in current times to make a
contribution to addressing the educational issues facing optometry
education in the country. Optometry is a dynamic profession where new
knowledge and methods are developed continually. Thus it is of
paramount importance to train students who have the skills to integrate
theory and practice; to contextualise their knowledge, skills and attitudes
into real-life situations; and who are equipped to be lifelong learners.
56
2.4.5 The South African Qualifications Authority (SAQA) and the
National Qualifications Framework (NQF)
The idea of an NQF is the result of debates, research and policy formation
discussions which started in the early 1990s. As early as June 1991 the
National Education Policy Investigation Renewal Strategy, a discussion
document, was released, while a final official policy document was due to
be released in the second half of 1992 (NEPI 1992:59-61). It emphasised
the importance of integrating education and vocational training into a
coherent system (Ministerial Committee 1995:9). The idea was submitted
in many forums, but it was developed in earnest in the National Training
Initiative which involved representatives from labour, management,
government and providers of education and training (SAQA 1997:3).
Much deliberation and the exchange of ideas followed. Consequently
agreement was reached on the concept of transparent national standards,
understood as specific descriptions of learning achievements, agreed
upon by all major stakeholders. The standards, it was decided, would be
housed within a qualifications framework designed to promote lifelong
learning; to integrate education and training; to recognise prior learning;
and to allow for portable, flexible credits and qualifications (SAQA 1997:3).
The strategy for transforming the higher education system, the ability of
the new system to meet a wider range of needs and an understanding of
the boundaries between higher and other levels of education all rely
heavily on the notion of higher education programmes. It was deemed
essential that such programmes be offered within a coherent qualifications
framework, namely the NQF (NCHE 1996: 15).
The first official endorsements of the key role of an NQF for education and
training were in the White Paper on the Reconstruction and Development
Programme (RSA DoE 1994), and in the White Paper on Education and
Training (RSA DoE 1995). An Interministerial Working Group was
57
established to draft the NQF Bill which was passed into law as the SAQA
Act (Act 58, 4 October 1995, Gazette No. 16725) (SAQA 1997:2).
SAQA consists of a chairperson and members nominated from the
education, labour and business sectors, higher education institutions, adult
education bodies, child development, the teaching profession and special
education (Nel & Bezuidenhout 1998:16). SAQA's functions include the
following:
o . The development of the NQF policy, directives and criteria for
registration and accreditation.
o The implementation of the NQF: registration and accreditation of and
assignment of functions to bodies that comply with the requirements
(registration of standards/qualifications).
o Advising the Ministers of Education and Labour.
o Consulting with parties/bodies involved (Nel & Bezuidenhout 1998: 17).
The SAQA Act makes provision for SAQA to see to it that an NQF be
developed, in addition to formulating policy and criteria for the registration
of bodies that can establish education and training standards (NSBs), as
well as the accreditation of bodies responsible for monitoring and auditing
performance in terms of such standards and qualifications (ETQAs)
(Bezuidenhout 1999b:9).
According to the White Paper on Education and Training (RSA DoE
1997a:21) the NQF will be "the scaffolding on which new levels of quality
will be built". This "scaffolding" (NQF) has eight qualification levels. It was
said that each level would be described in terms of registered statements
of essential outcomes. The framework that was established gives
recognition to general education and training (GET) (level 1 and lower);
further education and training (FET) (levels 2 to 4); and higher education
and training (HET) (levels 5 through 8). Table 2.1 depicts a schematic
58
presentation (diagram) of the three bands of the NQF (general, further,
and higher education and training), its levels and its sublevels. It also
indicates some of the providers at various levels, as well as the phases
within school in the GET band (Ministerial Committee 1995:31; Standard
Bank Human Resources - Information Technology 2003:3 of 3; GCIS
2003: 195-201).
TABLE 2.1: SCHIEMATIC PRESENTATION OF THE NATIONAL
QUALIFICATIONS FRAMEWORK (NQF)
NQF
level I BAND Types of qualificatlons and
certificates
8 Higher Doctorates, Further research degrees
7 Education Higher degree, Professional
qualifications
6 and First degrees, Higher diplomas
5 Trainin_g Band Diplomas, Occupational certificates
FIET Certificate
4 Further SchoollCollegelTrade certificates
Mix of units from all
3 Education School/CollegelTrade certificates
Mix of units from all
2 and Training Band School/CollegelTrade certificates
Mix of units from all
GIET Certificate
1 General ABET LEVEL 4 : Grade 9 (Standard 7)
Education and ABET LEVEL 3 : Grade 7 (Standard 5)
Training ABET LEVEL 2 : Grade 5 (Standard 3)
Band ABET LEVEL 1 : Grade 3 (Standard 1)
The objectives of the NQF as laid out in the Act are to:
o create an integrated framework of learning achievements;
~ facilitate accessibility to and mobility and progress within education,
training and vocational fields;
e enhance the quality of education and training;
59
o accelerate the rectification of unjust discrimination of the past in
respect of education, training and work opportunities; and consequently
o contribute to the complete personal development of each learner and
the social and economic development of the nation at large (SAQA
1997/1998:2; Kraak & Young 2001:162; NICATS 2002).
Phillips (1996:8) delineates the set of principles which underpins the NQF.
According to these, qualifications are required to be:
o credible both in South Africa and around the world;
o coherent in that they provide clear learning pathways;
o relevant in that they take into account changing knowledge, technology
and occupational structures;
o quality-focused in terms of nationally agreed learning outcomes and
assessment criteria;
o flexible enough to be gained anywhere and at any age and in ways
other than through formal education;
o accessible in providing appropriate entry points and multiple pathways
to the qualification;
o portable in that they recognise the importance of generic and
transferable skills;
o responsive to the rapidly changing needs and diversity of South African
society and its economy;
o reflective of the needs of both learners and providers of learning;
o progressive in that learners can progress through the eight levels of the
NQF;
o articulated so that learners' achievements are recognised across
providers;
(II effective and efficient in the use of resources, in order to minimise cost
barriers to learning; and
o appropriate in that they are "fit for purpose".
60
The demands of the future and the situation in South Africa as a
developing country require that education and training programmes, while
necessarily diverse, should be educationally transformative. Thus it is
required that these programmes be well-planned, coherent and integrated;
they should be value-adding, building contextually on learners' existing
frames of reference; they should be learner-centred, experiential and
outcomes-oriented; they should develop attitudes of critical inquiry and
powers of analysis; and they should prepare students for continued
learning in a world of technological and cultural change (NCHE 1996). It is
also emphasised that it is vital that qualifications obtained in South African
higher education should be internationally recognised (NCHE 1996: 18). In
determining the needs which should be addressed in optometry education
programmes, these demands were attended to and the principles stated in
this NCHE Report (1996:19) were taken cognisance of.
Three major challenges which face South African higher (health
professions) education have been identified from literature, namely:
o The need to create an equitable system of education and training
which serves all South Africans.
ti) In order to achieve significant levels of economic growth and to
become internationally competitive, the quality of education and
training needs to be greatly improved.
o Education and training have been separated, both by the way they are
organised and by the way society used to think about them (HSRC
1995:6).
For an institution to be allowed to award qualifications, the programme
leading to such a qualification has to be registered with SAQA. Thus
registration is subject to a number of definite conditions as set forth in the
Regulations under the SAQA Act (RSA 1998). For the purposes of this
study these regulations will not be dealt with in detail; suffice it to say that
61
in the process of defining the needs and opportunities for optometry
education and training.
To conclude, the NQF effectively began with the establishment of the
SAQA office in November 1997. According to Cosser (2001 :153),
progress achieved in the implementation of the NQF is documented
according to SAQA's three "infrastructural deliverables", namely
standards-setting, quality assurance and information management.
Critique directed against the NQF implementation and - more specifically,
delivery - is, infer alia, that research carried out by the Human Sciences
Research Council during the period from November 1999 to February
2000 indicates a number of inadequacies in the SAQA machinery which
retarded progress on standards generation. These problems include
"bureaucratic malaise"; lack of direction in SGB formation activity; lack of
policy on level descriptors; failure of SAQA to draw the DoE into standards
generating activity; and lack of consensus on the nomenclature,
articulation and entrance/exit features of qualifications. By February 2001
these and other shortcomings had, however, been addressed (Cosser
2001 :155).
To summarise, it has to be borne in mind that the difficulties confronting
SAQA in regulating the pace of delivery should not be underestimated, as
some regard the process as being too slow, while others who fear too
rapid a transformation, find the pace too quick. According to Cosser
(2001: 156), "[t]he NQF is an ambitious project, and SAQA does not have
the resources to please all of the people all of the time". The Authority
recognises certain imperfections, thus the interim registration process was
designed precisely to accommodate the qualifications currently offered by
providers nation wide on the premise that it is preferable to bring
qualifications into the fold now and to enjoin quality later than to strive for
quality now and risk losing the support of those most anxious to see
progress (Cosser 2001: 156). Thus for the time being the Framework with
62
its three bands, its objectives and its principles are the same as was
originally the case. Legislation with a view towards change is currently in
process, but no new legislation has as yet been passed.
2.4.6 Educatioll1lal strategies for health sciences educatlon
Making recommendations regarding the delivery of relevant and applicable
post-graduate studies in optometry education and training in which the
needs as defined in this study can be addressed, will be the ultimate goal
of this research.
One of the phases in curriculum development has to do with determining
the didactic course of teaching-learning (that is, the methods used). The
important question to answer here is: Which educational strategies should
be followed in the curriculum? (Nel & Labuschagné 1996:5). Health care
education and training as well as health care delivery are going through
profound changes and this will and should influence optometry education
and training. Health care workers are "learners for life" and they should
already be prepared for this from their early study years onwards.
Therefore serious attention should be devoted to educational strategies.
To adapt to changing demands and circumstances in education and health
care, as well as to address the needs of learners, changes in approaches
and strategies are required.
In the innovative approaches to health sciences education, a number of
strategies are receiving increasing attention. These have been put on
various continuums and a model for educational strategies, called the
"SPICES model", was established (Harden 2000; Harden, Sowden & Dunn
1984:285). Each of the strategies mentioned in this model represents the
starting point of a continuum extending between two extremes. It can be
depicted as follows:
63
Student -centred ~ ~ Lecturer -centred
Problem-based ~ ~ Information transmission
Integrated ~ ~ Discipline-based
Community-based ~ ~ Institution-based
Electives ~ ~ Standard programme
Systematic + ~ Needs-driven.
(Adapted by Nel & Labuschagné 1996: 10.)
The left-hand side represents the more modern SPICES approach; while
the more traditional approach is represented on the right-hand side. In a
programme for optometry education and training these strategies will have
to be considered to decide where on the continuum the education and
training should be situated to address the needs of the learners best.
Seen as a whole, it might be inferred that the more modern approach
would be appropriate in current circumstances and would also satisfy the
requirements set for optometry education and training better than the
traditional approaches.
These strategies were studied with a view to making informed decisions
regarding the needs in optometry education and training in South Africa.
Subsequently the strategies and what they entail will be discussed (Nel &
Labuschagné 1996:7-64; Harden et al. 1984:286-297). In the student-
centred strategy, the student is the central or key figure in the educational
process. Under guidance of the lecturer, the students participate actively
in the educational process and develop independence, which is required to
prepare them to accept responsibility for lifelong learning. Other
advantages of a student-centred approach are that the students:
a learn in an active way;
4) learn more self-discipline;
o learn to make decisions regarding the following:
64
learning objectives;
course content;
the method used to achieve the objectives;
learning resources and their use;
sequence and pace of learning;
time of assessment; and
o learn to assess their own work (Nel & Labuschagné 1996: 12; Harden
et al. 1984:286-287).
Students entering the university often have the common and incorrect
notion that the lecturer is the "ultimate source of knowledge" and that they
come to university "to be taught" and not to learn. These two notions are
immediately refuted if a student-centred approach is followed. When
students accept ownership for their learning, they are more motivated and
they receive an opportunity to actively participate in the teaching-learning
process. The responsibility this entails facilitates inter- and independence,
which are of cardinal importance in lifelong learning - a factor which is a
prerequisite for successful practice as an optometrist.
!Problem-Ibased learning is a method where a professional problem is
used as stimulus for learning and this approach is usually twofold, namely
to use problem-based learning as a method to develop a usable body of
integrated knowledge and to develop problem-solving skills. Problem-
based learning aims at establishing an integrated body of knowledge that
is related to the problem; developing problem-solving skills; and
developing clinical thinking skills (Nel & Labuschagné 1996:7; Harden et
al. 1984:287-288). Thus the development of self-directed learning skills is
encouraged through confronting students with professional problems
(Dolmans & Schmidt 1994:372).
A typical feature of problem-based learning is that it involves students
working together in small groups. Active participation in the teaching-
65
learning process empowers students to exert some influence on what and
how they learn, in addition to testing and deepening this learning by
means of discussion and debate. Problem-based learning contextualises
knowledge and promotes the development of skills and confidence in self-
directed learning (Usherwood & Primhak 1996:341).
By utilising clinical/practical problems as the basis for studies, the
relevance and importance of the material students have to study become
clear immediately, because they recognise the material as· needed to
understand and manage the problem. Immediate use of knowledge
(application) strengthens and consolidates the learning process. The
interdisciplinary nature of problems is aimed at promoting the integration of
learning content and interdisciplinary co-operation. A primary goal of
education is to help students to develop into independent learners who will
accept active responsibility for their learning for a lifetime of continuing
professional education in order to be able to stay abreast of developments
in the health sciences (Nel & Labuschagné 1996:22).
In an integrated approach, study material is organised in a way that
makes it possible to combine subjects/topics which are traditionally offered
in separate academic courses or disciplines. Interestingly enough, during
the past two decades more emphasis has been put on the lecturer taking
responsibility for this integration and on bringing the subjects together so
that they are presented to the students as a meaningful whole (Nel &
Labuschagné 1996:34; Harden et al. 1984:288-289). In optometry
integration is important, especially in the clinical applications.
The community-based approach refers to health sciences education and
training provided in an environment which resembles that in which
students will eventually work. It is designed to make students more
responsive to the real needs of people. A significant amount of training
66
should therefore occur outside of the tertiary care facility (Nel &
Labuschagne 1996:34).
Given the new priorities in South Africa as regards a holistic approach to
health and development, coupled with the need to integrate curative and
preventive systems, the basic premises of traditional South African health
education need to be revised. From the outset in this needs analysis
process it was accepted that one of the premises that should underlie
education and training for optometry should be that of training students to
be capable to respond to the most basic community needs, as well as
working in co-operation with other health science professionals on
development projects to achieve a multisectoral approach to health
promotion and eye care.
In 1988 the following principles, which had been adopted for medical
education, were taken cognisance of in deliberations on the needs in
optometry education and training:
o The curriculum should be based on community rather than tertiary care
experiences.
o The curriculum should be integrated by presenting a series of problem-
solving exercises rather than isolated special subjects.
o There should be emphasis on small group learning.
o The curriculum should represent the health care needs of the region.
GI Students should be recruited from the communities the institution
serves on the basis of community commitment and selected on the
basis of potential rather than academic merit (Nel & Labuschagne
1996:41 ).
One of the major criticisms against the current training of health science
practitioners is that it is not sufficiently relevant with regard to the health
care needs of the country (Nel & Labuschagné 1996:43; Wall 1999). As far
67
as the new health authorities in South Africa are concerned, relevance is a
priority, especially in the light of the emphasis placed on primary health
care, the call of the government to prevent blindness, and Vision 2020:
The Right to Sight (lAPS s.a.c,d).
In a traditional standard programme students go through a stereotyped,
standard, prescribed course and they have few, if any, opportunities to
study a subject in more depth or to study a subject of their own choice. All
the students are therefore subjected to exactly the same course as
regards content and methodology, whereas with an elective strategy,
room is left for more flexibility in the curriculum, allowing students some
choices, especially if they want to study a specific topic or subject more in
depth (Nel & Labuschagné 1996:56; Harden et al. 1984:293-294).
The goals of an elective strategy received attention in the needs analysis.
Of particular importance are the following:
o It is a way of coping with an overcrowded curriculum.
o It affords freedom and choices within the curriculum.
o Opportunities for students to develop personal interests.
CD Opportunities for students to take responsibility for and further their
own learning.
o Student participation in decision-making in curriculum development
processes.
(;) There is closer contact between the student and the lecturer.
o Opportunities to facilitate career choices by students.
61 Students' individual aspirations may be met in this way.
• A positive change may be brought about in the students' attitude
towards matters concerning health care in general and eye care in
particular (Nel & Labuschagné 1996:56; Harden et al. 1984:294).
68
There might, however, be some resistance against the elective strategy,
as electives can overload lecturers with work; lecturers might reveal a lack
of interest and awareness; electives can affect other course work;
assessment presents a problem; and some lecturers might take the view
that independent work undertaken during electives can be more profitably
engaged upon under supervision after qualification (Harden et al.
1984:294-295). It is abundantly clear, however, that the advantages far
outweigh the disadvantages.
The last strategy in the SPICES model is that of a systematically
structured curriculum. According to this strategy, the programme is
planned in a way that will ensure that each student receives ample
exposure to everything he/she will need to complete the programme
successfully (Nel & Labuschagné 1996:60). Harden et al. (1984:295)
claim that, in a planned or systematic approach to the curriculum, a
programme is designed for all students so that the experiences necessary
for their training are covered. With an opportunistic strategy, on the other
hand, the learning experiences of the students will be mainly determined
by the material available and, to a lesser extent, by the interests of staff
members (Harden 2000). According to Harden et al. (1984:295), factors
supporting a move towards a more systematic or planned approach are
the following:
o Students need to experience a variety and range of [eye care] health
problems.
o Rationalisation of competencies. A more systematic approach will help
students to identify with competencies.
o Rationalisation of time. A systematic approach has the potential
advantage that the students can become competent and confident with
the least waste of time and resources. The students do not need to
see further instances or receive further instruction in areas where they
are already competent.
69
The new outcomes-based approach fits well into this strategy, as the
outcomes which students have to achieve are clearly delineated. In this
way it is ensured that students will have sufficient exposure and the stated
outcomes will all be reached, even though provision is made for different
ways to do so. Learning programmes should in other words be structured,
but flexible (Lubisi et al. 1997:8).
Educational strategies used in health sciences education constitute a very
topical issue. The curriculum in health sciences education and in
particular the educational strategies which are used, were addressed in
the WHO's Edinburgh Declaration (Medical Education 1988:481-482) and
thereafter at each congress on health sciences education. It is abundantly
clear that expectations in this regard are high and that traditional systems
per se will no longer suffice. Nel and Labuschagné (1996:64) affirm that
changed and changing circumstances have to be considered. Therefore
the time is now ripe to ensure that the changes which are required to keep
in step with innovations, are taken.
It stands to reason that curriculum development is a task which cannot be
completed once and for all, but it is a dynamic and cyclic process, starting
with a needs analysis (see Appendix B; Instructional Technology Global
Resource Network S.8.; Instructional Technology 2000). Needs must be
determined before they can be addressed and actions should be tested
and questioned on an ongoing basis [see Appendix B; Nordby (1997); Wall
(1999)]. This is not a once-off exercise, but a cyclic process which should
be repeated, adapted and improved relentlessly and assiduously in the
interest of optometric education and training.
70
2.5 CONCLUSION
In this chapter it was pointed out once again that the aim of the study is to
establish the needs that should be addressed in optometry education and
training in a time of change and new perspectives. The changing health
scene in health care and health professions education were discussed,
while the competencies and characteristics of health care practitioners
were also highlighted (see 2.1). Factors influencing the design of
optometry education and training programmes, as described in literature,
were taken under scrutiny and the history of the optometry profession was
attended to (see 2.2). The transformation of the health care system in
South Africa was discussed by dealing with national and international
perspectives. Vision 2020 - The Right to Sight (IAPB s.a.c,d) (see
2.3.2.1) and the National Prevention of Blindness Campaign (see 2.3.2.2)
were discussed. Primary health care with special reference to the White
Paper for the Transformation of the Health System in South Africa (RSA
DoH 1997) was discussed (see 2.3.3). As professionals have to register
with statutory and professional bodies, the latter were discussed (see
2.3.4). The very important aspect of the transformation of education and
training in South Africa and legislation in this regard were dealt with. The
aspects which were discussed, were namely a programme-based
approach in education and training (see 2.4.2); outcomes-based education
and training (see 2.4.3); SAQA and the NQF (see 2.4.4); and educational
strategies for health sciences education.
In the next chapter a selective review of optometric education will be
provided.
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CHAPTIER 3
A SEllECTIVIE REVIIEW Of OIP1"OMIETR~CIEDUCAT~ON
3.1 INTRODUCTION
Early in the zo" century optometrists started moving from jewellery stores
into offices, while some pharmacists developed optometric skills and
made the career change to optometry. Most knew they were part of an
evolving profession, but few could have imagined that optometry would
evolve into the full-scope eye and vision profession of the current day
(Kogan 2000:333). Changing into a profession, of course, involved
changes in the education and training of optometrists.
Formal optometric training for a recognised profession is only about 100
years old. Recognition legislation was passed around 1900 to 1903 in
Minnesota, California and North Dakota in the USA. An ophthalmologist
established an optical school, "The Klein School of Optics", in the year
1894 before any statutory recognition of the profession (Normole s.a: px).
The 20th-century profession has dramatically changed since it separated
from its predecessors, the opticians. In 1909 the first Act governing the
practice of optometry in a Canadian province was proclaimed, and by
1925 all provinces in Canada had legislated optometry Acts (Spafford
2001:1 ).
In South Africa the profession was officially recognised in the Health
Professions Act of 1974 (RSA 1974). Most countries in Africa have no
optometry legislation and in Europe the process was led by the British. In
modern Europe a few countries are still in the process of recognising the
training of optometrists at University level, while in a developed country
72
like the Netherlands, the profession was only recognised in the year 2000
(Kogan 2000:333).
Undergraduate training in the former East Block and Asia is evolving
through different levels of higher education with China perhaps the first to
offer optometry as a subspeciality in medical schools. That is perhaps the
best example of post-graduate training in these parts of the world.
Australia and New Zealand are following a combination of British and
USA models which appear to merge what was previously post-graduate
into a longer undergraduate course.
Fierce legal battles preceded most legislation. In the USA and in Britain,
opticians argued that "eye testing and spectacle provision was a human
service of the optical sciences, spectacles belonging in the same category
as telescopes, cameras and microscopes. All these were aids to vision,
whose working principles were part of the science of optics and not
pharmacology". The medical profession, on the other hand, argued that
"any examination of the human body was a medical function and thus only
doctors were they entitled to prescribing spectacles" (Normale s.a.:px).
The above arguments governed the training and practice of optometry for
another 95 years (Penisten 1993).
Only 20 years ago, optometrists in most states in the USA were embroiled
in fierce legislative battles to win authority to use diagnostic and
therapeutic pharmaceuticals. Even then, however, most practitioners
probably could not have foreseen the major role optometry would soon
play in the care of eye disease and the co-management of surgical
patients (Kogan 2000:333).
73
At the start of the 21 st century, most optometrists are well aware that their
profession - as well as the entire world of health care - is once again in a
period of rapid change. However, just as most optometrists at the turn of
the zo" century might not have envisioned the contact lens or seriously
believed that in the mid-1970s they might soon be referring patients for
laser correction, most of today's practitioners have probably not yet begun
thinking seriously about many of the developments that could affect
practice in the not-too-distant future (Kogan 2000:333). These
developments are both rooted in, and impact on, optometric education.
Therefore it is necessary to take a look at optometric education and
training and what is happening in other countries, but especially in South
Africa, since it is the country with the most advanced optometric education
and training system in Africa. Furthermore it is also the country where
optometric education and training, as well as the practice of optometry,
have advanced most rapidly over the past couple of years. It is clear that
what has been lacking, is a mechanism that measures educational
content versus the fast-changing needs of the workplace and the public.
Such a mechanism needs to parallel changes in the health and
educational policy as well.
3.2 OPTOMIETRIC EDUCATION AND TRAINING IN SOUTH
AFRICA
3.2.1 Introduction
Compared to other African countries, South Africa has the oldest
optometric educational heritage. Round about 1931 formal courses were
started in Johannesburg at a vocational training institute (currently the
Wits Technikon), while at the moment there are four university-based
optometrie training programmes, one of which is at a technikon. In
74
addition, there is one programme for dispensing opticians, also based at a
technikon (Penisten 1993:726).
The political changes occurring in South Africa over the past several
years have been extraordinary, while optometry and optometric education
have also changed. All the education and training courses are now open
to all races and all have seen student enrolment increases (Penisten
1993:726). The restructuring of higher education curricula, including
optometric education and training, however, was not a priority in the flurry
of education policy proposals which accompanied the historic political
transformation of South Africa. 'The need for systemic change in higher
education - for a united system with an equitable distribution of access -
overshadowed demands for curriculum reform, temporarily at least"
(Breier 2001: ix). The National DoH, however, identified a need for
registered optometrists and in the National Prevention of Blindness
Programme (RSA DoH 2000:38) spelt out the objectives for their training,
which implied the restructuring of curricula.
As a profession, optometry was only recognised in South Africa around
1927, while formal training started at the Wits Technikon in 1931
(Penisten 1993:px). The training leaned heavily towards mathematics and
geometric optics and the more medically-orientated subjects were
probably taught with guilt and a sense of encroachment on the field of
doctors (Penisten 1993:px).
On 31 March 1924 13 opticians gathered in the Boardroom of the
Scientific and Technical Club in Johannesburg to witness the birth of what
is now known as The South African Optical Association. Of the 13,
whether lucky or otherwise, the following still remain in action for the
furtherance of the optical profession in South Africa (Green 1934: 18).
75
Early in 1927, the Association was gravely concerned with the legal status
of opticians, but - after investigation - legal opinion considered opticians
to be professional men. During this time the Medical, Dental and
Pharmacy Bill served before Parliament and the M.L.A.s who were
interviewed expressed the opinion that opticians had been left out of the
controversy over this Bill (Green 1934: 18).
The year 1931 was a true stepping-stone with regard to the future of the
optical profession in South Africa. A special committee was appointed to
draw up a syllabus for an optical course, resulting in a three-year course
presented at the Witwatersrand Technical College under the auspices of
the SAOA. Towards the end of 1931 a School of Applied Optics was
established at the Wits Technical College. On 7 February 1932 the
School started off with 10 students (Hamilton 1934: 17). That year the first
supplementary examination (the first of its kind ever to be written in South
Africa) was also taken by 10 candidates. Of these seven were successful
and three were referred (Green 1934: 19).
This part-time (evening) course was composed of Physical Optics, Optical
Bench Work and Workshop Practice in the first year; Anatomy and
Physiology, and Visual Optics in the second year; and Visual Optics and
Pathology and Ethics in the third year. The third year dealt with advanced
work in actual sight-testing with particular regard to the use of special
instruments like retinascopes, ophthalmoscopes and keratometers
(Hamilton 1934:23). At the end of the course a Fellowship examination
was written. This was conducted along the same lines and was of the
same standard as the fellowship examinations of the British Optical
Association and the Worshipful Company of Spectacle Makers.
Successful candidates were entitled to affix FOA and were recognised as
qualified opticians (Hamilton 1934:23).
76
In 1934 the efficient training of opticians in South Africa was an
accomplished fact (Hamilton 1934:23). The Witwatersrand Technical
College was the first and only institution in South Africa for the training of
opticians and it satisfied a much-needed and long-felt want. At the time
the need was expressed to consider the institution of full-time day
courses. Over the following decades the course evolved into a full-time
four-year diploma course by 1962 and it is still offered at Wits Technikon.
In 1974 the scope of optometry was defined as follows: "The performance
of eye examinations on patients with the specific purpose of detecting
visual errors in order to provide clear, comfortable and effective
vision, " Furthermore the following was stated: "The correction of
errors of refraction and related factors by the provision of spectacles
and/or spectacle lenses and/or spectacle frames and/or contact lenses
and/or the maintenance thereof by any means other than medical or
surgical" (RSA 1974).
In 2001 the scope of optometry was defined under Regulation No. R.228
as follows:
'1. In these regulations any expression to which a meaning has been
assigned in the Act shall bear such meaning and, unless the context
otherwise indicates - "scheduled substances" means any medicine or
other substance prescribed by the Minister under section 22A of the
Medicine and Related Substances Control Act, 1965 (Act No. 101 of
1965);
"use of a scheduled substances" means the use of a scheduled
substance by an optometrist in his or her practice exclusively during
procedures and not the dispensing or sale thereof;
"the Act" means the Health Professions Act, 1974 (Act No. 56 of
1974).
77
Acts pertaining to the profession of optometry
2. The following acts are hereby specified as acts which shall for the
purpose of the Act be deemed to be acts pertaining to the profession
of optometry:
(1) The performance of eye examinations on patients with the
specific purpose of detecting visual errors in order to provided
clear, comfortable and effective vision;
(2) The correction of errors of refraction and related factors by the
provision of spectacles and/or lenses and/or spectacle frames
and/or contact lenses and/or the maintenance thereof, or by any
means other than surgical procedures;
(3) The use of scheduled substance which is approved by the
Professional Board for Optometry and Dispensing Opticians and
the Medicines Control Council and subject to the -
(a) Conditions determined by the Professional Board for
Optometry and Dispensing Opticians and the Medicines
Control Council;
(b) Provisions of the Medicines and Related Substances
Control Act, 1965 (Act No. 101 of 1965) and;
(c) Person practising the profession of optometry being in
possession of a permit issued in terms of section 22A (12)
of the Medicines and Related Substances Control Act, (Act
No. 101 of 1965), to acquire, possess and use the specific
Schedule 1, Schedule 2, Schedule 3 or Schedule 4
substances for diagnosis purposes.
3. These regulations shall not prohibit the provision of spectacles
and/or spectacle lenses and/or spectacle frames by a registered
dispensing optician on the prescription of a registered and suitably
qualified medical practitioner or a registered optometrist.
78
Repeal
4. Government Notice No. R. 2315 of 3 December 1976 as amended by
Government Notices Nos. 1844 of 16 September 1977 and
R. 2613 of 29 December 1978 are hereby repealed' (RSA DoH
2001:1 ).
Currently it is clear that there is a need to train specialist optometrists in
South Africa, both for the private and the public sectors. In 2000 there
were three universities and one technikon offering training in optometry,
with 200 students qualifying each year. There were ± 2 000 registered
optometrists (1 970 of whom were working in the private sector, i.e.
98.5%); 20 were working in academic institutions (i.e. 0.1 %); while only 12
were working in Provincial Departments of Health (i.e. 0.6%) (RSA DoH
2000:37). Optometrists therefore represent an underutilised and
potentially valuable human resource for health care.
The African continent is characterised by an extreme lack of eye care
facilities and personnel (Naidoo 2000:8). In South Africa optometry was
the domain of the minority and literate white citizens, as training was only
accessible to them. Optometry was also restricted to optical appliances
and was never considered part of health care. Optical companies cashed
in on eyewear fashion as a major feature of optometry. Thus the
profession was never taken seriously by the medical profession and was
relegated to spectacle manufacturing for those who could pay. (SAOA
correspondence dated 24 November 2000.)
The establishment of a Department of Optometry by a group of Americans
at the University of the North in South Africa in 1974 set the stage for a
new era in optometry training in South Africa. In the USA optometrists
were compelled by law to refract, diagnose and treat eye diseases. Thus
the training was different with an emphasis on pharmacology and eye
79
diseases. At this stage two other departments of optometry were
established in South Africa: one at the Rand Afrikaans University and the
other one at the University of Durban-Westville (UDW). The training at
the University of the North, however, was ahead in terms of world
developments in the field of optometry, as - due to lack of expertise - the
other two departments could not cover the same scope as the Americans
at the University of the North did. The Americans left the country soon
after a state of emergency had been declared in 1986.
At present students can receive education and training in optometry at the
Technikon Witwatersrand, the University of the North (UN IN), the UDW,
the Rand Afrikaans University (RAU) and the University of the Free State
(UFS) - the latter having introduced its optometry programme in 2002.
Dispensing opticians are trained at the Cape Technikon.
In its National Prevention of Blindness Programme the National DoH set
forth the objectives that should be pursued in optometry education and
training in South Africa. These read as follows:
"The optometrist should be able to:
1. diagnose and manage all common eye problems
2. do all refractions and dispense prescription glasses
3. assess and manage low vision, and organise and run a regional low
vision clinic
4. recognise and refer those conditions which require referral to the
tertiary level
5. organise and run a school screening programme (only children> 8
years) [However, this regulation is currently being repealed.]
6. provide training, supervision and support to traditional healers,
community health workers and clinic nurses in primary eye care and
ophthalmic nurses
80
7. select patients who require eye surgery, and do post-operative
management of patients
8. manage a district eye clinic, including record keeping and
maintenance of stocks.
The practical skills of the optometrist include:
- Full refraction
_Slit lamp examination of the anterior segment of the eye
- Tonometry
- Fundoscopy
- Subconjunctival injection
- Removal of superficial foreign bodies
- Chalazion surgery
_Rehabilitation" (RSA DoH 2000:38).
In order to gain a clear picture of the education and training of
optometrists and dispensing opticians in South Africa, the programmes
offered at the different institutions will be described succinctly.
3.2.2 Technikon Witwatersrand (TWR)
The course in optometry at the Technikon Witwatersrand (Wits
Technikon) in Johannesburg was instituted in 1930 (or in 1931 according
to some sources) with the first students enrolment in 1932. The SAOA
was the custodian of what evolved into a four-year Diploma in Optometry
course (programme) and students wrote a fellowship examination which
qualified them as optometrists.
In 1996, under the new education dispensation, a programme offering a
B.Tech. degree was introduced. The B.Tech. programme in Optometry is
a four-year full-time programme at NQF level 7. Currently an average of
81
18 students qualify per year, but it is envisaged that eventually 40 will
complete the programme annually. To be admitted, students are required
to have completed NQF level 4 (highest school, i.e. further education and
training level), whereas in the areas of knowledge and skills, preference is
given to students with science, mathematics, biology and competence in
English. Students are afforded recognition of prior learning (RPL). When
submitted to SAQA for interim registration, the admission requirements
entail the FET (Further Education and Training) certificate at NQF level 4
with numeracy and science skills, biology and English language skills, or
an equivalent qualification. Students with an appropriate qualification at
NQF level 6 and with previous relevant registration with the HPCSA are
also admitted.
According to the interim SAQA submission the programme carries 120
credits per year. In the old curriculum all subjects had to be passed in the
third year to continue to year four.
The exit-level outcomes of the programme, as submitted for interim SAQA
registration, read as follows:
The qualifying optometrist will be competent to:
1. Apply scientific optometric skills, optical and allied technologies to
ascertain the accuracy of the prescription of the eye care products to
visually compromised people.
2. Apply scientific health care skills and optometric technologies in the
diagnosis, prescription and delivery of eye and vision care therapy
within the context of health services appropriate to the needs of the
community.
3. Interact consultatively in the delivery of eye care products, therapy and
medication to visually compromised people, while applying self-reflex
learning strategies during interactions.
82
4. Apply appropriate medico-Iegal ethics, health and safety regulations
and codes of conduct in the (assessment) evaluation, diagnosis and
delivery of service and products to patients/clients.
5. Apply advanced optometric skills in the assessment of ocular and
visual parameters.
6. Apply advanced optometric skills within the health care skills in the
assessment of ocular and visual anomalies.
7. Manage and administer human, technical and other resources to
ensure optimal diagnosis, prescription and delivery of eye and vision
care/services.
8. Apply self-reflective learning strategies to continually improve the
optometrically-related service within health care service appropriate to
the specific needs of the patient/client to ensure professional
contribution to the needs of society. (Written communication from Von
Poser dated 2 June 2002.)
A structured (clinical) master's programme, incorporating a research
dissertation, is awaiting Senate approval. (Personal communication with
Von Poser on 22 May 2003.)
In 2002 the Faculty of Health Sciences of Wits Technikon was split into
two Schools with Optometry, Podiatry and Radiography in one School and
Chiropractic, Homeopathy and Somatology in the other. A joint clinical
facility, which serves the densely populated Hillbrow patient base, was
established on campus. Currently institutional affiliation with the
University of the Witwatersrand is realised via an Academic Health
Service Centre (RSA DoH 2000:38).
The 2002 Asmal Report on Higher Education proposes that RAU and the
Technikon Witwatersrand should merge from 2003 onwards (RSA MoE
2002; GCIS 2003:200).
83
3.2.3 University of the North (UNIN)
In 1975 the four-year B.Optom. degree was implemented at UNIN in
Pietersburg (currently Polekwane). During the apartheid years this
department was under the leadership of various American educators and
survived on educational grants. At the moment the programme is still
suffering from a lack of capacity and renewed efforts are underway to
improve the situation. The Northern Province (the Limpopo Province) was
the first provincial authority to employ optometrists at a recognised
professional level. Amalgamation with the Medical University of South
Africa (MEDUNSA) is in progress (RSA MoE 2002).
The programme for optometry at UNIN delivers three qualifications,
namely a B.Optom., an M.Optom. and a Ph.D.Optom. (The latter was
approved and registered, but no student has enrolled to date.)
ei) B.Optorn.
The programme for the B.Optom. qualification has a duration of four
years. During 2002 there were 35 students in the final year. To be
admitted to the programme, a student only needs a matriculation
certificate (NQF level 4). The programme carries 240-250 credits per
year. No electives are available. Only one exit-level outcome is stated,
namely that the students must be able to examine a patient and provide
the necessary management or referral. The programme has been offered
since 1975 .
• M.Optom.
This is a two-year, non-modular, research programme. During 2002 only
one student was enrolled in the programme, the admission requirements
84
of which entail a B.Optom. or equivalent. The exit-level outcome of the
programme is stated as follows: The ability to carry out research in
Optometry and Vision Science and publish the findings in accredited
journals. The programme has been offered since 1997.
o Ph.D.OlPtom.
The programme for this qualification was approved, but no student has
thus far been registered. The programme is registered as a three-year
research course, with an M.Optom. being the only requirement for
admission. The exit-level outcomes entail that a qualifying student will
have the ability to carry out research and publish the findings, as well as
having the ability to train research students. (Written communication from
Alabi Oduntan dated 3 June 2002.)
3.2.4 The Unoversity of Durban-Westvolle (UDW)
In 1980 the UDW opened its doors to optometry students with a
programme for an entry-level bachelor's degree in optometry. The
programme carries 558 credits over four years and qualifies 35 students
per annum. Requirements for admission are a B.Sc. degree or studying
towards a B.Sc. degree or minimum matriculation requirements such as a
matriculation exemption certificate or a certificate with the university
admission endorsement; mathematics passed at higher grade or at least a
50% pass at standard grade; and biology and physical science with a
similar pass mark. All candidates are interviewed with final selection
based on academic merit (70%) and the interview (30%). A modular, part-
time clinical as well as a full research master's degree has been offered
since 2001. (Written communication from Naidu dated 2 June 2002.)
However, the clinical master's has now been re-routed into the research
master's. (Personal communication with Moodley during May 2003.)
85
Merger agreements with the University of Natal are underway.
3.2.5 The Rand!Afrikaans University (RAU)
In 1983 a programme delivering a B.Optom. degree was introduced at
RAU in Johannesburg with financial assistance from the SAOA. This
Department of Optometry has also over the years awarded several M.Phi!.
degrees with the main areas of research that of linear algebra. (Written
communication from Richter in May 2002.)
The B.Optom. degree offered at RAU is obtained after completing a four-
year programme. Approximately 60 students qualify per annum. The
admission requirements are a level 4 NQF certificate with at least a C
symbol for mathematics on the higher grade, as well as Science and
Biology. The programme carries 226 credits per year. This Department
also offers a non-modular programme without eieetives for a Master's
degree in Optometry. This is a research programme culminating in a
dissertation. (Written communication from Richter in May 2002.)
3.2.6 Cape Technikon (CT)
The Cape Technikon offers a programme for dispensing opticians. The
curriculum is currently being revised and a new curriculum has been
proposed for the three-year diploma programme in order to align it with
the career ladder concept. This will mean that the two academic years
will be similar in content to the B. Optom. degrees offered elsewhere.
86
3.2.7 The Unoversity of the Free State (UFS)
In 2002 the UFS initiated the first integrated B. degree in optometry in
South Africa, offering a broader biological base and expanded clinical
training compared to the education and training offered at other
departments.
An M. Optom. also gained SAQA approval at the same time as the B.
Optom. programme. Thus the master's programme is registered with the
education authorities, but no students have enrolled as yet.
It should be noted that prior to 1994 the Wits Technikon course trained
mainly white male students, UNIN mainly black students, the UDW mainly
Indian students, and RAU mainly white Afrikaans-speaking students. This
UFS programme, offered in Afrikaans and in English, has both male and
female students of all population groups.
A new era in optometric education, training and possibly scope of practice
has dawned with the introduction of a new Department of Optometry at the
UFS. This department is housed in the School of Allied Health
Professions, within a Faculty of Health Sciences that also houses a
School of Medicine. The programme is offered in close collaboration with
ophthalmology (Ramela 2002:6). Currently none of the other institutions
offering optometric education and training programmes have close links
with medicine and therefore have limited access to public sector teaching
hospitals, as well as the vast clinical training opportunities the public
sector offers. The UFS course is offered in close co-operation with the
Medical School and particularly the Department of Ophthalmology (Kriel &
Nel 2001 a:2).
87
o B. Optorn.
To be awarded a baccalaureus degree in Optometry (B.Optom.), students
have to complete a four-year programme. This is an outcomes-based
education and training programme in accordance with the SAQA Act (Act
58 of 1995) (RSA 1995) and the related regulations and guidelines. Other
important emphases entail those regarding resource-based instruction;
integrated education and training (with special emphasis on the
integration of theory and practice, as well as horizontal and vertical
integration of content); an emphasis on an approach which will foster
independent and lifelong learning; and a special emphasis on team and
group work (Kriel & Nel 2001 a: 1).
Candidates are afforded the opportunity to exit the programme at diploma
level, obtaining a qualification as dispensing optician, or continue to the
level of a professional baccalaureus degree in optometry which, in turn,
will form the basis for the Professional Master's degree (Kriel & Nel
2001a:2).
o M. Optometry
The M. Optometry programme is unique in that it will be offered in clinics
as well as in the training hospitals, while sharing facilities and material
with ophthalmologists, as there are many tangencies (Kriel & Nel
2001 a:2).
The programme offers an opportunity for a large market of optometrists in
South Africa to pursue post-graduate studies, in addition to affording them
the opportunity to make a contribution to the prevention of avoidable
blindness in South Africa and the general standard of care by fulfilling a
gatekeeper role at primary or secondary level (Kriel & Nel 2001 b:2).
88
In the programme the candidates are provided with the opportunity to
obtain a master's degree, or to exit with a post-graduate diploma in
optometry. After SAQA's approval had been gained, a thorough planning
phase for the master's programme was put into motion before the
programme would be implemented. The reason for this is threefold,
namely that the results and recommendations of this study would be
awaited; the successful implementation of the B. programme would be
well underway; and that a clinical service in the Free State, as well as the
necessary posts in the public sector would have to be created. It is
normal practice at the Faculty of Health Sciences at the UFS to only
phase in and implement programmes when the essential proven research
has been done; when the necessary facilities have been created; and
relevant expertise has been obtained. (Personal communication with
Prof. M. Nel, Head of Educational Development, Faculty of Health
Sciences at the UFS on 20 May 2003.)
The programme will compare favourably with similar programmes in other
countries, albeit with a unique South African approach geared to this
country's needs and resources. The Professional Board lays down the
guidelines for optometry training, therefore the requirements for practice
as professional optometrist will be met on successful completion of the
programme. The education and training in the programme also satisfy
international norms and standards for optometry training (Kriel & Nel
2001 b:3). The modular course work will focus on core content, offering
learners the opportunity to address their own needs - the main task of the
facilitators in the learning programme will be to support learners in the
process.
The programme for the master's degree in optometry will be an outcomes-
based education and training programme in accordance with the SAQA
89
Act (Act 58 of 1995) (RSA 1995), and related regulations and guidelines.
In the course work (modules) specific and professional outcomes will be
set, while the research module will provide an opportunity to enlarge and
refine the knowledge base of the discipline. In both the programmes for
the bachelor's and the master's degrees there is an emphasis on directed,
learner-centred education, resource-based instruction, integrated
education and training (with a special focus on the integration of theory
and practice), as well as a team and group work approach. In the
modules core content is replenished by directed, resource-based studies
and a module with electives will provide an opportunity to learners to
satisfy individual needs and pursue areas of special interest. The module
on research methodology will lay the foundation and prepare learners for
the research project and the writing of the research report (script) (Kriel &
Nel 2001 b:6).
Assessment in the programme will be based on an integrated and
continuous evaluation approach. The end evaluation will comprise a
written and an oral examination, as well as an evaluation of practical and
clinical work, in addition to the research script. Skills will be evaluated in
real settings (Kriel & Nel 2001 b:6).
3.2.8 The Graduate Institute of Optometry (GlO)
In the past, the only post-graduate optometry education in South Africa
was offered through the New England College of Optometry (NEWENCO)
in collaboration with the SAOA and later the GlO, which worked together
for furthering the profession of optometry in South Africa. (Figure 3.1
provides a visual presentation of the work done by the GlO; the role it has
played up to now and which it can still play in the future.)
90
FIGURE 3.1: THE ROLE OF THE GlO IN POST-GRADUATE
OPTOMETRY EDUCATION IN SOUTH AFRICA (MASTER'S
LEVEL)
B.OPTOM./
DIPL. OPTOM.
(SA)
OCULAR DISEASE
MODULES 1-5 ------- ,,,,,,,,
NEUROLOGY MODULES .c..
,,,
1-3 ,Cl) , /~
)(
C..l). STRUCTURED RESEARCH
Cl)
1/1 CLINICAL MASTER'S
1/1
~ MASTER'S (SA) (SA)VISION DEVELOPMENT ...
AND PUBLIC HEALTH 0...
MODULES 1-3 .Cc.l)..u
. l
Cl). COMPULSURY
, Clcu MODULES
0
HUMAN BIOLOGY AND ...>-
CLINICAL MEDICINE cu ,,'~C. ,
MODULES 1 -3 c ,j---< ..,cu , , +
U , '&
Q ELECTIVE
(!) MODELS
Cl)
SUCCESSFUL OD ..c..
PARTICIPANTS ONLY Cl)
'.0..
CLINICAL ROTATIONS Cl)
...c
+
..
DOCTOR OF RESEARCH AND
OPTOMETRY DISSERTATION
(US-ACCREDITED) (MINISCRIPT)
- ______ 1
(Adapted from the Graduate Institute of Optometry 1999:6.)
*The Doctor of Optometry (USA) follows after a basic science degree.
A Doctor of Optometry degree serves as the entrance requirement for a
Masters degree in Optometry (USA).
91
In 1994 an agreement was reached to provide graduates of optometry
approximately 190 contact hours of course work in the areas of ocular
disease, pharmacology, the treatment and management of ocular disease,
and clinical medicine. These courses were identified from the NEWENCO
curriculum as ones that are greatly needed, especially to help towards the
diagnostic and therapeutic optometric legislation for South Africa (The
Graduate Institute of Optometry 1999:7).
To date, the Certificate of Advanced Study (CAS) NEWENCO has been
repeated three times with some 550 optometrists successfully completing
the course. In 2001 The Professional Board approved a revised syllabus
for the CAS, which included an introductory module covering selected
topics in human biology and excluded the module on treatment and
management of ocular disease. Some 180 optometrists completed this
version of the CAS delivered by South African faculty.
Between 1996 and 2001 the rest of the course work identified by
NEWENCO from its Advanced Standing International Programme was
delivered in South Africa. This took on the form of three further
Certificates of Advanced Study, covering some 300 lecture hours. A total
of 35 South Africans completed all the courses and a small number
enrolled for the clinical rotation year required for the NEWENCO-
accredited degree.
Each course was taught within a number of modules over an extended
period of time. Examinations were given for each course and the grading
system was based on the USA system. On successful completion of all
the course work and examinations, a CAS was awarded (The Graduate
Institute of Optometry 1999:6-7). Besides the CAS Ocular Disease and
Pharmaceutical Application, three other certificates were offered. These
92
were CAS Neural Basis of Vision, CAS Vision Science and Public Health
and CAS Clinical Medicine and Biological Sciences.
NEWENCO accredited a six-month clinical rotation site at the Edendale
Hospital in Pietermaritzburg. The irony of the situation is that South
African optometrists are paying an American Institution $23 000 tuition
fees for the clinical year, while they spend half of that time in South Africa
in a clinical situation that is crucial to their training in general. Most South
African Optometry and provincial Health Departments have yet to
recognise this opportunity. At the Edendale site, graduates perform the
duties they have been educated for as part of the eye care team; this
being a major contributing factor in the cataract surgery waiting period of
less than a week at this hospital.
The reason why this is not happening at other hospital Eye Departments
is partially due to the inability of South African Optometry Departments to
establish clinical training in the public sector and the unwillingness of
Ophthalmology Departments to accept optometrists as part of the eye
care team, thus resulting in primary care being performed by
ophthalmologists, whilst the surgical backlog is not addressed effectively.
The GlO has therefore played a catalyst role in the post-graduate training
for optometrists and will continue to do so in an effort to redefine what is
needed in under- and post-graduate training in order to address the
needs of Africa and South Africa in particular (The Graduate Institute of
Optometry 1999:7).
3.2.9 Summative remarks
Optometric education and training in the developed world have
progressed by leaps and bounds over the past decade. Educational
93
institutions are striving towards satisfying the needs of the population, as
well as of the health and higher education policy. The process is,
however, a slow one that is hampered by the regulatory process, the lack
of political will, and "own turf' struggles.
The post-graduate programmes that will be offered at the UFS will make a
contribution to equip optometrists better for practice, especially in the light
of the expansion of the scope of practice in South Africa.
Currently, about 180 graduates per annum are still trained largely from the
20.0% of the population who can afford private care, in order to serve that
same 20.0%. This results in an oversupply in the private sector and
inappropriately trained practitioners for the public or rural settings.
One may also assume that, during this period of redefinition of what is
required in under- and post-graduate training, a certain amount of cross-
pollination between under- and post-graduate training as well as among
Institutions will be realised. This may well result in a movement of accent
in certain fields to post-graduate level and vice versa as the public need,
the need for community service and the need for specialisation are
addressed.
Controlling this process will be a challenge for educators and regulators,
but it should be seen against the ultimate goal of transforming the
profession into a public utility, adhering to the demands of primary health
care.
Table 3.1 provides a visual presentation of the major strengths and
weaknesses of undergraduate and post-graduate optometric education
and training in South Africa as perceived by the researcher.
94
TABLE 3.1: SOME OF THE MAJOR STRENGTHS AND WEAKNESSES
OIF UNDERGRADUATE AND POST-GRADUATE OPTOMETRIC
EDUCATION AND TRAINING IN SOUTH AFRICA
UNDEIRGRADUATE OPTOMETRIC EDUCATION
STRENGTHS Sound Physical Sciences base.
Relatively well funded.
Broad exposure to all related fields.
WEAKNESSES Inadequate education and training in the bio-medical
sciences and the diagnosis of related disease.
Little exposure to public health and public sector clinical
settings (service delivery).
Limited clinical exposure in:
D general clinical skills;
D ocular trauma and emergencies;
D surgical co-management;
D contact lens fitting procedures;
D low vision procedures;
D rehabilitation and mobility training;
D paediatrics and binocular vision.
• Inadequate education and training in the neurological basis
of vision, treatment and management of ocular disease and
practice management.
Education and training not addressing immediate public
need.
POST-GRADUATIE OPTOMETRiC EDUCATION
STRENGTHS Well-structured overall (researched-based) programmes.
Research in M.Phil. programmes at the forefront of the field
of linear algebra and its applications.
Availability of physical and financial resources.
WEAKNESSES No clinical programmes implemented with success.
No education and training in speciality areas offered to date.
Not aimed at addressing immedicate public need or that of
the profession.
Lack of faculty capacity to offer higher clinical degrees.
Not using Qublic sector opportunities (service delivery}
95
3.3 OPTOMETRIC EDUCATIONAND TRAiNING IN THE REST OF
AFRICA
3.3.1 Introduction
The profession of optometry was introduced in Africa by way of European
immigrants. This process occurred over several centuries and by the turn
of this century, optometry was practised in South Africa and a few
scattered African cities by European immigrants who had trained primarily
in England or Germany. In addition to those practitioners with formal
training, self-designated professionals could be found who acquired
"sight-testing" skills by apprenticeship, correspondence, private tutoring,
or sheer ingenuity (Penisten 1993:726).
Until recently, those countries which retained a population of European
professionals were the countries most likely to recognise the profession of
optometry and, therefore, also to have at least a few optometric
practitioners (e.g. South Africa, Kenya, Zimbabwe and Namibia). This
situation is now changing. With the opening of several new teaching
programmes during the past two decades, optometry is now presenting a
significant presence in four African countries (Penisten 1993:726).
Western Africa is represented by Nigeria and Ghana; eastern Africa by
Tanzania; and southern Africa by South Africa, as described above.
There are no optometric training programmes in northern Africa (Penisten
1993:726).
In total there are nine optometric teaching programmes in these four
African countries. Similar to situations in other parts of the world, the term
"optometrist" is used in all four of these countries, but the training and
practice of optometry vary somewhat among them. The factors which
96
have influenced the development of optometric education and optometric
practice in each of these four countries, are also different (Penisten
1993:726). Since the UFS initiated the first integrated B. degree in
optometry in South Africa in 2002, there is now a total of 10 teaching
programmes in the above-mentioned four African countries.
The unmet vision needs in Africa are staggering and the state of eye care
provides an alarming contrast to the rest of the world. The continent is
characterised by an extreme lack of eye care personnel and facilities. A
paucity of educational programmes is one of the hallmarks of eye care on
the continent (Naidoo 2000:8). Even in the countries with the highest
number of eye care professionals (South Africa and Nigeria) current
numbers are by far too low (Penisten 1993:728).
Part of the underdeveloped nature of third-world countries is the state of
the educational systems. A significant feature of the eye care crisis in
Africa is the lack of programmes to train optometrists adequately and
appropriately. Onyelucheya (1993:710) asserts that some disciplines
have never been developed in third-world universities; most universities
offer programmes leading to degrees in "more common" disciplines, whilst
the "more rare" disciplines find little or no place in these education and
training institutions. Optometry happens to be one of these "more rare"
disciplines. The majority of the small number of optometrists in the third-
world countries studied abroad, due to the non-availability of optometric
programmes at their home universities (Onyelucheya 1993:711). South
Africa seems to be the exception here.
Apart from South Africa, only Ghana, Nigeria and Tanzania train
optometrists. These programmes vary in scope and produce far too few
optometrists to meet the needs of their own countries (Naidoo 2000:9), let
97
alone make a contribution to the eye care needs of the countries without
optometric training programmes.
The challenge to the optometric profession in Africa is to increase the
numbers of optometrists graduating from programmes within Africa.
Almost a decade ago it was said that new optometric education and
training programmes should be established in Africa and that the
programmes offered at the time should produce more optometrists willing
and able to serve in the countries where they trained, as well as in the
neighbouring countries (Penisten 1993:728).
The following is a brief overview of what could be found in literature on
optometric education and training in Africa, excluding South Africa, as the
latter was discussed earlier in the chapter.
3.3.2 Ghana
In 1993 Penisten reported that new optometric programmes in this west
African country represented the meagre beginnings of the profession in
this country (Penisten 1993:727). In a few short years a university-based
programme was established, but severe financial constraints and
equipment shortages limited the effectiveness of the programme. At the
time optometry was not legally recognised in Ghana, as 25 persons had to
be practising a profession before official recognition could be granted. In
1993 there were only 10 practising optometrists in Ghana and 11
optometric students (Penisten 1993:727).
The weo, in addressing the global concern for a lack of educational
programmes in optometry, commenced with a fellowship programme in
2000, focusing on building human networks of optometric practitioners,
educators and public health specialists. In 2001 an American optometrist
98
started a fellowship at the University of Science and Technology (UST) in
Kumasi, Ghana. This fellowship is intended to last for two years and to
increase the awareness of much needed resources among the public,
government and practising optometrists (paraschak 2000). The main
objective of this fellowship is to provide instruction in ophthalmic and
physiological optics to students, as well as consultation in planning and
assistance in integrating optometry with medical and public health
systems.
After a two-year college training, UST admits students to a two-year
optometric programme. The School is, however, now in the process of
expanding the programme to four years. Assessing the curriculum
development also forms part of the fellowship brief (paraschak 2000).
The School, with only a half a dozen academic staff members, is reported
to have expressed a dire need for equipment and professional books.
Such materials will increase the students' learning capabilities and
improve optometry's professional image in Ghana (paraschak 2000).
3.3.3 Tanzania
The only optometric educational programme in east Africa is that of the
School of Optometry of the Kilimanjaro Christian Medical College in
Moshi, Tanzania. In 1993 the curriculum came under review in order to
obtain affiliation with the University of Dares Salaam. Penisten (1993:727)
adds that, in a move which could have significant impact on the east
African region, plans are being developed to admit a select number of
students from surrounding countries. Currently the Department of
Ophthalmology of the Kilimanjaro Medical College offers the following
programmes:
99
o M.Med. Ophthalmology
Post-internship doctors with a first medical degree may apply for this four-
year course, including a year of primary sciences and three years of
clinical training in medical and surgical ophthalmology. At present
students are from Tanzania and other African countries (Kilimanjaro
Christian Medical College 2001 :s.p.).
o Assistant Medical Officer in Ophthalmology
Assistant medical officers with two years' experience after graduation may
apply. This is a two-year course in the practice of ophthalmology, the
second year of which involves cataract surgery training. Graduates are
recognised by the Ministry of Health as Cataract Surgeons (Kilimanjaro
Christian Medical College 2001 :s.p.).
o OplhUuaimoc O1lLJ1rSDB1lg
This two-year advanced diploma course is open to applicants who are
already registered nurses. Theoretical and practical aspects of nursing
and the eye patient are involved in the course (Kilimanjaro Christian
Medical College 2001 :s.p.).
(3 Optometry diploma
Form 4-6 school-leavers are allowed to this three-year diploma course in
refractions, dispensing and the manufacturing of spectacles and visual
devices (Kilimanjaro Christian Medical College 2001 :s.p.).
In total four programmes are therefore offered in Tanzania, varying in
length from two to four years.
100
3.3.4 Nigeria and French-speaking Africa
In 1993 Nigeria was the only country in Africa to offer a doctoral
programme in optometry. The Department of Optometry of the University
of Benin has been offering optometry since 1974 and up to 1993 it
awarded a B.Sc. Optom. degree after four years' of study. The other
School of Optometry is in the Abia State University. Both the Nigerian
Schools of Optometry now award the OD (Doctor of Optometry) degree
after six years' training (Penisten 1993:727-8).
According to Penisten (1993:727), the Nigerian government decree
defining the profession of optometry provides what at the time was
regarded as the broadest scope of optometric practice in Africa. The
1992 optometry decree defines the scope of optometric practice to include
the treatment of anterior segment disorders.
Penisten (1993:727) adds that no optometric teaching programme exists
in Africa north of Nigeria and none exists in Africa for French-speaking
students. This has left a large vacuum for those African countries which
were formerly Belgian and French colonies where French, not English,
remains the predominant European language (for example Zaire, Algeria
and Niger). This situation has been partially addressed by a programme
created four years previously at the Ecole Superieure Internationale
D'Optometrie in France. The three-year optometry course trains French-
speaking nationals from countries where no optometry programmes exist.
Upon successful completion of the course, students are awarded a
Diploma in Optometry, whereafter they return to their native countries to
practise. Students from several north African countries are currently
enrolled.
101
3.3.5 Summative remarks on optometric education and training in
Africa
A significant feature of the eye care crisis in Africa is the lack of
programmes to adequately train sufficient numbers of optometrists in
Africa. The entire continent has only 10 optometric programmes, which
are based in four countries, namely South Africa, Ghana, Nigeria and
Tanzania (Naidoo 2000:9). These programmes vary in scope and
produce far too few optometrists to meet the needs of their own countries
and the continent (Naidoo 2000:9).
Apart from the optometry programmes offered in South Africa, the entire
continent has only four optometric education programmes, based in three
countries. Very few optometrists are produced in Africa every year and
the programmes offered only lead to diplomas and first degrees. Nigeria,
for example, had a ratio of one optometrist for every 400 000 people in
1993 (Onyelucheya 1993:710). In 1993 Ghana had but 10 optometrists
and 14 ophthalmologists who served the needs of 15 million people
(Penisten 1993:727). Of the few optometrists practising in Africa
(excluding South Africa), the majority studied abroad due to the
unavailability of programmes at home (Onyelucheya 1993:711).
According to Naidoo (2000: 10), private optometry practice in Africa has
had limited success in spite of the few practitioners in some countries.
This is a direct result of the economic devastation of some of the
countries. Most care is provided by nurses and ophthalmic assistants
who are employed in state clinics and hospitals as well as by
philanthropic organisations which conduct various eye care programmes.
The range of personnel providing eye care further includes refractionists,
optometrists and ophthalmologists. The scope of practice of the various
personnel varies tremendously. In some countries (e.g. Malawi)
102
ophthalmic assistants are primarily responsible for cataract and other
surgical procedures. These personnel are often thrust into this role after
one or two years of training. According to Western standards, this may
sound shocking and incredible; however, for many African countries the
evaluation of these programmes is based on the outcome, which is often
the alleviation of blindness and access to some care rather than no care
at all (Naidoo 2000:9).
In contrast to the situation in Africa, the education and health systems -
with special reference to optometry - in the USA seem to be well
developed and optometrists from Africa mostly receive their post-graduate
training in the USA or through USA programmes. Therefore it seems
appropriate to discuss optometric education and training in the USA to
establish links with what is happening in South Africa.
3.4 OPTOMETRIC EDUCATION AND TRAINING IN THE USA AND
CANADA
3.4.1 mtroductlon
In the USA a doctor of optometry is an independent primary health care
provider who examines, diagnoses, treats and manages diseases and
disorders of the visual system, the eye and associated structures. The
duties of an optometrist include prescribing glasses and contact lenses;
rehabilitation of the visually impaired; and the diagnosis and treatment of
ocular disease. Optometrists perform comprehensive examinations of
both the internal and external structure of the eye; they perform subjective
and objective tests to evaluate patients' vision; analyse the test findings;
and diaqnose and determine the appropriate treatment (US-UK Fulbright
Commission 1999: 1).
103
Optometry is taught only at post-graduate level after an undergraduate
university education. The majority of USA students who apply to
optometry schools in the USA take their bachelor's degree in a science-
related subject; it is not mandatory, however (US-UK Fulbright
Commission 1999: 1-2).
Four years of undergraduate study is followed by four years of post-
graduate training at an accredited optometry school in order for a student
to be eligible to practise in the USA. Upon successful completion of an
accredited optometry programme, the Doctor of Optometry (OD) degree is
awarded. For international applicants, some USA optometry schools may
recommend that at least one year of undergraduate education must be
completed (US-UK Fulbright Commission 1999: 1).
All optometry schools and colleges in Canada (Spafford 2001) and in the
USA require applicants to take the Optometry Admission Test (OAT).
This is a standardised examination designed to measure general
academic ability and comprehension of scientific information. This test
includes quantitative reasoning, reading comprehension, physics, biology,
general chemistry and organic chemistry (US-UK Fulbright Commission
1999:3).
The OD degree is usually completed in four years. In general the four-
year programme includes classroom and clinical training in geometric,
physical, physiological and ophthalmic optics, ocular anatomy, ocular
disease, ocular myology, ocular pharmacology, neuroanatomy and
neurophysiology of the vision system, colour, form, space, movement and
vision perception, design. and modification of the visual environment,
visual performance, and screening. Unique to the educational
requirements of optometrists is the advanced study of optics, the science
of light and vision, as well as extensive training in lens design,
104
construction, application and fitting (US-UK Fulbright Commission
1999:2).
MS (master's in science) and Ph.D. programmes are for those who wish to
study vision science. These may be taken following a baccalaureate
degree or for foreign-trained optometrists who are interested in a
research-orientated curriculum. They do not, however, give the candidate
the right to practise (US-UK Fulbright Commission 1999:2). In order for a
student to become licensed to practise optometry in the USA, he or she
must attend a school that is accredited by the Council on Optometric
Education of the American Optometric Association, which has a list of 17
accredited schools of optometry (US-UK Fulbright Commission 1999:2).
Residencies are not required for licensing in the USA and they are usually
not part of the four-year optometry programme; clinical training is usually
part of the last year of the degree course. However, a small number of
OD graduates continue with either a clinical or non-clinical residency
programme for extended learning in a special area. They may also plan
to become a teacher of optometry or a researcher and may begin their
master's or doctoral degree studies in a residency programme (US-UK
Fulbright Commission 1999:3).
According to the Association of Schools and Colleges of Optometry
(ASCO) (ASCO 2000a), the Accreditation Council on Optometric
Education (ACOE) defines an optometric residency programme as a
planned programme of post-OD clinical education that is designed to
significantly advance the optometric graduate's preparation as a provider
of patient care services beyond entry-level practice. A residency must
last a minimum of 12 months and must be composed of appropriately
supervised clinical eye/vision care provided by the resident. A residency
105
should also include a well-designed mix of self-directed learning, seminar
participation, instructional experiences and scholarships (ASCO 2000a).
In the USA there are 17 schools and colleges of optometry: 16 in the
States and one in Puerto Rico. The programmes are all accredited under
the strict guidelines of the ACOE and therefore meet the educational
requirements for eligibility to practise in any State in the USA. Two
Canadian schools of optometry are also accredited by the ACOE, namely
those of the University of Waterloo and the University of Montreal (ASCO
2000b).
The training of optometrists in Canada has notably changed in a matter of
a few decades. Perhaps one of the best barometers of this change has
been the relationship of optometry to pharmaceutical use. Optometry was
initially a drugless profession. In 1979, the first Canadian law authorising
the use of diagnostic pharmaceutical agents (OPAs) by optometrists was
promulgated in the province of New Brunswick. By 1992, all provinces
had OPA legislation in place. In 1996, the province of Alberta became the
first region of Canada in which a law authorising optometrists to use
therapeutic pharmaceutical agents (TPAs) was adopted. Since then, two
of the remaining nine provinces have developed similar laws for
optometrists. Optometry curricula in Canada have needed to keep pace
with this shift towards disease detection and management (Spafford
2001:1 ).
Currently there are two Doctor of Optometry programmes in Canada. At
the Université de Montréal, École D'Optometrie, the language of
instruction is French. Each year 40 students are admitted to the four-year
programme, which has been offered since 1925. Its predecessor existed
in a private Montreal College from 1910. At the University of Waterloo
School of Optometry (UWSO) the language of instruction is English. The
106
UWSO began offering a four-year optometry programme in 1967. Every
year 60 students are admitted to the UWSO. Its predecessors were the
Central (originally Toronto) Technical School since 1920 and the College
of Optometry since 1953 (Spafford 2001: 1).
In order to gain a clear understanding of optometric education and
training in the USA, examples of the programmes that are being offered,
will be discussed briefly.
3.4.2 Programmes for optometric education and training
Applicants seeking admission to the Ferris State University must complete
80 credit hours of pre-professional courses prior to admission. Pre-
professional training must include some of the following, namely general
biology, general inorganic chemistry, college mathematics, etc. (Ferris
State University 2002: 1).
All optometry schools and colleges require applicants to take the
Optometry Admissions Test (OAT). The OAT, which is sponsored by the
Association of Schools and Colleges of Optometry, is a standardised
examination designed to measure general academic ability and
comprehension of scientific information. The OAT includes quantitative
reasoning, reading comprehension, physics, biology, general chemistry
and organic chemistry (US-UK Fulbright Commission 1999:3).
The Doctor of Optometry programme at the Michigan College is a four-
year professional degree programme. The degree Bachelor of Science in
Vision Science is granted, following completion of the first two years of the
professional programme, provided the student has completed all of the
university distribution requirements and does not hold a prior bachelor's
degree (Ferris State University 2002:1).
107
First-year courses cover the basic health and vision sciences which serve
as foundation for the clinical sciences. Students also begin their clinical
experience in the first semester in a clinical simulation laboratory with
fellow-students serving as "patients" (Ferris State University 2002: 1).
Second-year students begin their first direct patient care experience
during the Fall semester, while third-year courses focus on contact
lenses; assessment and management of vision and developmental
problems in children; and care of the elderly and low vision patients
(Ferris State University 2002:2).
All didactic courses are offered within the first three years of the
curriculum, freeing the entire fourth year for a concentrated clinical
experience. Except for practice management courses, administrative
conferences and senior research projects, emphasis is on real time
clinical activities (Ferris State University 2002:3).
Off-campus experiences also allow the student to gain a degree of
independence from the parent institution and are viewed as advantageous
for both individual professional and personal development (Ferris State
University 2002:3).
Prior to graduation, students attending the Ferris State University will
typically experience in excess of 1 500 patient examinations - an
extraordinary number of patient contacts and an exceptional educational
opportunity (Ferris State University 2002:3).
In 2000 the Pennsylvania College of Optometry introduced a reinvented
curriculum which, according to Thomas Lewis, President of the College,
"sets the standard of excellence for optometric education" (Pennsylvania
108
College of Optometry 2001). This curriculum is asserted to redefine
optometric education for the 21 st century, emphasising a more "hands-on",
self-directed educational model, featuring cutting-edge technologies like
Internet-based education and telemedicine; increased clinical experience;
and problem-solving modules linking basic and clinical science courses
(Pennsylvania College of Optometry 2001).
This Curriculum 2000 of the Pennsylvania College of Optometry is said to
incorporate the view of the College of optometrists as primary eye and
vision care providers. It is designed to produce an exceptional clinician
equipped with the knowledge, skills and values essential for career
success in an increasingly diverse and health-conscious society
(Pennsylvania College of Optometry 2001). The curriculum is built around
five major components, namely a primary care philosophy; increased
clinical skills training; new learning strategies; integration of new
technologies; and personal and professional development (Pennsylvania
College of Optometry 2001).
The Pacific University College of Optometry offers a 21-month post-
graduate programme terminating in a Master's of Science degree with the
emphasis on clinical optometry. This programme is built around a core of
seminars, designed to enhance the students' knowledge over a broad
spectrum of optometric subjects and that also allow for specialisation in a
specific area of optometry. The master's programme may be combined
with a residency (described in 3.4.1). The goal of the programme is to
provide post-graduate education in optometry directed toward preparing
individuals for careers in optometric education and the delivery of
advanced levels of care (Pacific University 2001:1).
The Optometric Residency Programme at the University of California,
Berkeley, School of Optometry, as well as affiliate programmes seeks to
109
recruit and admit the best-qualified post-graduate optometrists and to
provide them with advanced clinical education and concentrated clinical
experience in speciality areas of optometry in an institutional or hospital-
based setting. The mentored educational and clinical experience will
prepare optometrists for lifelong scholarship in patient care, education
and optometric leadership (The University of California at Berkeley 2002).
The objectives of the programme are to extend the education of a
selected group of graduate optometrists by one year so that they may
expand and refine their professional and speciality skills. The didactic
and clinical training will improve overall skills as well as develop a
speciality area/areas. This programme is enriched by means of additional
seminars and other educational opportunities. The duration of the
programme is 53 weeks. There are a limited number of positions and only
the best-qualified candidates are admitted (The University of California at
Berkeley 2002).
With regard to the eye care of elderly patients which was previously
referred to, Cohen, Soden, Martin, Liss, Hodson and Meyer (1987:386-
389) in an article on a comprehensive eye/vision programme describe the
eye care which has been provided to veterans at the Northport VA
(Veterans Affairs) Medical Center for the past approximate 36 years.
What started as basic eye care, developed into a comprehensive
eye/vision programme which started on 1 April 1984. The administration
of Northport VA Medical Center and the SUNY State College of Optometry
had signed an affiliation agreement establishing a residency programme
in rehabilitative optometry. In 1980, the programme was expanded to
include positions for two residents, who - among other things - present
lectures to various medical centre groups (e.g. nurses, etc.); receive
continuing education via monthly staff meetings; and receive veteran
affairs education once a week. The establishment of this programme has
110
provided the residents with experience they will need to meet the changes
in eye/vision care delivery systems of the immediate future, while there
has also been a vast improvement in patient satisfaction and an increase
in essential surgery rates (up to 150.0%) and productivity.
The above-mentioned programme testifies to the fact that, when
optometry is co-ordinated with the other health disciplines, patients
benefit because they are offered optometry's insights and skills in
providing health care as well as ready access to physician services,
ophthalmology and other medical specialities (Cohen et al. 1987:386).
3.4.3 SlUImmativeremarks
Optometric education and training in the USA and Canada are far
removed from what is found in the developing world, with special
reference to Africa. In contrast to the training in Africa, which is mostly
(almost exclusively) undergraduate, the training in the USA is exclusively
post-graduate. The optometric education system is well established, with
17 schools and colleges offering a variety of programmes, some with
more than one exit level (e.g. Bachelor of Science in Vision Science,
Doctor of Optometry) and the possibility of further studies in Optometry
(Master of Science, Ph.D.). In the programmes of the USA the various
needs of the population are addressed and students have opportunities
for research. Innovation is taking place in programmes, while new
developments in health and specifically in eye care are addressed in
various residency programmes. It should be noted that vast therapeutic
privileges are now afforded to optometrists in all states in the USA.
Whilst Africa experiences a serious lack of sufficient numbers of
optometrists, a study in the USA indicated a "surplus of eye care
providers" or an "excess capacity" (Di Stefano 1999:280). In Canada the
111
primary vision care needs of the population of just over 30 million people
are taken care of by approximately 3 300 practising optometrists (Spafford
2001). Di Stefano (1999:281), however, makes it clear that a
convergence between optometry's current capacity to deliver quality eye
and vision care and the serious unmet public needs would not only quickly
utilise the extra capacity, but may even produce a potential shortage in
future. Optometry in the USA is poised well to expand its role as primary
eye care practitioner. The expanding scope of practice, increasing
participation in managed care, and the quality and breadth of the services
optometrists provide, will define the future of optometry in the USA (Di
Stefano1999:281 ).
The picture of optometric education and training will not be complete if the
programmes in the United Kingdom (UK), Europe and Australia are not
attended to.
3.5 OPTOMETRIC EDUCATION AND TRAINING IN EUROPE, THE
UNITED KINGDOM AND AUSTRALIA
3.5.1 Introduction
The education and training of optometrists in Australia and the UK seem
to be at a high level and the institutions providing optometric education
provide in the needs of the countries. In Australia optometry can be
studied at three universities (Optometrists Association Australia 2001)
and in England eight universities offer optometric education and training
(City University London 2002). Europe seems to be having problems in
providing education of a level that will be acceptable to all the different
countries on the continent, but that is now being resolved through the
European Council of Optometry and Optics (ECOO) (ECCO s.a.).
112
3.5.2 Optometric educatioll1 programmes in Australia, the United
Kingdom and Europe
3.5.2.1 Australia
In Australia optometrists are educated to degree level at one of the three
institutes conducting optometric courses, namely the University of New
South Wales, the University of Melbourne, or the Queensland University
of Technology (Optometrists Association Australia 2001).
The duration of each course is four years and it leads to a bachelor's
degree in optometry. Teaching in the courses is undertaken by
optometrists, doctors and senior academic staff from various faculties.
Practical as well as theoretical training is involved. Students must
examine patients under the supervision of experienced clinicians in
general optometric and specialised clinics. A demonstrated competence
in clinical skills is a prerequisite of graduation (Optometrists Association
Australia 2001 ).
Subjects studied early in the training of optometrists include physics,
chemistry, physiology, biochemistry, microbiology, anatomy of the eye,
and optics. The later stages of the education include the study of
pathology of the eye and the diagnosis and treatment of disorders of
vision. Particular attention is paid to ensuring that every optometrist is
competent in the detection and diagnosis of eye disease (Optometrists
Association Australia 2001 ). Appropriately qualified optometrists in
Australia, Tasmania and New Zealand now enjoy therapeutic privileges
(Clinical and Experimental Optometry 2003: 193).
Optometrists may proceed to higher degrees (M.Sc., M.Optom., Ph.D.) at
each of the schools of optometry. Research in optometry and vision is
113
also carried out at several other institutions associated with the
universities, e.g. the Optometric Vision Research Foundation, the
Victorian College of Optometry, the Cornea and Contact Lens Research
Unit (CCLRU), the Collaborative Research Centre for Eye Research and
Technology (CRCERT), and the National Vision Research Institute.
These institutions are in the main financed by donations from members of
the profession, associated industries and Federal and State Governments
and instrumentalities (Optometrists Association Australia 2001).
The Department of Optometry and Vision Sciences of the University of
Melbourne is research-focused and has a strong graduate school. Higher
qualifications are:
o postgraduate Doploma onClinical Optometry
Master of Optometry (by research or by research and clinical work)
(University of Melbourne 2000a; University of Melbourne 2000b).
The Department also teaches Vision Science Research with the Master of
Science and offers a Doctor of Philosophy (Ph.D.) (University of
Melbourne 2000a; University of Melbourne 2000b).
Graduates in optometry interested in research training usually proceed to
the Ph.D. or M.Optom. degree. The choice of a Ph.D. or a master's
degree by research depends on the qualifications of the applicant and the
requirements of the individual laboratories. An optometrist graduating
from a four-year or a 3+1-year course in Australia, New Zealand, the USA
or the UK with a good honours degree is eligible to register for a Ph.D.
degree (University of Melbourne 2000a; University of Melbourne 2000b).
114
Graduates in other disciplines can register for either the Ph.D. or the
M.Sc. degree, depending on their undergraduate performance (University
of Melbourne 2000a; University of Melbourne 2000b).
o Postgraduate Diploma in Advanced! Clinical Optometry
This course is designed to further the knowledge and skills of optometry
graduates in selected fields of clinical optometry. It is usually studied for
one year full-time or two years part-time. A three-year part-time course
may be permitted with formal approval (University of Melbourne 2000a;
University of Melbourne 2000b).
Students are required to complete four course work subjects chosen from
a list of six subjects. Candidates may be permitted to substitute one of the
four required subjects for a subject or a short course of study offered by
another department of the university, or by another institution, provided it
is approved by the Department as a subject of equivalent workload and
standard and is appropriately related to the objectives of the diploma
(University of Melbourne 2000a; University of Melbourne 2000b).
Entry to the Postgraduate Diploma requires a four-year full-time degree in
optometry, or a degree awarded on completion of a three-year course
followed by a year of supervised clinical practice, and completion of
professional examinations at the end of that year (University of Melbourne
2000a; University of Melbourne 2000b).
Course objectives are to allow optometrists to re-examine the basic
sciences of optometry with the benefit of the latest information and an
emphasis on understanding and dealing with clinical problems. Courses
are in depth, challenging, and are designed to significantly advance
115
optometrists' clinical skills in selected fields (University of Melbourne
2000a; University of Melbourne 2000b).
Methods of teaching (with the exception of one course) are designed as
far as is practical so that they can be pursued without the need for regular
attendance at the university. Candidates are provided with a study guide
which includes notes and reading material. The study notes guide
reading, ask questions and suggest exercises designed to promote
understanding. It is expected of candidates to spend six to 10 hours per
week study time on the course. In most modules seminars are held once
or twice during the semester to answer candidates' questions (University
of Melbourne 2000a; University of Melbourne 2000b).
As far as assessment is concerned, formal arrangements are made for
written examinations to be taken in the city of residence of the candidate
or a nearby city (University of Melbourne 2000a; University of Melbourne
2000b).
o Master of Optometry (!by Researclh or by Research and ClilJ1lDcal
WorIk)
The Master of Optometry may be studied by research or by research and
advanced clinical training. Candidates proceeding by research and
advanced clinical training undertake a planned programme of clinical work
occupying one-third of their time. The principal areas of specialisation
include visual psychophysics, clinical visual function, clinical optics,
neurophysiology of vision, regulation of ocular growth and refractive
errors, binocular vision anomalies, and paediatric vision (University of
Melbourne 2000a; University of Melbourne 2000b).
116
Entry to the Master of Optometry requires a qualification which entitles the
graduate to practise optometry. A Master of Optometry by Research
takes one to two years full-time, or two to four years part-time to complete.
A Master of Optometry by Research and Advanced Clinical Training take
two years full-time to complete. Candidates undertake research under the
supervision of an academic staff member, producing a thesis of
approximately 30 000 words in length on their topic area. Candidates
spend approximately one-third of their time on clinical work and the other
two-thirds on research under the supervision of an academic staff
member/members (University of Melbourne 2000a; University of
Melbourne 2000b).
In addition to carrying out their research, all graduate students of the
Department attend and participate in the weekly graduate seminar
programme throughout their studies. Graduate students are expected to
complete a short course on statistics for research workers and are
encouraged to attend some of the short courses offered by the School of
Graduate Studies on the skills of being a successful researcher and an
academic. Graduate students are encouraged to develop their ability to
present their research work and ideas, both in writing and verbally. They
are given assistance with writing up their work for publication in a
scientific or professional journal and they make a short formal
presentation of their work to the Department once a year. Students are
encouraged to travel overseas to attend major international conferences
and present their research. There are travel grants to assist in attending
conferences (University of Melbourne 2000a; University of Melbourne
2000b).
The Department also teaches Vision Science research with the Master of
Science and offers a Doctor of Philosophy.
117
3.5.2.2 The United Kingdom
In the United Kingdom eight universities have departments of optometry,
namely the City University London, Anglia, Aston, Bradford, Cardiff,
Glasgow Caledonian, Ulster, and Manchester UMIST (City University
London 2002).
The General Optic Council (GOC) is the regulatory authority responsible
for the regulation of opticians in the UK and Northern Ireland. It does this
by providing for statutory registration, as well as by the accreditation and
monitoring of education, training and examination. It also enforces proper
standards of practice and conduct. Registration with the GOC is
necessary in order to practise as an optometrist or a dispensing optician
in the UK (GOC s.a.).
In the UK there are two types of opticians - "optometrists" (previously
ophthalmic opticians or 00) and "dispensing opticians". They must be
registered by the GOC in order to practise in the UK according to legal
requirements. In order to register, they must have undertaken training at
and passed examinations of a university or other training institute
approved by the GOC. However, European Community (EC) Directives
provide for the recognition of qualifications awarded in countries of the
European Economic Area (EEA) and there are special arrangements,
including an examination for those qualified in countries outside of the
EEA (GOC s.a).
With regard to Optometrists (00), the law states that (apart from medical
practitioners) only an optometrist can test sight. Dispensing opticians
(DO) are not permitted to test eyes. They fit and supply optical
appliances, according to prescription from an optometrist (GOC s.a.).
118
post-graduate courses offered by the Department of Optometry at the
University of Bradford are aimed at optometrists or those with a
qualification in a related discipline (e.g. Orthoptics, Ophthalmic Nursing).
The course provides further training in advanced methods of eye care
provision, in addition to specialist knowledge in a range of subjects
related to the clinician's own area of practice. The programme is
designed to be as flexible as possible in that, depending upon the number
of credits attained, candidates can be awarded a Post-graduate
Certificate. Through credit accumulation and transfer, candidates
studying for individual modules may be eligible for a Post-graduate
Certificate in the relevant module. Accumulation of further credits leads to
a post-graduate Diploma (120 credits) and then the degree of M.Sc. (180
credits) (University of Bradford 2001).
The programme has a modular structure and may be taken on a full-time
or a part-time basis. Candidates joining the programme on a part-time
basis are normally optometrists in practice who are registered with the
GOC. Through the University's Acquired Prior Learning (APL) scheme,
such candidates qualify immediately for 60 credits, leaving a remainder of
120 credits to be gained for the award of an M.Se. A total of 60 credits
can be earned through a choice of modules offered by the Department.
The modules on offer in any given academic year will come from the
following list:
o Ocular therapeutics; Diagnostic Techniques; Binocular Investigation,
Clinical Ocular Pathology; Paediatric Optometry; Contact lenses (all
30 credits).
e Low vision and ageing (20 credits).
o Clinical tests and decisions (10 credits) (University of Bradford 2001).
119
A total of 30 credits is offered each semester. The remaining 60 credits
are earned through the research projecUdissertation module. Part-time
candidates can normally complete the M.Sc. programme in around 18
months' time (University of Bradford 2001 ).
Full-time candidates may be UK optometrists who have not yet passed the
professional qualifying exams set by the College of Optometrists, or those
with a qualification in a discipline related to optometry. Alternatively, they
may be European Union or overseas candidates. Such candidates will
not normally be eligible for credits via APL and will therefore be expected
to acquire a total of 180 credits in order to be awarded an M.Sc. degree.
A total of 120 credits can be acquired through two taught modules (60
credits) and the compulsory research project/ dissertation (60 credits).
The remaining 60 credits are obtained from the following modules:
• Clinical Investigation (30 credits).
• Abnormal Ocular Conditions (20 credits).
• Binocular Vision and Orthoptics (10 credits) (University of Bradford
2001 ).
If taken full-time, the programme can be completed in one calendar year.
Candidates are examined in each module (apart from the research
projecUdissertation) during the last two weeks of the semester.
Assessments consist of a mixture of written papers, multiple choice
questionnaires, as well as practical or oral examinations. The
assessment of the research project takes the form of a report on an
approved topic (which can be undertaken in the candidate's professional
practice) or by the submission of a dissertation (University of Bradford
2001 ).
120
For research for the M.Phi!. and Ph.D., newly renovated and equipped
laboratories and close collaboration with local Departments of
Ophthalmology enable the Department to offer outstanding research
opportunities which are organised into two main groups, namely Visual
Neuroscience, and Optics and Ageing. Entrance requirements are
normally a good honours degree or an M.Sc. in Optometry, Neuroscience,
Orthoptics, Psychology, Ophthalmology, or a related discipline (University
of Bradford 2001 ).
3.5.2.3 Europe
The EGOO represents 24 nations. It is a confederation of the leading
professional bodies representing 22 countries in Europe, namely Austria;
Belgium; Groatia; the Czech Republic; Denmark; Finland; Greece; Ireland;
Italy; Luxembourg; the Netherlands; Slovenia; Spain; Sweden;
Switzerland; the UK; France; Germany; Norway; Poland;' Portugal; and
Slovakia (EGOO 2001:1).
European law defines the rules for recognising qualifications and requires
free movement of professionals. However, European law does not set a
common standard for the profession. Optometry has established the
highest levels of its own standards via the EGOO's European Diploma.
-
The profession protects existing standards, encourages higher standards,
and advocates new laws recognising the scope of optometry (Di Stefano
1999:11 ).
At the 1999 General Delegates Meeting, the WGO concluded that the
best approach to producing internationally accepted standards of
qualifications for entry into the profession was not via a world diploma, but
agreed that a modular system based on regional examinations would
provide a practical and flexible approach (Di Stefano 1999: 11).
121
The optometric profession in Europe is evolving from a technical
profession into a health care profession. Optometrists are trained
increasingly at universities and institutes of an equivalent level. Courses
normally last three or four years. This is the case in Finland, France,
Germany, Ireland, Italy, the Netherlands, Norway, Portugal, Spain,
Sweden and the UK. Elsewhere, optometrists are usually trained at a
technical school after high school, having gained either an intermediate
high school certificate or a final high school certificate (baccalaureat).
Usually a course lasts two or three years and includes a period of
apprenticeship with an optical firm (ECOO s.a.).
Opticians are also trained at a technical school after leaving secondary
school. The Member States of the European Union have their own
national policies on the training of the professions in general (the training
of a handful of professions, including doctors, has been harmonised by
EU law). Nevertheless, the optometric profession is beginning to
standardise its training by applying the ECOO European Diploma in
Optometry (ECDO s.a.).
The European Society of Optometry is the promotional and informational
vehicle and uniting force of the profession in Europe. It uses the various
languages of members and according to its statutes, its field of action
includes all the territory of historic Europe. Linguistic character must not
be confused with nationality. Borders do not exist in scientific work
(European Society of Optometry 2000). The Society is apolitical and
aconfessional. It is a transnational organisation with its headquarters in
Brussels and there are no national sections. The main goal of the Society
is the recognition of a free and independent profession. As far as
education and training are concerned, the European Society of Optometry
insists that it must be carried out at university level. The Society prepared
122
a syllabus of minimum university teaching which is the basis of a
professional diploma and which is being adopted by schools of optometry
in Europe (European Society of Optometry 2000).
This diploma, the ECOO European Diploma in Optometry, was developed
by the ECOO. The diploma is aimed at harmonising the standard of
optometry in Europe in order to facilitate the free movement and practice
of optometrists throughout Europe. The diploma demonstrates that
optometrists in Europe have the training and skills necessary to be a
principal provider of primary eye health care (ECOO 2000: 1). This
diploma comprises three parts, namely:
e Visual perception and optical technology.
@ Management of visual problems.
Cl) General health and ocular abnormality (ECOO 2000: 1).
To gain the ECOO European Diploma in Optometry, candidates are
required to pass a written multiple choice question examination and a
practical (patient care) examination of all three parts. Within each part,
candidates must successfully pass the written examination before they
can sit the patient care examination (ECOO 2000: 1).
The patient care examination will test the clinical, practical and
communication skills of candidates. Candidates need to possess the
fundamental knowledge and understanding of the scientific principles on
which optometric practice is built. They must have the ability to apply this
knowledge to the prevention, detection and management of clinical
conditions (ECOO 2000:1).
Depending on demand, the written examinations take place at various
centres throughout Europe. The patient care examinations are run at
123
examination centres in France, Germany and the UK. Initially and still at
present the examinations have been run in three languages, namely
English, French and German. It is hoped that more languages will soon
be available (ECOO 2000: 1).
Various education and training institutions therefore exist in the 22
different European countries previously referred to. These institutions
make provision for education and training at technical school level (post-
16 or post-18 years of age, i.e. technicians and opticians), as well as at
university or equivalent level (i.e. optometrists) (ECOO s.a.).
According to an overview of optometric education compiled after the
World Conference on Optometric Education 3rd session held on 8
November 1998, it was indicated that continuing education is organised in
83.0% of the European countries, professional and educational
organisations are involved at 44.0% (professional) and 41.0%
(educational). Post-graduate training represents 83.0% of continuing
education. Seminars which are organised, cover the entire field of activity,
namely scientific, technical and commercial. Professional organisations
set up compulsory continuing education in only three countries (17.0%)
(AEUSCO s.a.:page 6 of 9).
The ECOO states that optometric profession in Europe is evolving from a
technical profession into a health care profession, with more and more
entrants having been educated at university or university-level institutions
(ECOO 2001). It is foreseen that the majority of optometrists will still
combine the activities of refracting and dispensing optical appliances due
to the structure of the health care systems and the retail market for optical
products. The ECOO believes that optometrists are the most appropriate
clinical providers of eye care and examinations and, as national health
authorities seek to control the expenditure on health care, it is expected
124
that they will increasingly turn to optometrists as alternative providers of
primary eye care, particularly refractions (ECOO 2001). It should be noted
that certain European countries have vast numbers of ophthalmologists
who would perform more refractive work than their counterparts in, for
instance, the UK, the USA, Australia or South Africa where surgery and a
consultant role are favoured.
3.6 SIUMMATIVE PERSPECTIVE
Summatively it has to be pointed out that, just as economic and cultural
factors differ world-wide, education - and higher education in particular -
differs. Because optometry is recognised at different levels in the eye
care team in different parts of the world, education has advanced at a
different pace and no one model can be implemented on a universal basis
(at least not for the foreseeable future). However, it is clear that
optometry is striving world-wide to achieve wider recognition and, if
political matters are set aside, the public need demands that the
profession plays a bigger role in the avoidance of blindness.
The challenge for South African educators is to find a model that will
address the immediate public need, whilst allowing for the vertical
development within a career path to the highest post-graduate level
possible.
Post-apartheid policy created the opportunity that needs to be seized and
developed beyond the borders of South Africa in order to play a part in
Africa where there is perhaps the greatest potential for the profession to
realise its multiple exit model in addressing needs at primary and
secondary level.
125
When trends in optometry education are considered, it is not only
important for students to develop, but also for lecturers to develop
themselves in order to give the best possible education to others. Elam
(1996: 114) indicates that there are different ways for educators to do this.
While health care teachers may learn predominantly from experience,
there are more methodical ways of learning about teaching, cognition and
learning, as well as research in education. These are, for example:
o Individual initiatives reflection and teaching scripts. One method
would, for example, be to create a journal about teaching experiences,
while teaching scripts might also prove useful for instant instructional
purposes.
o Self-directed learning would, for example, include extending personal
knowledge (by writing and conducting personal research; by critically
observing a colleague's teaching in order to learn his/her methods; by
actively soliciting feedback from learners; and by having discussions
with colleagues and students to increase the awareness of
perspectives and assumptions about teaching and learning).
o Formal faculty development programmes, which would include
mentorship programmes teaching rounds, workshops, advanced
education, sabbaticals, organisational change efforts, etc. (Elam
1996: 114-115).
3.7 CONCLUSION
This chapter dealt with a selective review of optometry, not only in South
Africa, but also world-wide. The humble beginnings of the profession as
well as its development into a fully-fledged force to be reckoned with,
were depicted. Optometric education and training in South Africa were
dealt with first and legislation as encompassed in the Regulations defining
the Scope of the Profession of Optometry of the Health Professions
126
Council of South Africa (RSA DoH 2001) were expounded (see 3.2). The
different South African institutions where education and training are
offered, coupled with what education and training entail in each of these
institutions, were discussed. The institutions referred to are the TWR
(see 3.2.2), UNIN (see 3.2.3), UDW (see 3.2.4), RAU (see 3.2.5), the CT
(see 3.2.6), and the UFS (see 3.2.7). The roles of the GlO and
NEWENCO in South Africa were discussed, while the nature of CAS, as
well as the different kinds of CAS, was also explained (see 3.2.8).
Subsequently optometric education and training in the rest of Africa were
reviewed (see 3.3.1). Ghana (see 3.3.2), Tanzania (see 3.3.3), as well as
Nigeria and French-speaking Africa (see 3.3.4) were addressed. This
was followed by describing the nature of optometric education and
training in the USA and in Canada. Besides the general background;
requirements for study; different degrees and programmes as well as the
length of time they take; various bodies involved and residencies were
discussed; while prominent institutions were also referred to (see 3.4.1 -
3.4.3). Hereafter optometric education and training in Australia, the
United Kingdom and Europe, as well as the role of the ECOO in these
countries were addressed (see 3.5.2.1 - 3.5.2.3). Summative perspec-
tives were provided and trends in optometry education and training were
touched upon (see 3.6).
In the next chapter the role of CPD will be examined in great detail,
especially as it is playing an increasingly important role in optometry in
South Africa at the moment and will continue to do so in the future.
Criteria for CPD programmes and the content of the programmes will be
discussed, in addition to the role these programmes can and should play
in improving eye care.
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CHAPTIER .4
CONT~NU~NG PROIFIESS~ONAl DEVElOPMIENT (CPD) ~N
OPTOMETRY
4.1 ~NTROIDUCTION
Currently higher education is characterised by further or continuing
learning or development. The notion of a "vocation for life" learnt once will
have to be surrendered in favour of the idea of constant, that is, lifelong
learning, especially in the field of health professions. This fact is
emphasised by the European Union of Medical Specialists (UEMS) in the
following statement: "Continuous training shall ensure, in accordance with
the procedures specific each country, that persons who have completed
their studies are able to keep abreast of medical [and eye care] progress"
(2002: 1 of 3).
The rapid rate of developments in health sciences, coupled with the impact
of this on health care practice, has made it impossible to keep up to date
with developments relevant to practice. The knowledge and skills of every
individual decay over time and need to be refreshed and reinforced. From
a professional point of view, it should be mandatory to maintain
professional competence. Different reasons exist for this, among which
are legal considerations (Nel 1995:1).
CPD is an independent third phase of education, geared to the renewal,
maintenance, enhancement and facilitation of knowledge and skills.
On the one hand, research has indicated that knowledge starts becoming
obsolete from day one of an optometrist's practice and the situation
deteriorates over time. By the time an optometrist has been in practice for
128
20 years, serious gaps in knowledge and skills exist. On the other hand,
primary health care is receiving increasing emphasis and most practice-
based optometrists have little or no knowledge of community work. They
have little experience of detecting the early presentation of vision failure,
the extent of eye disease in communities, or the impact of disability on
relationships in family units. In practice they are not always kept informed
of the latest developments in basic care.
Lewis (1998: 339) asserts that students and practitioners are expected to
learn and know an enormous number of facts; some (perhaps many) of
which will be useless or false within a decade. A recognition of the
contribution of research and technology to practice has reinforced the
concept of "a lifetime of learning" which is so essential for optometrists.
Thus there is a serious need for optometrists to be re-educated. "We must
grow, we cannot afford to shrink" (Marren 1995:3).
4.2 RATIONALE
CPO [in optometry also called continuing optometry education (COE)] has
undergone enormous changes in recent years in terms of its theoretical
base, the methodologies used, and the expectations of what should be
delivered (Cantilion & Jones 1999: 1276). CPO has become increasingly
important for health professions and patients. As
reaccreditation/reregistration with regulating bodies has become more
widespread, the effectiveness of CPO programmes has come under closer
scrutiny.
Another aspect which has to be borne in mind is that there is no sharp
division between continuing medical education and CPO, as - according to
Peck, McCall, Melaren and Rotem (2000:432) - during the past decade
continuing medical education has come to include managerial, social, and
129
personal skills. These authors add: "The term continuing professional
development acknowledges not only the wide ranging competencies
needed to practise high quality medicine but also the multidisciplinary
context of patient care" (Peck et al. 2000:432).
The primary purpose of CPD is to maintain and improve clinical
performance (Cantilion & Jones 1999:1276). Recertification and
reaccreditation are part of the international trend to shift the purpose of
CPD to assuring adequate performance (Levine, Moore & Pennington
1984). The world in which health care professionals work, has changed
enormously. Increasing consumerism and patient empowerment; growing
accountability to professional and external bodies; and more emphasis on
efficiency and effectiveness have led to an intolerance of variance in
practice. Quality assurance' and the maintenance of standards have
become powerful forces for change. In optometry the expansion of the
scope of practice has put an increasing pressure on optometrists to
engage in COE activities.
Since South Africa is undergoing a period of change, it is important to
determine the impact of changes and, as change is usually a costly
process, it should be brought about in the most effective and efficient
manner possible. In accordance with the World Health Organisation's
philosophy, South Africa - with the rest of the world - strives for the
elimination of preventable blindness by 2020 and CPD is one of the
measures that can be employed in endeavours to achieve this (lAPS
s.a.d: 1 of 21).
One of the major objectives of accreditation and certification bodies,
professional associations/boards and employers, is to ensure that
professionals in health services are kept sufficiently qualified to keep on
practising. Research has indicated that, as time goes by, major
deficiencies occur in what the practising professional ought to know and
130
be able to do. These deficiencies increase the longer the practitioner is in
practice - to the extent that it becomes a serious matter by the time he/she
has been practising for 20 years (Cohen 1992). In South Africa long
distances to centres where courses are offered, coupled with a lack of time
and funding to undergo retraining, contribute to most health practitioners
being on their own to stay informed of developments in their field.
The profession of optometry is undoubtedly in need of CPO programmes
as well. The importance of CPO programmes for optometry to keep up to
a professional level cannot be denied. This fact is emphasised repeatedly
in the literature by various authors. Gutman (1998:9), for example, states
that optometrists must update their knowledge and keep up with scientific
innovations which are changing at an astonishing speed. Since
knowledge is rapidly being generated in all health care fields, the need for
occupational specialisation is enhanced. Le Roux (1992: 109) reiterates
that - in order to stay professionally productive - the practising
professional's knowledge and skills must be updated continuously, while
he or she must also be brought up to date concerning developments in the
particular field. Universities are especially equipped to fulfil this function.
The necessity of updating courses, completion courses and other CPO
programmes increases with policy changes and changes in the regulation
of practising optometry. There is an increasing need of CPO programmes
in a situation such as the current one in South Africa, where necessary
change in the educational level required in the profession is brought about
and the scope of practice is broadened.
Education based on new theories and techniques, stretching beyond what
students have learned in the structured curricula, is a valuable asset for
professionals who wish to gain up-to-date knowledge and enhance their
professional roles (Kabouridis & Link 2001: 103).
131
4.3 CRiTERIA FOR CPO PROGRAMMES
The need for CPD is now well recognised. An undergraduate professional
qualification is no longer regarded as a lifelong certificate of competence.
To keep abreast of developments in professional practice, the professional
has to find some way of keeping up to date (Harden & Laidlaw 1992:2).
There is growing international consensus regarding which forms of CPD
are most effective in stimulating behavioural change. Systematic reviews
of educational literature revealed that, although there have been
comparatively few rigorous evaluations of educational interventions, there
is sufficient evidence showing that continuing education programmes
could improve clinical performance and patient outcomes (Cantillan &
Jones 1999: 1277).
The traditional approach to CPD will no longer suffice. Thus proactive
action is called for from the side of the health care professions, including
optometry, to ensure that services remain relevant and that the needs of
the community and the public at large are satisfied. An undergraduate
optometry qualification is no longer regarded as a lifelong certificate of
competence; to keep abreast of developments in optometrical practice an
optometrist has to find some method of keeping up to date. The need for
COE has been well documented and, with the formalising of COE by the
Professional Board in South Africa, swift and innovative approaches are of
the utmost importance.
The demands made on adults in vocational life are subject to accelerating
change in a highly industrialised and mechanised society, with a
knowledge explosion in all fields. Education based on new theories and
techniques, offered by universities and other institutions beyond the
structured curricula, is a valuable asset for professionals and young
132
graduates who wish to gain up-to-date knowledge and improve their skills
(Kabouridis & Link 2001 :103).
The following factors play a role when CPD programmes are considered:
o The most recent, practically-oriented knowledge, skills and attitudes
must be transferred.
o The most effective, time-effective instructional methods, which are
educationally suitable for adult learners, must be applied.
o There must be a direct link between CPD, practice and current
optometry education approaches.
o Training must be provided by teams with different professional
backgrounds.
o Educational inputs (in the planning, preparation and presentation) are
imperative (Nel 1995).
To maintain and encourage quality in all forms of CPD and post-graduate
education and training, sets of educational criteria are required. By using
such criteria, programme designers and presenters can ensure quality in
their products; those responsible for auditing and administering
programmes can verify high standards; and clients can choose between
programmes and assess their value.
Harden and Laidlaw (1992) identified a set of criteria, called the CRISIS
criteria, which must be met to produce effective CPD programmes.
"CRISIS" is an acronym which stands for "convenience", "relevance",
"individualisation", "self-assessment", "interest", "speculation" and
"systematic presentation" (Harden & Laidlaw 1992:2). CRISIS is a
practical tool, based on 15 years' experience in the production and
evaluation of CPD programmes at the Centre for Medical Education at the
University of Dundee, while the criteria have since been proven to be
suitable for use in other CPD programmes too.
133
The criteria contained in CRISIS are the following (Harden & Laidlaw
1992:3):
Convenience makes voluntary participation easy.
Relevance reflects the user's day-to-day role in practice.
Individualisation allows learners a say in what is learnt and to adapt the
programme to their own needs.
Self-assessment encourages learners to evaluate their understanding
of the subject and to remedy gaps that exist.
Interest arouses attention and encourages learners to
participate.
Speculation recognises controversial and grey areas in the field
and
Systematic offers a planned programme with coverage of the
whole subject or an identified part of it.
The CRISIS criteria have been used in areas other than medicine (cf.
Harden & Laidlaw 1992:3) and have been found to be closely related to
Brookfield's (1986) principles for effective practice in facilitating adult
learning (Mulholland 1990:69-72).
Factors related to health professionals' decision to attend CPO
programmes were identified by research. These included such items as
convenience, travel, scheduling, preferable days, months, and fees.
Aspects related to delivery systems also play a role, e.g. programme
format, programme amenities, and programme location (Escovitz &
Augsburger 1991 :42). Other factors which influence the quality of CPO
programmes are the involvement or participation of the learners,
methodology, content, and the subject knowledge and teaching ability of
the programme deliverers (Kabouridis & Link 2001: 103). All these are
included in CRISIS.
134
CRISIS, it is acknowledged, may seem a simplification in the complex
world of continuing education and the real life situations of professional
practitioners, but it does identify the characteristics of programmes that are
successful in achieving the goals of CPO (Harden & Laidlaw 1992: 15).
Each of these characteristics as described by Harden and Laidlaw
(1992:3-15) is relevant in designing CPO programmes and in defining the
needs of practitioners with regard to professional development. Therefore
they demand further attention.
4.3.1 convenience
Continuing education opportunities must be available at the right place, at
the right time and at the right pace. Access to resources should be rapid
and easy. Subsequently each of these aspects will be discussed.
4.3.1.1 Place
Attending courses away from a professional's practice is expensive in time
away from the practice, travelling costs and accommodation. Thus a
tradition has long existed whereby practitioners keep up to date by
"educating" themselves at home through journals, books and magazines.
Far greater resources go into centralised learning, whilé community-based
learning has stayed the poor relation (Harden & Laidlaw 1992:3). In the
1990s research indicated that the most frequently used form of continuing
learning was conference or seminar attendance, whilst the next in
prevalence was continuing education through printed home study
materials (Escovitz & Augsburger 1991 :41).
Harden and Laidlaw (1992) recommend that centralised courses should be
made more convenient by adjusting the hours of post-graduate centres
and by providing practitioners with more details of events and resources.
135
The need for convenience has been reflected in the rapid expansion of
distance-learning activities, where the learner is situated at a distance from
the teacher, but with interaction between the two (Harden 1988:140).
4.3.1.2 T;~e
To attend a conventional course at a post-graduate centre or university,
the learner must adapt to fixed hours and schedules. This may be difficult
for busy practitioners with a range of commitments. The co-operation of
partners in a group practice may be required. This problem can also be
intercepted by distance learning where the user chooses the time and
duration of each period of activity (Harden & Laidlaw 1992:4).
Any fixed time, even a regular commitment at a set hour on a particular
day of the week, is awkward to keep to for professionals in practice. In a
study conducted in Ohio (Escovitz & Auqsburqer 1991 :45) among health
care professionals to determine their preferences in CPD programmes, the
respondents generally indicated a preference to attend one-day
programmes and preferred these programmes to be held on a Wednesday
or a Saturday. Medicine and optometry indicated a preference for two-day
programmes (Saturdays and Sundays), with optometry the only discipline
indicating a preference for one-day programmes held on a Sunday. With
regard to the time of the year programmes should be offered, December
was the least preferred month overall, but August was the least preferred
by optometrists.
4.3.1.3 Pace
In formal courses learners are traditionally constrained to learn at the
same pace. On the one hand, practising professionals who are new to a
topic may find it difficult to keep up. Those with the same previous
experience, on the other hand, could learn more quickly, but are forced to
136
slow down and may then suffer boredom in the course (Harden & Laidlaw
1992:4). The ingenuity of the course planner can be taxed here to make
allowances in the planning of the courses. Distance learning offers a
solution, as learners can work at their own pace, repeating as necessary
or skimming material already known.
Convenience in CPO can be increased by taking the education to the
learner rather than expecting the learner to come to the education - the
features and advantages of distance learning for CPO have been
described by Harden and Laidlaw (1992).
Practising optometrists frequently find it impossible to schedule long
periods for study and the times which are available for learning
programmes may be irregular. In these circumstances it is best to divide a
programme into a series of modules, each of which may stand
independently. This is also in line with the new policy for education and
training in South Africa.
It is likely that the future will see continuing efforts to make CPO more
convenient for the practising optometrist and most likely distance learning
will be part of this - not a replacement of other forms of CPO, but an
adjunct.
4.3.2 Relevance
Topics addressed in CPO programmes should be seen by the learners as
being relevant, as well as of practical importance, dealing with everyday
problems rather than just being of academic interest.
In the research of Escovitz and Augsburger (1991 :43), "currentness" and
"content" were consistently the two top reasons indicated by respondents
137
for attending GPO courses (optometrists also indicated requirement for
relicensure as a top reason).
The presentation of a series of facts is often seen as the basis of
continuing education programmes, but by themselves they may not be
regarded as relevant. It is how these facts are applied in practice that
makes them relevant. Facts themselves are simply inert knowledge, of
little use; therefore GPO programmes should not be overly theoretical
(Harden & Laidlaw 1992:6). Newton and Newton (1991 :45) assert that
relevance should be made explicit. Knowledge alone is in other words not
enough - the learner must be shown the uses to which that knowledge
may be put. According to Sheets and Henry (1988:82), it was found in an
evaluation of programmes that participants did best in topics that they
could apply immediately or in the near future.
Lack of relevance is a complaint found frequently among users of GPO
programmes. Relevance is related to the choice of topic and also to the
way or context in which the content can be put to use. In a survey
optometrists ranked the content of continuing education programmes as
the primary factor for attending a course (Escovitz & Augsburger 1991 :43).
Kabouridis and Link (2001: 108) in their study of short courses for adult
learners (GPO) found that such courses should be designed around the
real needs of the learners. They found that the theoretical parts of a
programme were deemed important, but that the relevance should be
Clear and that adults needed more practical training to absorb new
concepts.
According to Harden and Laidlaw (1992:6), relevance of a programme is
determined by three factors, namely the extent to which there is a match
or a mismatch between the content of the programme; the aims and
objectives of GPO in the area under consideration; and the deficiencies in
the learner's knowledge or competence.
138
Relevance of a programme can be improved by doing a needs analysis
among the professionals for whom the programme will be designed. To
ensure relevance, content and material should be aimed at a particular
audience and carefully checked for appropriateness. Eraut (2001 :9) states
that his experience in researching ePD in several professions identified
three problem areas which are rarely given sufficient attention, namely the
identification of learning needs; prioritisation of those needs; and matching
prioritised needs to learning opportunities and activities. These can all be
classified under Harden and Laidlaw's (1992) description of relevance.
Figure 4.1, which is adapted from Harden and Laidlaw (1992:6), is a
graphic presentation of the relationships between the three components of
relevance.
139
FIGURE 4.1: THE RELATIONSHIP BETWEEN THE THREE
COMPONENTS OF RELEVANCE IN A CPD PROGRAMME
PROGRAMME CONTENT DEFICIENCIES
What is covered in the Gaps in the practitioner's
programme knowledge or competence
AIMS OF CPD
Competences required of the
practitioner for optometry
practice
140
The components can each be described as follows:
o A: Aspects of the programme where there is a mismatch between the
educational activity on the one hand and the objectives of CPD and the
needs of the participant on the other hand.
o B: Aspects of the programme which, though relevant to continuing
education in general, are not relevant to the participant, as he/she is
already competent in that area.
o C: Aspects of the programme which address areas where the
participant is not fully competent, but which are not relevant to his/her
practice.
o D: Deficiencies in the participant's competence in areas where he/she
should be competent, but which have not been addressed by the
programme.
o E: A relevant programme. The area of competence addressed is, for
example, required for optometry practice. The optometrist is not fully
competent in that area and the topic is addressed in the programme.
Relevance depends heavily on meeting the learning needs of
professionals (cf. Eraut 2001). Dunn, Hamilton and Harden (1985) discuss
methods available to identify the needs of practitioners with regard to
CPD. These include, infer alia, the following:
o Task analysis.
@ Delphi technique ("panel of wise men").
o Critical incident survey.
e Behavioural event interview.
G Interviews with recent graduates.
Q Study of recent text books and other information of the subject.
E) Statistics.
e Study of errors in practice.
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Relevance can be accentuated by presenting the subject-matter in a
context with which the learner can identify. Lay-out and design in a printed
programme may also be used to emphasise relevance (Harden & Laidlaw
1992:7).
4.3.3 Individualisation
Learners following a CPO programme come from various educational
backgrounds and differing professional circumstances. Their needs will
therefore differ. A recently qualified optometrist may be up to date on a
subject, but lacking in experience; more senior colleagues may have the
experience, but lack up-to-date theory and skills.
The variation in individuals' needs may be divided into 10 areas (cf.
Harden & Laidlaw 1992:9):
o The type of practice, e.g. rural, urban, community, state.
o Previous experience and information of the topic.
o The degree of interest in the specific field.
o Preferred learning strategies and methods, e.g. lectures, group work,
problem-based learning, practical skills.
e Learning ability and speed.
o Amount of time available/willing to spend on CPO activities.
Q Time of day and day of week available for learning.
Q Preferred location for learning, e.g. home, in the practice, post-
graduate institution, conference centres, etc.
G Learning on one's own or with other professional members of the
health care team .
., Teaching responsibilities, e.g. in an academic position, participating in
undergraduate training, etc.
142
A real effort should be made to individualise continuing education
programmes in order to increase the likelihood of success. A number of
strategies can help a programme meet the individual needs of the learners
(Nel & NeI1995:8):
o Do not involve too large a target group in the ePD programme. The
smaller the group, the better the individual needs of each learner can
be addressed.
o Page lay-out and design, the use of headings and summary lists can
help learners to match the programme to their needs. A carefully
designed contents page and a quick reference guide may help learners
to find parts of the programme which are of particular interest to them.
o Feedback and self-assessment provide a powerful method of
individualising a programme (Harden & Laidlaw 1992:9). Responses of
learners can, on the one hand, indicate whether they are competent in
an area and they can then simply be given a brief reinforcement. On
the other hand, if responses demonstrate a failure to understand a
particular area, more detailed information can be provided.
o Programmes may also be designed to· take account of different
learning styles and strategies. Learners should be afforded the
opportunity to choose between problem-based, problem-oriented or
information-oriented approaches.
o Programmes should be designed to take into account the time the
learners have available to study the topic. In this case the learner must
be given the opportunity to make a choice between a programme
which briefly summarises facts and makes proposals as to, for
example, patient management challenges or an in-depth programme,
including, for example, an extended series of case studies, complete
descriptions and explanations, as well as full information on the topic.
li) Some professionals choose to share continuing education programmes
with other members of the health care team. To meet this need,
programmes can be designed for use by different disciplines.
143
Individualisation seems to be of particular importance in a COE
programme in South Africa, as the training of optometrists spans a wide
range and it is important to satisfy individuals' needs, also depending on
their field of interest and their practice circumstances.
4.3.4 Self-assessment
According to Harden and Laidlaw (1992:10), a feature which often
distinguishes successful from unsuccessful CPD programmes, is the
incorporation of a self-assessment component. Continuing education has
been equated to continuing self-assessment; critical self-appraisal being
the hallmark of the good professional. The examination of clinical practice
should be the key element in continuing education, which otherwise
becomes an intellectual or scientific game without a clear consequence
[New Leeuwenhorst Group (1986) as quoted in Harden & Laidlaw
1992: 10]. Even excellent practitioners can develop bad habits and
become outdated, an aspect which will show up in the mirror of self-
assessment.
Self-assessment can contribute in various ways to successful CPD:
o It can serve as a diagnostic test to determine whether learners need to
participate in a learning activity/programme and, if so, to select parts of
the programme from which they would benefit.
o It can assess whether learners have the competence or prerequisites
to undertake the programme.
o It can indicate whether learners have mastered the topics covered in
the programme.
o It can demonstrate to practitioners that they can go beyond the
contents of the programme and apply it in their own context. (Harden &
Laidlaw 1992:10).
144
Harden and Laidlaw (1992: 10-11) describe self-assessment as a three-
stage process:
o In the first stage, a question is put to the learner. This may be in the
form of an illustrated description of a patient with a choice of various
management options. In a computer-based course patient
management problems can be presented as evolving cases, with
developments affected by prior decisions.
o The next stage entails providing the learner with a mechanism to
respond. This may be in writing, or the response may be to make
selections from a range of options, or to score various choices on a
scale. In computer-based courses the responses may influence the
further development of the problem - the learner then faces the
consequences of his/her own decisions and the assessment is a
valuable learning opportunity. If learning takes place in a group, the
required response may be a discussion by the group.
e The key part of self-assessment is feedback. Feedback should
indicate whether the answer was correct or wrong and provide a
reason. The learner should be referred back to the learning
programme or additional reading matter where appropriate.
Implicit in any self-assessment is the notion of a standard as a benchmark.
The standard may be derived from the views of an expert in the field or the
consensus of a panel of experts. It was found very valuable to allow
participants in ePD programmes to compare their responses with those of
peers (Harden & Laidlaw 1992: 11).
The feedback may be available immediately or provided later. Feedback
provided later may be more sophisticated, more individualised and may
145
contain information about the responses of other participants. Harden and
Laidlaw (1992: 12) found self-assessment to be the most important aspect
of CPD in predicting the effectiveness of a programme. It can clarify or
even change the participant's educational objectives and can prompt
reflective deep processing of information, rather than surface learning.
The inclusion of self-assessment in a CPD programme is regarded as
being important, even if it has a minor place in the programme.
Computerised programmes provide the learner with the opportunity to
repeat assessments as often as regarded necessary to understand and
master the learning experiences (Super 1989:705).
4.3.5 Interest
Any continuing education programme has to compete for time in the lives
of very busy people. Even such a simple thing as the title of a course may
motivate a practitioner to take part. According to Harden and Laidlaw
(1992: 12), continuing education must be interesting to be successful.
There are three main reasons for this, namely:
(il To attract the attention of a potential participant.
e To encourage potential users to become actual users, as well as to
invest money, time and effort.
o To hold attention and sustain the participant's motivation to complete
the course.
The biggest motivator for continuing education seems to be the inherent
satisfaction of finding out new things and developing new talents (Harden
& Laidlaw 1992:12). A study (Levine, Moore & Pennington 1984:45)
showed that optometrists expressed the highest interest in continuing
education programmes which were related to specific case management
protocols, as well as programmes addressing general continuing
146
education topics with regard to patient and professional relations, and
interprofessional relations.
Personal contact with optometrists may help to gain their interest, while
the topic of the programme will also always be a major motivator. A
combination of five factors has been identified to maximise the
attractiveness of a programme and the interest of potential participants
(Nel & NeI1995:10; Harden & Laidlaw 1992:12-13):
o Relevance: This is most important. Anything that makes a programme
more relevant, will also make it more interesting.
o Presentation: The way in which the programme is "packaged", affects
interest. Escovitz and Augsburger's (1991 :44) research indicated that
even travelling long distances will not be a hindrance if a potential
participant is really interested in a particular programme. The
respondents in this study indicated a preference for programmes which
include a key note speaker as part of the package. Other matters with
regard to the "packaging" of a programme include the way in which the
material is presented, the medium or approach that is utilised, and the
persons presenting the programme.
o Text design and lay-out: With printed materials, a well-designed and
laid-out package may help to motivate learners to enrol for a
programme and to study the material. The design must guide them
through the material; colour and blocked paragraphs are helpful in this
regard. Material should also be offered in manageable chunks, while
sufficient space for notes encourage learners to annotate the text.
~ Visuals and colour: The use of illustrations, in text or by means of
projection during presentations, adds to the interest of learners and
facilitates learning.
Gl Active involvement: Learner participation is well recognised as of the
utmost importance for effective learning - no less so in the case of
professionals enrolling for continuing education programmes. In
147
computer-assisted learning and simulations active participation is a key
contributor to maintaining interest.
4.3.6 Speculation and systematic presentation
Presentation should consist of two aspects, namely speculation and,
furthermore, it should be systematic. Subsequently each of these aspects
will be dealt with.
4.3.6.1 Speculation
CPD programmes should not only concentrate on aspects of the discipline
which are established facts and in the process ignore areas where there
may be controversy. Areas of speculation and controversy should also be
included for the following reasons (Harden & Laidlaw 1992:14):
I') They will add to the interest of the programme.
o They will make the programme more credible - neglect to include
issues of controversy may lead to the programme being seen as
irrelevant to every-day practice, where issues are seldom clear-cut and
where uncertainty is common.
o Confronting such issues in a CPD programme may help the learner to
address them with more confidence in practice.
These areas - which are a focus for speculation - should, however, be
clearly distinguished from aspects which should be objects of mastery.
Areas where speculation may exist, include the following:
o Topics where there can be more than one "correct" answer.
Cl Recent advances which may not have been generally adopted or about
which there is still uncertainty.
148
o Subjects which are socially sensitive and have different interpretations
(Harden & Laidlaw 1992:14).
4.3.6.2 Systematic
Much of CPD takes place in a haphazard way. Practitioners may read
optometry journals and attend all the meetings in the local post-graduate
centre for a year, but not be sure what has been covered at the end of that
time. Barker and Suchoff (1995:44) define an optometric COE programme
as "a planned program of post-O.D. clinical education which is designed to
advance significantly the optometric graduate's preparation as a provider
of patient care services ... ". Although some CPD learning may proceed
happily in an ad hoc, opportunistic and unstructured manner, this is not a
satisfactory basis if optometrists are to keep up to date in all aspects of
practice. Structures are critical when undertaking further vocational
education: a lack of or unclear structures are often criticised by
participants in CPD programmes (Kabouridis & Link 2001: 106). The
learning capability of older people - who are used to thinking in a wider,
more holistic sense - is often superior to that of younger people and
because the attention span of learning is restricted by the stamina of the
participants during longer learning efforts, the systematic structuring of
CPD learning activities is a priority task (Kabouridis & Link 2001 :106).
To be systematic, a CPD programme should let the learners know how
and why aspects of the subject will be covered over a planned period. The
benchmark for systematic coverage of a particular topic is that a
programme should cover all that the learners need to know or be able to
do (Harden & Laidlaw 1992:15). CPD programmes should include a well-
designed mix of self-directed learning, seminar participation, instructional
experiences and scholarship (Barker & Suchoff 1995:44).
149
4.4 TYPES OF ePD PROGRAMMES
The CRISIS criteria for CPO programmes cover a wide field, but do not
distinguish among various types of CPO interventions. Jennett, Jones,
Mast, Egan and Hotvedt (1994), quoted in Eraut (2001: 10), distinguish
three types of self-directed CPO:
o Informal, ongoing habitual activities directed to the maintenance of
competence.
e Semi-structured learning experiences which typically have their basis in
immediate patient problems.
o Formal, intentional, planned activities.
As has been indicated, traditional approaches to updating knowledge and
skills in a profession will no longer suffice. Traditionally formal initial
education and training were supplemented by means of seminars; during
local, national and international conferences and other meetings; and
lectures or self-enrichment, mainly through printed media. Today,
however, structured CPO activities are required to ensure that CPO
reaches the practitioners; to keep them informed of the latest
developments and knowledge; to help them master new technology; to
support them in developing and maintaining clinical skills at the highest
possible level; as well as to satisfy the demands of the health care
dispensation and professional requirements. These are conditions which
have come into force with re-examination and reregistration (Nel 1995:3).
It is advisable to link CPO activities to departments of optometry and
faculties of health sciences. In general, it may be said that programmes
for CPO can be offered by means of disciplinary congresses, seminars
and workshops, as well as over longer periods, e.g. summer or winter
schools. It is important, however, to note that programmes will also have
150
to be taken to the practitioner; therefore a strong component of distance
education must be built into COE programmes.
The criteria which should apply in designing CPD programmes have been
discussed extensively, but can be summarised in four main points [to
some of these points Harden and Laidlaw (1992) did perhaps not
specifically pay enough attention]:
o Educational efficiency (educational interface, infrastructure, planning
and support).
o Availability of resources (financial, human, physical, technological).
o Attitude towards change (the demands and requirements of our times
need to be addressed).
o Interest and needs (needs analyses to be done) (NeI1995:3).
Programmes which are currently offered or may be considered, include the
following:
4.4.1 Formal programmes
o Course/programmes (theory and practical) offered according to a fixed
schedule, throughout the year, at a particular institution, but also
decentralised if the need arises and resources are available.
o Workshops and seminars (clinical skills will be emphasised).
o Distance learning programmes (e.g. printed materials, computer
modules, video programmes, audio lectures created at the institution
offering the programme and on which those taking the course can be
formally evaluated).
e Subject and optometry journals, in addition to other literature (source
retrieval, cataloguing and classification are done, while participants
work through the material on the basis of a participant manual -
efficient library services are a requirement) (Nel 1995:3-4).
151
4.4.2 Informal CPD
o Subject and optometry journals and other literature brought to the
attention of practitioners on a regular basis.
o Conferences, subject meetings, interest group meetings.
o The use of technology (computer programmes, video tapes, etc. as
commercially available, radio and television programmes).
o Refresher courses and practical workshops in departments, training
hospitals, other training facilities and clinics (Nel 1995:4).
4.5 ePD IN SOUTH AFRICA
In April 2002 a formal system of CPD was established for optometrists in
South Africa. In the document introducing the system (Kriel 2001b:2), it is
stated that the system has been developed in such a way as to be user-
friendly; that the 25 points required annually will be easily obtainable; that
CPD will be neither complicated nor costly for the individual practitioner;
and that it will take South African conditions into consideration. The
priority in CPD is said to be to achieve improved patient care, while it will
at the same time be of benefit to the development of the optometry
profession as a whole.
4.5.1 Adlministration
In South Africa the Professional Board for Optometry and Dispensing
Opticians administers the CPD system under the jurisdiction of the
HPCSA. The responsibility to accredit and review CPD activities is,
however, outsoureed to Departments of Optometry. Other professional
bodies wishing to be accredited for CPD activities have to apply to the
Board for appointment. The Board bears the responsibility to ensure that
activities which are outsourced, are carried out in a fair, equitable and
responsible manner. Therefore the Board retains the right to review or
152
withdraw any outsourced responsibilities from accreditors, should the
circumstances require it. Prior approval of educational and developmental
activities for GPO purposes must furthermore be obtained from the Board.
The Board sets the criteria and guidelines for such activities, as well as for
the approval and allocation of GPO points. Approved activities are
allocated a specific reference number by the Board for administration
purposes (Optisight 2001 :2).
Practitioners whose names appeared on the register for optometrists or
dispensing opticians on 1 April 2002, as well as those who registered as
optometrist or dispensing opticians in any category of independent
practice or public service (excluding those who are registered for non-
clinical purposes) after 1 April 2002, are required to comply with the
conditions of GPO as a prerequisite for such a practitioner to retain
registration.
A practitioner whose name was removed from the register or one who was
registered for non-clinical purposes, has to comply with any condition(s)
the Board may specify prior to restoration/registration for the purposes of
rendering clinical services. If a practitioner does not accumulate the
prescribed minimum of points in anyone year, such a practitioner will be
permitted to obtain as many points as required in the subsequent year
(Optisight 2001 :3).
4.5.2 Categories of educational and developmental activities and
allocation of points
The basic premise for point allocation for activities in the three categories
of educational and developmental activities for GPO purposes is that one
hour equals one point. The eventual responsibility rests with the
Accreditors to adapt sub-optimal activities downward to an appropriate
153
point allocation per time unit and to recommend to the Board accordingly.
The following requirements apply:
o Every optometrist is required to accumulate at least 25 points within
anyone year, provided that any points accumulated during one year, to
the excess of 25 points, may be forwarded only to the subsequent
year.
o Every dispensing optician is required to accumulate 15 points within
anyone year, provided that any points accumulated to the excess of 15
points may be forwarded only to the subsequent year.
During one year, not more than 80% of the points may be accumulated in
anyone category. To comply with this requirement, at least two points
have to be obtained by every practitioner in professional ethics annually.
A maximum of five points may be obtained in non-clinical but health-
related activities annually. Any relevant educational or developmental
activity that does not fall within the activities as listed in the categories
given, may be submitted to the Board for approval and, if the Board
agrees, such activities will be accredited.
4.5.2.1 Category 1: Organisational activities
Attendance of formal learning opportunities is credited with one point per
hour for attendance. These activities include, but are not restricted to,
conferences, congresses, workshops, lectures, seminars, and refresher
courses.
4.5.2.2 Category 2: Small-group activities
Participation in non-formal learning opportunities is credited with one point
per hour where participants are actively involved. In addition, one point
per hour is granted for presenting such activities.
154
4.5.2.3 Category 3: Individual activities
These activities include the following:
o Self-study
Only self-study activities evaluated by an approved provider are
considered. These activities include, but are not restricted to, studying
journals, as well as electronic or computerised material.
o Individual learning
These activities are credited with one point per hour. These include, but
are not restricted to, skills training, e.g. gonioscopy and short-term studies
at training institutions. Prior approval has to be obtained for such activities
to be taken into account for points and attendance must be verified.
o Research and publications in peer reviewed/continuing
professional development journals
The first author is credited with 10 points and co-authors are credited with
five points each per published article.
ct Teaching and/or training activities
Teaching and/or training of undergraduate, post-graduate students and/or
peers is credited with one point per hour. This is restricted to practitioners
who hold part-time teaching posts.
ct Paper/poster presentations/lectures to peers
Papers, posters, invited lectures and keynote addresses are credited with
10 points.
ct Relevant additional qualifications
25 points per year are allocated for academic qualifications. These points
are added to other points accumulated during the period of study.
155
o Evaluations/assessments/examinations
These activities are credited with one point per hour and include, but are
not restricted to, undergraduate and post-graduate examinations,
evaluations undertaken on behalf of the Professional Board, and
assessment of theses or scripts.
o Supervision of candidates for higher degrees
These activities are credited with 10 points per candidate per year and
include being the promoter, mentor or study leader for master's or
doctorate qualifications.
o Community service
As compulsory community service is not yet regulated for optometrists and
dispensing opticians, points for community service are awarded to
encourage practitioners to participate in such activities, with the added
advantage that feedback is provided to the Board and the Department of
Health so that specific needs may be identified. One point for every hour
worked on a voluntary basis in a recognised government or non-
governmental organisation facility is awarded. Application may be made
for the recognition of special projects.
o Professional ethics
A minimum of two points in professional ethics is required from all
practitioners annually.
e Non-clinical but health-related activities
A maximum of five points may be obtained in non-clinical but health-
related activities in anyone year (Opfisighf 2001 :2-3).
156
4.5.3 Deferment and non-compliance
Practitioners may apply for deferment of ePD and the Board reviews such
applications individually, on the basis of reasons acceptable to the Board.
In the event of a practitioner not complying with the requirements of the
ePD system, the Board may impose anyone or more of the following
conditions:
Cl) Granting the practitioner a concession for one year extra.
e Requiring the practitioner to follow a remedial programme of continuing
education and training as specified by the Board.
e Requiring the practitioner to write an examination as determined by the
Board.
o Registering the practitioner in a category of registration which shall
provide for supervision as regarded as appropriate by the Board.
o Registering the practitioner in a category of registration restricted to
non-clinical practice.
o Erasing the practitioner's name from the relevant. register.
The practitioner has a right to appeal against any decision of the Board.
4.5.4 Providers of ePD activities
Providers of ePD activities include any body such as a faculty/department
of a university/technikon, a professional association/society/group or any
other body which offers educational and development opportunities to
practitioners for ePD purposes and may include other related industrial or
provider organisations. Providers of ePD activities are required to submit
their proposed programmes of activities to a relevant ePD Accreditor for
assessment of the professional content and the ePD points value thereof.
157
Applications for approval of CPO activities must be submitted on the
application form provided by the Board (Optisight 2001 :5).
4.5.5 Aceredttors of ePD activities
As referred to previously, the Board accredits a variety of bodies to serve
as accreditors of CPO activities. Such accreditors are required to submit
their applications for approval on a specified application form. Applicants
are required to specify the area(s) for which they wish to be accredited, as
well as their expertise and representativeness in the proposed area(s), in
addition to their administrative infrastructure.
To get the process going, the Board provisionally approved a number of
bodies as accreditors. Specific applications are considered for approval in
anyone or more of the areas. It is the responsibility of the accreditors to
receive and assess applications by providers for the approval of CPO
activities. Such assessment is based on the criteria provided and in terms
of professional content. After positive assessment, an application is
referred to the Board with a recommendation for approval and the
proposed point value of the activity (Optisight 2001 :5).
4.6 THE HIEAl TH PROFIESSlONS COUNCil OF SOUTH AFR~CA
(HIPCSA)
4.6.1 Background
The HPCSA is a statutory body established in terms of the Health
Professions Act of 1974 (RSA 1974). The HPCSA is an umbrella body with
12 professional boards functioning under its jurisdiction. The Council, in
conjunction with the professional boards, is committed to promoting the
health of the population; determining standards of professional education
158
and training; and setting and maintaining fair standards for professional
practice.
The HPCSA is an autonomous body which receives no grants or subsidies
from the government or any other source. It is totally funded by the
relevant professions. The main consumer of its services, namely the
public, does not and is not expected to contribute financially to its
functioning.
4.6.2 Registration with the HPCSA
In order to safeguard the public and indirectly, the professions, registration
in terms of the Act is a prerequisite for practising any of the health
professions with which the HPCSA is concerned. Practising any of the
professions falling under the jurisdiction of the Council for which a scope of
practice has been promulgated without being registered with the Council,
is a criminal offence in terms of the Act.
Registration confers professional status to a practitioner and thus the right
to practise the profession for which he/she is qualified. Practitioners
therefore enjoy the security of being registered in terms of the Act in the
knowledge that no unqualified person may practise their profession. The
HPCSA's registers are to the advantage of practitioners whose names
appear in them, since this confers public recognition of the competence of
the practitioner, who are therefore in a position to command a reward for
the services rendered (Optisight 2001 :6).
Professionals who register in terms of the Act are: audiologists,
audiometricians, biokeniticists, clinical biochemists, clinical technologists,
dental therapists, dentists, dieticians, emergency care personnel,
environmental health officers, genetic counsellors, hearing aid acusticians,
medical orhotists/prothetists, medical physicists, medical practitioners,
159
medical scientists, medical technologists, medical technicians,
occupational therapists, optical dispensers, optometrists, oral hygienists,
physiotherapists, podiatrists, psychologists, psychometrists, psycho-
technicians, radiographers, as well as speech-language therapists.
Pharmacists, nurses, chiropractors, homeopaths, and dental technicians
have their own statutory regulatory bodies (Optisight 2001:7 -8).
4.6.3 !Professional Boards
There are 12 professional boards functioning under the jurisdiction of the
HPCSA. They are:
o The Professional Board for Dental Therapy and Oral Hygiene
o The Professional Board for Emergency Care Personnel Practitioners
o The Professional Board for Medical Technology, Medical
Orthotics/Prosthetics
o The Professional Board for Optometry and Dispensing Opticians
o The Professional Board for Psychology
o The Professional Board for Speech, Language and Hearing
Professions
o The Professional Board for Dietetics
o The Professional Board for Environmental Health
o The Medical and Dental Professions Board
o The Professional Board for Occupational Therapy
o The Professional Board for Physiotherapy, Podiatry and Biokinetics
e The Professional Board for Radiography and Clinical Technology.
The Professional Boards assist in the promotion of health of the population
on a national basis; control and exercise authority regarding all matters
affecting the education and training of all persons in any of the professions
falling within the ambit of the Professional Boards; promote the standards
of such education and training in South Africa; advise the Minister of
160
Health on any matter falling within the scope of the Act in order to support
universal norms and values of the professions; and maintain and enhance
the dignity of the professions and the integrity of the persons practising the
professions in order to guide the professions and protect the public.
All matters specifically pertaining to a particular profession, that is those
that do not infringe on the functioning and practice of another profession,
are dealt with and finalised by the Board concerned. This includes full
powers in respect of professional conduct issues and financial matters,
including the budget (Optisight 2001 :7).
A Professional Board's function, as it relates to professional practice, is to
set, maintain and apply fair standards of professional conduct and practice
in order to effectively protect the interests of the public. It should be noted
that the HPCSA itself is not involved in this process, except in so far as
decisions relating to strategic policy need to be reached.
The regulations pertaining to professional conduct inquiries of the
Professional Boards are discharged in accordance with legal principles,
following upon formal complaints lodged against a registered person. The
need for impartiality is self-evident and clearly implies the observance of
every nuance and fact of legislation, as well as of the basic human rights
of the public, but, at the same time, also those of practitioners. The public
has the freedom to lodge a complaint with a Professional Board, in
addition to having access to avenues of civil legislation. Furthermore, the
courts have a legal obligation to inform the HPCSA of proceedings in
which registered persons are found guilty.
161
4.7 DISCUSSION
With knowledge becoming so proliferated, diverse and specialised, it is
apparent that no profession, let alone that of a teacher or being a student,
can know or master everything that has to be learned (Super 1989:708).
In a literature study by Grant and Stanton (1998), they came to the
following conclusions regarding ePD:
o The key to the effectiveness of ePD is not to be found in the learning
methods adopted.
o There is not a best learning method and no best approach to learning.
() Instead, the key to effectiveness is to make sure that the process of
ePD is effectively managed to have the following components:
- A stated reason for the ePD to be undertaken. This might be
specific (for example, a need to develop a new skill), or it might be a
general professional reason (for example, a wish to undertake
general professional updating with colleagues at a conference). It
might also arise from the needs of the service (e.g. to develop the
skill to offer new areas of care to patients).
- An identified method of learning, which might be formal or
informal.
- Some follow-up after the ePD for reinforcement and
dissemination of the learning. This might be actions such as
reporting back to colleagues, developing new services,
demonstrating new skills, or simply feeling more confident in
practice.
The role of optometrists in the health care of our nation cannot be denied.
The current problem of practitioners who are not up to date with recent
developments can be solved by means of eOE programmes, designed to
meet individuals' needs and serving the health care needs of our
communities.
162
4.8 SUMMATIVE PERSPECTIVE
The profession of optometry has been a leader in the movement to
formalise continuing education through mandatory participation related to
renewal of licensure in the USA (Escovitz & Augsburger 1991:41). The
assumption has been that, by means of this vehicle, practitioners can keep
abreast of scientific, technological, clinical patient care, as well as social
changes affecting their practices so that they can actively participate in
these changes. South Africa is now undergoing the same processes and
the following questions need to be answered with regard to eOE: Do
optometrists participate in continuing education because it is mandatory?
Do other factors enter into the decision to undertake eOE? Are providers
of eOE addressing the perceived needs of optometrists? What changes
can be made to offer optometrists better opportunities for eOE? A needs
analysis has therefore become mandatory to find answers to these
questions.
Another issue which has to be addressed with regard to eOE, is the issue
of standards (cf. Barker & Suchoff 1995). With the numbers and types of
ePD programmes expected to grow with the establishment of mandatory
ePD in South Africa, it has become important to revisit current
programmes and reach conclusions as to standards. This will ensure
uniformity in the quality of programmes. The philosophy of optometry and
eOE should encompass a willingness and commitment to change so as to
adapt to new knowledge, scientific discovery technological advances, a
changing environment, as well as changing human needs.
In summary, this chapter raised several issues that should be attended to
when eOE programmes are designed. The basic factor that is often
criticised by participants in ePD programmes is the structure. ePD
programmes must also be based on the real needs of the potential
participants. Aspects of participants' motivation should not be negated.
163
Education and the delivery of health care are interdependent. Currently
the nation's emphasis on health care reform raises questions as to the
appropriate educational processes to keep optometrists' education and
training current and relevant for their participation in the new health care
dispensation. The expanding scope of practice and the increased
professional responsibility for the treatment and management of ocular
disease require that a new look be taken at COE. Therefore a framework
for establishing a model to reflect the changes occurring in the profession
and in health care in South Africa needs to be established.
Properly designed continuing optometry education activities, meeting
professional needs and interests, together with proper evaluation
techniques, can and will make effective and efficient contributions to
promoting positive change in the attitudes, knowledge, skills and
behaviour of health professionals, which, in turn, will positively impact on
the welfare of our patients.
Peck et al. (2000:435) state that legislated revalidation and recertification
of practitioners are driving the profession towards mandatory professional
development programmes internationally, covering a spectrum of clinical,
professional, and managerial activities. Most systems worldwide rely on
professional self-regulation. Even where there is no mandatory system,
many optometrists are already active participants in the process.
Increasingly there are common features between specialities and across
borders and recognition of such between national and international bodies.
Whatever system is adopted, however, every optometrist has a personal
responsibility to participate in CPD and has a choice of a wide range of
accredited educational activities to fulfil that responsibility.
164
4.9 CONCLUSION
This chapter emphasised the nature, necessity and extreme importance of
CPO (cf. 4.1; 4.2). The criteria for CPO programmes were outlined and an
exposition of the well-known CRISIS criteria provided (see 4.3). Each of
the characteristics of the CRISIS criteria was described and explained in
depth, while the perspectives of various authors were also provided.
Paragraph 4.4 dealt with the different types of CPO programmes,
whereafter paragraph 4.5 described CPO in South Africa. The latter
paragraph discussed its administration (see 4.5.1), while the categories of
educational and developmental activities and the allocation of points were
also outlined (see 4.5.2). Other aspects which were touched upon, were
deferment and non-compliance (see 4.5.3), as well as providers and
accreditors of CPO activities (see 4.5.4; 4.5.5).
Subsequently an exposition of the HPCSA with the 12 professional boards
functioning under its jurisdiction and its function, background and
importance was provided, while the aspect of registration with this body
was also explained (cf. 4.6.1; 4.6.2; 4.6.3). Finally, some serious issues
which should be attended to when CPO programmes are designed, were
broached in paragraph 4.8, while the importance of CPO was once again
reiterated.
In the next chapter the research methodology will be discussed and dealt
with in detail.
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CHAPTIER 5
RESIEARCH METHODOLOGY
5.1 INTRODUCTION
A wise man once stated that a fool can ask more questions in one hour
than a wise person can answer in a lifetime. In the same way any analyst
finds him/herself in a maze of questions and variables. Therefore it is not
possible to proceed without a plan or a method. In planning a research
project, it is of extreme importance to decide which methods and
techniques will serve the purpose of the research best (Leedy 1993:127).
Research has been described as the assumptions, methods and
procedures used to create knowledge by empirical and rational means
(Landman 1988:80). This research took the form of a descriptive and
exploratory study (Babbie & Mouton 2001), comprising a literature review
and an empirical investigation.
The literature review covered factors influencing the design of optometry
education and training programmes; aspects of optometry education and
training; the demands made on optometry education and training as part of
higher and health professions education and training, as well as CPD; and
the needs and possibilities for optometry education and training in
changing circumstances in South Africa.
The data in the empirical study were collected by means of a
questionnaire survey, carried out among practising optometrists in South
Africa to determine their needs in connection with post-graduate studies,
as well as the possibilities available for optometrists in South Africa to
further their studies and enhance their knowledge and skills as
professionals in health care services.
166
The empirical study therefore took the form of a needs analysis. A needs
analysis is not a new or a rare phenomenon in education - back in 1975
English and Kaufman (in Wolmarans & Eksteen 1987: 1) pleaded for a
process of defining the ends of education and then selecting the means
most promising to assist educators in reaching the "promised land".
Curriculum development has to be based on needs. The potential gain of
a profound needs analysis includes higher levels of efficiency (that is
productivity) and, in the case of educational institutions, consumer
satisfaction, which will lead to increasing community service and support
(Woimarans & Eksteen 1987:2).
Recently the optometry profession experienced several significant
changes, namely an expanding scope of practice; advances in diagnostic
and treatment methods; and the implementation of a reregistration system
(based on COE). In tandem with this, HET has also undergone several
changes, with an emphasis on OBET; a focus on generic skills; and RPL.
Taking this into consideration, if optometry wishes to ensure continued
viability, it is essential that the present and the future needs of the
professional, as well as of the patient, be taken into consideration - thus
the necessity for a needs analysis.
5.2 THEORETICAL PERSPECTIVES ON THE RESEARCH
METHODOLOGY
This research was based on a phenomenological preparation, namely the
literature review, to provide reliable data for understanding the
phenomenon (cf. Verma & Beard 1981:187). The phenomenology here
served the purpose of ensuring sufficient background knowledge on the
subject, in addition to generating a number of criteria to be used to
determine the needs of optometrists with regard to their education and
training. These criteria were eventually converted into items contained in
167
a questionnaire used for the needs analysis. The questionnaire survey
constituted the empirical part of the study.
The two main paradigms (models) (Landman 1988:73) which have
dominated the educational research scene for the past century were
quantitative and qualitative research methodologies (Mafisa 1999:118).
The quantitative approach is typically used to answer questions about
relationships among variables with the purpose of explaining, predicting
and controlling phenomena, while the qualitative approach is typically used
to answer questions about the nature of phenomena with the purpose of
describing and understanding the phenomena from the participants' point
of view (Leedy 1997:104). For this study, a quantitative design was used
(cf. Babbie & Mouton 2001), but open-ended questions were also
included, adding a qualitative dimension (cf. 5.1). The greatest emphasis
was, however, on a quantitive design. According to Robson (in Mafisa
1999:118), a research problem can be addressed by using more than one
method, an aspect which seems to have substantial advantages. One
vital advantage of the use of multiple methods is the reduction of
inappropriate certainty. Using a single method and finding a clear-cut
result may delude investigators into believing that they have found the
correct solution. Using an additional method may then point to differing
perceptions, which might remove specious certainty (Mafisa 1999:118).
The two approaches are used to complement each other and to provide a
broader understanding of the research problem. As used in this
investigation, the multiple approach also enhanced the interpretability of
the research findings.
While quantitative methodology relies heavily on figures for analysis,
qualitative methodology, with its emphasis on the human element
(expression of opinions and ideas), on the other hand, provides additional
information which cannot be covered by quantitative methods (Mafisa
1999:119). The open-ended questions in the questionnaire survey
168
represent the qualitative responses (opinions and ideas expressed in the
respondents' own words), while, for the closed questions, quantitative
methodology was employed (Babbie & Mouton 2001 :52).
The study reported here falls into the category of descriptive surveys. A
survey that is primarily descriptive, seeks to describe the distribution within
a population of certain characteristics, attitudes, or experiences (Singleton
& Straits 1999:243). The objective of a descriptive study, as the name
implies, is to describe a phenomenon. Basically a fact-finding enterprise,
a descriptive study is structured, and focuses on relatively few dimensions
of a well-defined entity. These dimensions are measured systematically
and precisely, usually with detailed numerical descriptions (Singleton &
Straits 1999: 91). Landman (1988:59) defines descriptive studies as
research which does not set out to test hypotheses, but desires to find
distribution of variables. This is the type of survey which is primarily
concerned with the nature or degree of existing situations or conditions. In
this study the existing situation with regard to post-graduate and/or
continuing professional optometry education and training was investigated.
It is important that control measures should be applied for research
credibility. The two main mechanisms of quality control in research are
reliability and validity (Mafisa 1999: 120). "Reliability" refers to the extent to
which studies can be replicated, that is, consistency of obtaining the same
relative answer when measuring phenomena which have not changed
(Landman 1988:80). "Validity" is the extent to which an instrument or
procedure satisfies the purpose for which it was constructed, that is, it
determines that which it was designed to determine (Landman 1988:96).
In this study the reliability of the instrument (questionnaire) was
established by means of a pilot study, the inclusiveness of the sample, and
the response rate. The validity of the findings rests on the in-depth
169
literature survey, the experience of the researcher, as well as the number
of respondents who participated in the study.
5.3 METHODS AND PROCEDURES
The methods used in this investigation comprised a literature study - which
formed the basis of the study - and a needs analysis, the empirical study,
to determine the needs of and the opportunities available to optometrists in
South Africa with regard to further, post-graduate and/or continuing
optometry education and training. Quantitative and qualitative measures
were applied.
5.3.1 Literature revlew
A literature review has as its aim placing the problem in the context of
related theory and research, as well as to ensure that the researcher is
sufficiently informed about the topic to be able to investigate it in an
informed manner (Singleton & Straits 1999:544). A literature review must
make clear the theoretical context of the problem under investigation and
how it has been studied by others. Thus the idea is to cite relevant
literature in the process of presenting the underlying theoretical and
methodological rationale for the research (Singleton & Straits 1999:547).
In this study the purpose of the literature review was to establish a
background to and a context for the research problem; to justify the need
for the research; and to indicate that the researcher was knowledgeable
about the field of study and the particular area under investigation (cf.
Landman 1988:69). Based on the literature study, a phenomena logical
perspective was established, as the focus was on the meaning of the
phenomenon of continuing/post-graduate/further optometry education and
training. This was a search for meanings and, through it, assumptions in
concepts and methods were uncovered (Landman 1988:75).
170
The focus of the literature survey was factors influencing programme
design, namely the current state of optometry education and training in
South Africa within the context of higher education; the current demands
on health professions education and training; the new higher education
dispensation in South Africa; health care demands; and the changes in
optometry education and training, not only in South Africa, but also world-
wide. Attention was paid to the history of the optometry profession, as well
as that of education and training in South Africa; the role of statutory
bodies; the transformation of education and training in South Africa.
Use was made mainly of research results as reported in journals,
government publications and publications of optometry institutions and
bodies. The development of the profession; the requirements of world
optometry and health organisations; as well as the demands, needs and
requirements of the South African health care dispensation received
particular attention, in addition to needs identified in the profession,
especially with regard to the expansion of the scope of practice. CPO, or -
within the narrower focus - COE, was also included.
The literature study (see Chapter 2) indicated that in optometry education
and training in South Africa, a need might have developed for further
education, based on the developments in the scientific field and the needs
and expectations of society, health authorities and the profession. As
practising optometrists have it in their ability to address these needs, the
logical procedure would be to identify their (the practising optometrists')
needs in order to devise a programme that would enable them to satisfy
their own needs, the needs of society, the health system and the
profession.
171
5.3.2 The empirical study
"Data sometimes lie buried deep in the minds or attitudes, feelings or
reactions of people. As with oil beneath the sea, the first problem is to
devise a tool to probe below the surface" (Leedy 1997: 191). A
commonplace tool for collecting data beyond the physical reach of the
observer, is the questionnaire. Questionnaires and data-collecting for
traditional researchers are almost synonymous. Questionnaires are
defined in literature as a reasonable way to tap attitudes, opinions,
perceptions, reactions to specific events, as well as information on
developmental needs (Woimarans & Eksteen 1987:39). Questionnaires
can be described as a set of questions dealing with some topic or related
group of topics, given or sent to a selected group of individuals for the
purpose of gathering data on a problem under consideration (Landman
1988:78).
This method of gathering data is exceptionally suitable for a needs
analysis of national scope, as was required in this study (cf. Wolmarans &
Eksteen 1987:39). The questionnaire designed for this study comprised
six categories, divided into 77 subsections. Some of the items were open-
ended questions, while others were closed questions. During the pilot
study it was determined that the questionnaire would take approximately
30 to 35 minutes - and, in some cases, even 40 minutes - to complete.
The length of time depended on the way in which a respondent answered
the questions, i.e. whether all the questions were answered, which would
indicate that the respondent was indeed interested in post-graduate
studies. The fact that there were approximately 35 questions which
required long and detailed answers (e.g. follow-up items or completion
items), was another factor to be taken into consideration. The more
comprehensively questions were answered, the longer it would take, of
course. Questionnaires were dispatched by post as well as by means of
electronic mail. Respondents were granted three weeks to complete and
172
return the questionnaires. (See Appendix C for the questionnaire.) Each
questionnaire sent out was accompanied by a covering letter, explaining
the purpose of the research, in addition to containing instructions as to
how the questionnaire was to be completed. (See Appendix A for the
covering letter.) There were in fact eventually four questionnaire rounds
over a period of 16 weeks. The covering letter was followed by a list of
definitions, which the respondents would need to better understand the
questions asked in the questionnaire (see Appendix B).
5.4 RESEARCIHI DESIGN: EMPLOYING A NEEDS ANAL YS~S AS
RESEARCH METHOD
5.4.1 The questionnaire
The questionnaire (Appendix C) which was the research instrument in this
study, consisted of six different categories, namely:
o Category 1: Personal information. This category aimed at obtaining
personal information; information about the biographic details and
qualifications of the respondents; as well as the kind of practice and the
location thereof (cf. Appendix C 1.7 and 1.8).
o Category 2: Professional development. This category dealt with the
professional development of the respondents and it also touched on
CPO.
o Category 3: Post-graduate/Post-diploma studies. In this category
respondents' needs with regard to post-graduate education were
determined.
(I) Category 4: Further studies to obtain a formal qualification. This
category dealt with further education and/or CPO in optometry, as well
as with the respondents' views with regard to opportunities available for
further optometry studies in South Africa. Reference was also made to
173
other countries, although the main emphasis was by no means on such
countries.
o Category 5: Detailed information on post-graduate/post-diploma pro-
grammes. Here the respondents had to provide information as to
exactly which were the programmes in question, as well as provide
information about the nature of these programmes
o Category 6: Awareness of the public need. It is interesting to note that
this category mainly consisted of questions requiring long and detailed
answers. It comprised 17 subsections and was definitely the most
comprehensive of all the categories.
The following types of items were used:
e Dichotomous questions (two response possibilities, e.g. "Female/male";
"Yes/no").
o Multiple choice questions (e.g. multiple options are mentioned;
respondent has to select one).
o Completion items (i.e. a statement that must be completed, because
there are too many possible options to include all of them in the item).
G Open-ended items.
o Follow-up items (utilised to collect more information on a previous
response) (cf. Wolmarans & Eksteen 1987:50-51; Landman 1988:78).
The rationale for using a questionnaire format to collect information is that
it is a cost-effective data collection method; it allows for a large sample
size; and geographic dispersion is not a problem. There is also greater
accessibility to respondents and they may respond at a time when it is
convenient for them (cf. Singleton & Straits 1999:258).
Disadvantages of questionnaire surveys cited in literature include the
following:
174
o To develop a good questionnaire is a difficult task.
o Target groups may sometimes be uninformed, unmotivated, or
disinterested.
o Response rates tend to be lower than with other survey methods
(Woimarans & Eksteen 1987:51; Singleton & Straits 1999:259).
To counter these problems which were foreseen, post-paid return
envelopes were included. In addition, respondents could also make use of
electronic mail, which is inexpensive and fast. The importance of the
survey was impressed on respondents in the covering letter and the
researcher repeatedly made contact with them (cf. Singleton & Straits
1999:259).
5.4.2 The empirical study: Needs analysis
In programme planning needs analysis as a form of evaluation research
has been proven successful (Singleton & Straits 1999:431). A needs
analysis or assessment may be undertaken to identify and forecast
problems which need attention; to establish perceived priorities among
problem areas; to study the scope of a problem; and to estimate the extent
to which a programme may be used to address the problems (Singleton &
Straits 1999:431). As this study is concerned with education and training
needs, Wolmarans and Eksteen's (1987:6-7) definition of the different
levels of needs is relevant. They distinguish between macro-level needs,
meso-Ievel needs and micro-level needs. The latter, micro-level needs,
are identified by comparing individual workers' performance in terms of a
competence norm; meso-Ievel needs are organisation-specific and occur
within departments or organisations. This study, however, is concerned
with macro-level needs, that is, needs which occur at national and even
international level (e.g. Africa). Rapid technological developments and the
knowledge explosion often result in skills and knowledge not keeping up
with the latest developments. The proactive analyst must also show a
175
sensitivity with regard to factors such as economic, social and political
developments, because these have an impact on expectations and
changes in those fields will also impact on education and training needs
(Woimarans & Eksteen 1987:6). For this reason, an in-depth literature
review was done and a questionnaire was developed to identify the needs
of practising optometrists with regard to their education and training; the
needs of the society and other stakeholders; and the opportunities they
saw with regard to further education and training.
(For further definitions of "needs" and related aspects, see Appendix B:
1.6; 1.7 & 1.8).
5.5 THE PARTICIPANTS
Before dealing with the participants who represented the target population
of this research study, the term "target population" should first be clearly
defined. Michael Halldorson (1999) of the Department of Psychology at
the University of Winnipeg provides a definition of this concept which is
eminently suitable for the purposes of this study. According to him, it is
the "[p]opulation to which we hope to generalize the findings of a research
study. In most research, the entire target population is not accessible to
the researcher".
For the purposes of this research study, the above-mentioned definition is
directly applicable to it. Thus the researcher wishes to emphasise that it
should be noted that the target population for the questionnaire did not
comprise the total population of optometrists in South Africa. The reason
for this statement is that 1 400 addresses were obtained from the GlO
and, indirectly, from the Professional Board where these optometrists had
been registered. Two lists of addresses were obtained. One of the lists
was the property of the GlO, being their own list which they made use of.
The second list also belonged to the GlO and had been obtained from the
176
Professional Board at some earlier stage. Since it is expensive to obtain
an address list directly from the Professional Board (one has to pay to
obtain it) and funds for the research project were limited, the researcher
made use of the two lists which had been obtained from the GlO, as this
did not entail significant costs. Another possibility which had been
considered, was obtaining an address list from the SAOA. However, this
Association was not prepared to provide such a list, unless questionnaires
were provided to them, in which case the Association would send out the
questionnaires in question. The costs involved concerning such a
scenario had to be considered, especially since it was foreseen that
several rounds of questionnaires would have to be sent out. Thus, after
consideration, the researcher preferred to handle his questionnaires
himself and to send them out either by mail or electronically. Not all of the
addresses obtained in this way were correct and usable, however, as
there was a good deal of overlapping and duplication. It occurred that
sometimes more than one address (a street address and/or an e-mail
address and/or a postal address) were provided, while in some cases the
optometrist might also have moved. This resulted in the fact that the
target group to whom questionnaires had been posted, was eventually 1
131. Of these, 314 came back undelivered ("Not delivered") in closed
envelopes. The number of questionnaires which it can thus be assumed
had reached their destination, was 820. Of these, 576 had been
completed and returned, giving a response rate of 70.2%. An aspect
which has to be borne in mind, is that certain exclusion criteria had been
applied. After the 576 questionnaires had been received, these criteria
were then applied, for example:
G The age group was restricted to between 20 and 60 years, as this age
group was deemed to be the most probable age group who would
show interest in post-graduate education.
f) Individuals who were already in possession of a clinical applicable
post-graduate qualification, were excluded.
177
o Some questionnaires had to be eliminated as a result of the fact that
the handwritingwas illegible.
o Furthermore, there was also some duplication. Several respondents
returned as many as three copies in different manners (e.g. by post,
electronically, etc.). In such cases the extra copies were discarded and
only one was used. Eventually, after the above steps had been taken,
397 fully completed questionnaires were used for statistical analysis, in
other words 68.9% of the questionnaires which had been returned.
When measured against Landman's (1988:46) definition of "population"
or "universum", namely that it indicates a group that is similar or alike
with regard to one or more characteristics as defined by the
researcher, the latter is of the opinion that the number which was
eventually used, can be regarded as a representative target group.
Thus, for the purpose of this study and after completion of the
questionnaire (see Appendix C), "population" can be defined as
optometrists who:
o were registered with the Professional Council;
(3 were in South Africa at that stage;
o were practising (i.e. who were not on sabbatical, on maternity leave,
etc.) in the private or the public sectors;
o were between 20 and 60 years of age; and
e did not have a clinical applicable post-graduate (master's or doctoral)
Optom. qualification and who might thus be wanting to obtain a
qualification which would allow them to register for practice in the
broader scope of practice envisaged for optometry (e.g. the use of
diagnostic agents) and/or for self-development.
Finally, the respondents' needs with regard to post-graduate studies, as
well as their views on possibilities available to them to satisfy these needs,
were determined.
178
5.6 ETHICALCONSIDERATIONS
Registered optometrists in South Africa were used for the empirical study
and respondents had to provide personal information in order to enable a
meaningful profile of needs to be drawn. The respondents had the option
as to whether they wanted to fill in the questionnaire anonymously or not.
Demographic details had to be provided, however. The information
collected by means of the questionnaire was dealt with strictly
confidentially and no names or personal information was or will be made
known.
The protocol for the study had been submitted to and approved by the
Ethics Committee of the Faculty of Health Sciences, the UFS, for approval
(ETOVS number: 12/02).
5.7 ANALYSIS Of DATA
Open responses were recorded manually and grouped into categories.
After extensive data checking, results were summarised by means of the
percentages of respondents answering a specific question. The focus was
on simple analysis, i.e. frequency distribitions. The data analysis was
done by the Department of Biostatistics at the University of the Free State
by using the S.A.S. Programme.
5.8 CONCLUSION
In this chapter the research methodology was described. A thorough
literature review as well as an empirical investigation was conducted. The
data in the empirical study were collected by means of a questionnaire
survey. This empirical study took the form of a needs analysis, the nature
of which was explained in 5.4.2. The quantitative and the qualitative
research methodologies were described and it was pointed out that, for
179
this study, both these approaches had been employed. The study
furthermore falls into the category of a descriptive survey. The concepts
"descriptive study", "reliability" and "validity" were described for
measurement purposes (see 5.2). In addition, the use of questionnaires
during the empirical study was discussed (see 5.3.2) and the pros and
cons thereof referred to (see 5.4.1 ).
The six-category questionnaire used for this study was also discussed
(see 5.3.2) and the manner in which the participants were contacted, was
described. Ethical considerations, e.g. confidentiality, were referred to
(see 5.6) and the data analysed (see 5.7).
The next chapter will deal with the results of the study and outline the
findings of the investigation.
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CHAPTIER S
RIESUl TS, DATA ANAL YS~SAND D~SCUSS~ON OIF
IF~NDINGS
6.1 INTRODUCTION
This chapter will deal with the results, the data analysis and a discussion
of the findings which resulted from the questionnaire, Appendix C,
designed for this study.
Questionnaires were dispatched by post as well as by means of electronic
mail (cf. 5.3.2; 5.4.1). Respondents were granted three weeks to complete
and return the questionnaires. There were four questionnaire rounds, i.e.
four questionnaires were sent out over a period of 16 weeks. The
questionnaire comprised six categories, divided into 77 subsections. A
great many open-ended questions were included. The six categories were
divided as follows:
e Category 1: Personal information.
c Category 2: Professional development.
o Category 3: Post-graduate/Post-diploma studies.
e Category 4: Further studies to obtain a formal qualification.
Q Category 5: Detailed information on post-graduate/post-diploma pro-
grammes .
., Category 6: Awareness of the public need.
The number of questionnaires returned was 576, giving a response rate of
70.2%. Some exclusion criteria were applied, leaving a number of 397 fully
181
completed questionnaires which were then used for statistical analysis (cf.
5.5).
Open responses were recorded manually and grouped into categories.
After extensive data checking, results were summarised by means of the
percentages of respondents answering a specific question. Percentages
were rounded off to one decimal, which may result in the fact that - when
total percentages are added in a table - the total may not be exactly
100.0%. Such cases are indicated in the tables by means of an "(x)".
Where the respondents could exercise more than one option, the
percentages will also not give a total of 100.0%. Such cases are indicated
by means of a "(y)". The data analysis was done by using the S.A.S.
Programme by the Department of Biostatistics at the University of the Free
State (cf. 5.7).
Descriptions and discussions of the data will now follow.
6.2 RESULTS OF CATEGORY 1: PERSONAL INFORMATION
The category "Personal information" is the first of six categories of
information which was collected by means of a questionnaire (cf. Appendix
C). Demographically determined variables, e.g. race, gender and age were
taken into account. Information with regard to the qualifications of the
respondents, the institutions where the qualifications had been obtained,
the kind of practice in which optometrists worked, and the area in which
the practice was located was recorded. In addition, respondents could
also indicate whether they would be interested in obtaining a further
(higher) qualification in optometry.
In each category, results were summarised by indicating the percentages
of respondents answering a specific question. Open responses were
182
recorded manually and subsequently divided into subcategories. Note
should be taken that this applied to each of the six categories. Tables
were compiled to summarise or represent the data collected, while pie
charts and bar codes were compiled to give a visual representation of
some of the main findings. The pie charts and the bar codes will only be
used as a summary of some of the main findings which had been
summarised. These will, in other words, be provided at the end of each
category.
The data in the first category, namely "Personal information", will now be
presented and discussed. That will be followed by a description and a
discussion of the data in the following category, namely "Professional
development" .
183
TABLE 6.1: DEMOGRAPHlIC CHARACTIERISTICS OF RESPONDENTS
(QuestioD1s 1.3 - 1.5)
White
Asian 19.7
Black 16.4
Coloured 1.0
No indication 8.2
31 - 40 years 43.3
41- 50 years 15.2
51 - 60 years 6.6
DESCRIPTION
Table 6.1 indicates the demographic characteristic of the respondents.
The racial breakdown was as follows: 54.7% White, 19.7% Asian, 16.4%
Black and 1.0% Coloured, while 8.2% of the respondents preferred not to
indicate to which racial group they belonged.
184
The gender subcategory of the respondents indicated that 53.3% were
male and 46.7% were female.
The age distribution was as follows: 43.3% fell into the 31-40-year-old age
group, followed by 34.9% between the ages of 20-30 years. The older
respondents were divided into two groups, namely 15.2% in the 41-50-
year-old age group and 6.6% in the 51-60-year-old age group.
DISCUSSION
It appears from the data that the respondents were fairly evenly distributed
between male and female. About half of the total were from the White race
group, while more than 70.0% were between the ages of 20 and 40 years.
This is a fair reflection of the current overall demographics of the
optometry profession in South Africa.
185
TABllE 6.2(a): QUALIFICATION PROFILE OF THE
RESPONDIENTS
(Questooln 1.6)
Optorn.
Applicable
qualifications Post-graduate 15.9
but not clinical
Undergraduate 5.1
Post-graduate 1.5
Optorn. 0.5
Applicable
qualifications
1.0
qualifications
Optorn.
Applicable
qualifications Post -graduate NA
Undergraduate 0.0
Post -graduate 0.3
Optorn. 1.5
Applicable
ualifications
DESCRIPTION
In Table 6.2(a) the qualifications were divided into the categories of South
African and non-South African qualifications and were then subdivided into
formal and informal (undergraduate) qualifications. A further differentiation
was made between undergraduate qualifications which are applicable to
186
the profession of optometry and those which are not. The same was done
with regard to formal and informal post-graduate qualifications.
A formal South African undergraduate qualification was reported by 99.0%
of the respondents. Non-clinical, formal post-graduate South African
qualifications were reported by 15.9% of the respondents. Other formal
South African qualifications were divided into 5.1% at undergraduate level
and 1.5% at post-graduate level.
Informal South African qualifications applicable to optometry were reported
by 0.5% and 1.0% related to non-applicable informal South African
qualifications.
In the non-South African group, the undergraduate formal, applicable
figure was 5.1%. Candidates who had obtained an applicable post-
graduate clinical optometric qualification abroad, were excluded from the
survey, since it would be unlikely that they would be interested in post-
graduate optometry study in South Africa (cf. the exclusion criteria in 5.5).
Only 0.3% achieved other post-graduate qualifications not in the field of
optometry. In this latter field no one reported an undergraduate
qualification. Some 1.5% reported an informal non-South African
qualification applicable to optometry.
DISCUSSION
The data show that the majority of the respondents achieved a formal
South African entry-level degree. The formal South African post-graduate
optometry-related qualifications were all non-clinical, followed by a very
limited group in the other formal South African post-graduate category.
The non-South African qualifications lacked any applicable post-graduate
representation. It therefore appears that optometry applicable, formal post-
187
graduate qualifications are very limited and that the greatest opportunity
will be in the formal clinical post-graduate optometry qualification.
188
TABLE 6.2(b): PROfiLE Of INSTITUTIONS (WHICH HAD BlEIEN
ATTENDED BY THIE RESONDENTS) OFFERiNG
QUALIFICATIONS
(Question 1.6)
Institutions that offer
optometric applicable undergraduate level 3.8
qualifications
Both at
undergraduate and
post-graduate level 93.7
Institutions that offer Both at
other qualifications, but undergraduate and 4.5
not directly applicable to
optometry post-graduate level
Institutions that offer Post-graduate level 1.5
optometric applicable
ifications
undergraduate level 2.0
Institutions that offer
optometric applicable Only at post-
qualifications graduate level 0.5
Both undergraduate
and post-graduate
level 19.4
Institutions that offer Undergraduate
other qualifications, but level 0.3
not directly applicable to
189
DESCRIPTION
Table 6.2(b) offers a profile of the institutions which had been attended by
the respondents. It is divided into South African and non-South African
institutions and then again subdivided into institutions which offer
applicable education at undergraduate level only or at both undergraduate
and post-graduate levels. The latter division also includes institutions
which only offered or are still offering applicable education at a diploma
level. A further division separated institutions that offer other qualifications
at both levels. In the South African institutions differentiation was made
between State and Private Institutions.
The results were as follows: The majority of the respondents (93.7%)
qualified from South African institutions which offered both under- and
post-graduate qualifications. Only 3.8% qualified from a South African
institution that only offered undergraduate training. At the time some 4.5%
of the qualifications were obtained at institutions offering non-applicable
degrees at both levels. Only 1.5% of applicable post-graduate
qualifications were obtained at private South African institutions.
At non-South African institutions, 2.0% received applicable qualifications
from institutions that only offered undergraduate training; 0.5% where only
!, .
post-graduate qualifications were offered; and 19.4% received
,~, qualifications from institutions that offered both levels of training. Non-
applicable undergraduate qualifications represented a figure of 0.3%.
DISCUSSION
From this data it is clear that the majority of the respondents qualified from
South African institutions that offered applicable under- and post-graduate
qualifications. From Table 6.2(a) one will note that the post-graduate
l
r
190
South African qualifications were all of a non-clinical nature. A similar
overall distribution is seen in the non-South African institutions and this
again points to the fact that, although most South African institutions offer
both levels, relevant clinical post-graduate optometry qualifications are
lacking.
TABLE 6.3{a): TYPE Of' PRACTICIE
(Questions 1.7 and 1.8)
Private solo 49.6
Private group 39.8
Other 9.0
State 1.0
Solo and group 0.5
DESCRIPTION
Table 6.3(a) offers the following information on the type of practice: The
respondents reported that 49.6% of them were in private solo practice;
39.8% in private group; 9.0% in other types of practices; 0.5% within solo
and group practice; and 1.0% worked for the State.
DISCUSSION
99.0% of the respondents were from the private sector with about half in
solo practice. The balance was made up of group practice, locum or
consultant work and some in a combination of solo and group settings.
191
From this data it became clear that the State employed 1.0% of the
respondents, which reflects a lack of commitment from the State to the
delivery of comprehensive eye care services.
TABLE 6.3{b): lOCALITY OF THE PRACTICE
[QuestoOD1S 1.9{a) and (b)]
Commercial district
Residential 42.8
Both commercial district and residential 4.2
Semi-residential/community 0.3
NA (e.g. university staff, etc.) 0.3
City area 64.3
Rural area 34.7
Township 0.3
Both city and rural areas 0.3
NA (e.g. university staff, etc.) 0.3
DESCRIPTION
Table 6.3(b) reflects the location of the practices where the respondents
worked. The commercial district setting was most popular (52.4%),
followed by residential areas (42.8%). A combination of the first two
192
indicated 4.2%; semi-residence/community 0.3%; and 0.3% did not fit into
any profile offered.
The table further differentiates between practice locations in a city
(64.3%); rural locations (34.7%); township practice locations (0.3%); both
city and rural settings (0.3%); while 0.3% did not fit into any of the settings
offered.
DISCUSSION
The data reflect that most of the respondents were from practices located
in the commercial district of a city. The locations of practices in residential
areas is not to be ignored at 42.8%, as well as rural practice locations at
34.7%. It is likely that the residential and the rural practice locations will
increase as competition increases and lower rentals are recognised.
Township- and community-based practice locations were very low at 0.3%
as a result of a previous policy of separate development in the apartheid
era. The practice location that did not fit into any category represented
locum/industrial consultancy and NGO work. The locality profile may also
change as the effect of community-based education and compulsory
community service takes effect, whereby the profession is forced to learn
and work in the rural and suburban community.
193
TABLE 6.4(a): RESPONDENTS WHO WOULD LIKE TO OBTAIN A
FURTHER (HiGHER) QUAlIlFlCATION IN
OPTOMETRY
(Question 1.10)
Yes
No 39.5
"Yes" and "No" 0.5
DESCRIPTION
The data in Table 6.4(a) confirm that 60.0% of the respondents would
have liked to obtain a further qualification in optometry. A smaller group of
39.5% declined (higher) qualifications and 0.5% answered both "Yes" and
"No".
DISCUSSION
The data clearly indicate that there is a strong positive attitude towards
further (higher) qualifications in the field of optometry and again
emphasise the need/opportunity that exists. The next two data tables offer
the reasons for the positive and the negative responses respectively. [It
should be noted that "further education" means "further/continuing" tertiary
formal study and not "further education" as applicable on the NQF (i.e. not
the so-called "FEr), in other words approximately standards 6-10 in the
informal sector.]
194
TABllE 6.4(b): MOTIVATION/REASONS OF RIESPONDENTS WHO
WOULD LIKE TO OIBTAIN A FURTHIER (HIGHER)
QUAUflCATION IN OPTOMETRY
(Ouestion 1.11)
For a broader scope, skills base, better, wider care 60.0
To update knowledge and skills, resulting in self- 27.8
developmenUpersonal development
To enhance the importance of education 4.8
For international accreditation/degree 4.3
To meet CPD requirements 2.7
Development with a view to an academic career 0.5
DESCRIPTION
Table 6.4(b) reflects the motivation behind the positive answers in Table
6.4(a). Here, 60.0% of the respondents reasoned that further qualifications
would assist them in a broader, better skills and care base. A smaller
group of 27.8% gave reasons of a more personal, self-developmental
nature. This was followed by 4.8% of the respondents who felt that it would
enhance the importance of education. A slightly smaller group of 4.3%
gave the main reason as international accreditation, while 2.7% felt it was
the way in which they preferred to meet CPD requirements. The last group
of 0.5% wanted further qualifications in order to develop an academic
career.
195
DISCUSSION
The data confirm that most of the respondents who answered affirmatively
in Table 6.4(a), felt that a broader scope (skills base) should be preceded
by formal (higher) qualifications. About a third felt the need to develop
more on a personal level, but did link it to up-to-date skills and knowledge
and may indicate to a broader scope as well. The recognition of the
importance of education in the third group relates to the first group as well,
while international recognition and an academic career in this context did
not rate high.
From this data it is clear that, for higher educational optometric
programmes to be popular and successful, they will need to be aimed at
broadening the scope of the profession. The challenge for providers would
be to address this need by providing appropriate education and training
matching the needs of the public and the work place.
Scope should be based on the public need, while competency should not
be determined by what medicine wants to allow on "their" turf.
196
TABLE 6.4(c): MOTIVATION/REASONS GIVEN BY
RESPONDENTS WHO WOULD NOT UKE TO
OBTAIN A FURTHER (HIGHER) QUALIFICATION
IN OPTOMETRY
(QuestooB11.12)
No interest
Scope must be broader first 15.8
Too old 14.7
Would rather do short courses 10.5
Problem with logistics 8.4
No increase in remuneration 8.4
Adequately lover -qual ified 6.3
Would rather do CPD 3.2
Looking for a new career 2.1
Only clinical training 1.1
DESCRIPTION
Of those who said "No" in Table 6.4(a), Table 6.4(c) reflects a large group
of 29.5% who were not interested in formal studies at all. Some 15.8% felt
that broader scope parameters should be in place first, followed by 14.7%
who felt that they were too old to study further. Short courses only were'
preferred by 10.5% and 8.4% indicated that logistics presented the biggest
problem. The lack of increased remuneration was the main reason
197
provided by 8.4%, while 6.3% felt that they were adequately or over-
qualified. A smaller group of 3.2% felt that they would rather do CPD
courses, followed by 2.1% who were looking for a new career and 1.1%
who only wanted clinical exposure.
DISCUSSION
The data indicate that almost 30.0% of the respondents who answered in
the negative had no interest in a higher qualification. This was followed by
a group who wanted legislation prior to education. These two reasons
amounted to about half of the negative answers and the balance can be
accounted for as follows: Some respondents showed a preference for
short courses or they felt they were too old; logistics presented a problem;
no increase in fees was a negative aspect; and, to a lesser extent, the
reasons of adequate qualification; adequate CPD courses; a different
career was sought; and only clinical exposure was needed.
Most of the reasoning behind the negative answers is of such a personal
nature that institutions that wish to offer higher qualifications, cannot use
this information to tailor post-graduate programmes. However, this group
should be kept informed, as there are some obvious misconceptions about
the process of education and scope reform.
It became clear that, for various reasons, there is resistance to change,
e.g. general apathy, professional jealousy, comfort zones, fear of the
future, etc.
198
6.3 SUMMATIVE CONCLUSION ON CATEGORY 1: PERSONAL
iNFORMATION
The demographic data confirm a modern trend in the gender
representation, while data on race show a demographic shift towards the
normalisation of South African society that is arguably the most advanced
in all of the health professions. It is therefore ironic that the State employs
such a small number of optometrists and that the State's sincerity in
addressing the delivery of eye care to the broader population can be
questioned. It is a fact that State policy in eye care was traditionally based
on ophthalmology input and that ophthalmology obviously withheld
motivation to include optometrists in the public sector. This history of
reluctance on the side of the State, supported by ophthalmologists,
indirectly limited optometry education and training in the public sector and
the exposure to that sector, thereby increasingly driving optometrists into
commercial activity hemmed in by a limited scope.
The above-mentioned factors, as well as the policy of separate
development, are central to the lack of an economically viable middle class
and resulted in the fact that about 75.0% (30 million) of the population
cannot afford private care, thereby placing huge demands on inadequate
and fragmented public care. From the researcher's personal experience as
Chairman of the Professional Board for Optometry and Dispensing
Opticians, it should be noted that the State employs only 40 to 50
ophthalmologists and 20 to 25 optometrists country-wide.
Although it is clear from the data that the majority wished for higher South
African qualifications in clinical optometry, local schools have failed to
address this need or to redress training to meet the needs of the public
sector.
199
Figure 6.1 provides a graphic presentation of some of the aspects of the
main findings on Category 1.
200
FIGURE 6.1: GRAPHIC PRESENTATION OF SOME OF THE ASPECTS
OF THE MAIN FINDINGS ON CATEGORY 1: PERSONAL
INFORMATION
a) Demographic characteristics of respondents with regard to:
RACE (n=391)
CAsian: 19.7%
• Black: 16.4%
• Coloured: 1.0%
.White: 54.7%
o No indication:
8.2%
AGE (n=395)
020 - 30 years: 34.9%
.31 - 40 years: 43.3%
.41 - 50 years: 15.2%
.51+:6.6%
GENDER (n=392)
• Male: 53.3%
• Female: 46.7%
201
b) Type of practice (n=387)
• Private solo: 49.6%
o Private group: 39.8%
• Solo and group: 0.5%
• State: 1.0%
Oather: 9.0%
c) Locality of practice (n=355)
oCommercial districts
(Cd): 52.4%
o Residential (R): 42.8%
Both Cd and R: 4.2%
community: 0.3%
d) Area where practice is situated (n=294)
• City area: 64.3%
• Rural area: 34.7%
.Township: 0.3%
• Both city and rural areas:
0.3%
.NA: 0.3%
202
6.4 MAiN FiNDINGS OF THIS CATEGORY
The following are the main findings of this category:
o As a result of the researcher's experience as the Chairman of the
Professional Board for Optometry and Dispensing Opticians, he
reached the conclusion that the respondents' demographics are a fair
reflection of the current demographics of the profession.
o The racial distribution is still not representative of society in general.
e 99.0% of the respondents achieved a South African undergraduate
degree with no clinical post-graduate qualification. The opportunity for
clinical post-graduate qualifications is therefore without question.
e Although most South African institutions do offer post-graduate
qualifications, they are for the most non-clinical or research-based.
o Only 1.0% of the respondents were employed by the State. This fact
correlates well with the ± 25 posts nationally.
o Almost 35.0% of the respondents practised in rural settings.
o 49.6% of the respondents practised private solo, while 60.0% of the
respondents indicated that they wished to obtain a higher qualification.
Of this group 60.0% reasoned that a broader scope would be their
motivation for obtaining a higher qualification.
oAbout 20.0% of those who did not indicate a willingness to obtain a
higher degree, had no interest.
203
6.5 RESULTS OF CATEGORY 2: PROFESSIONAL DEVELOPMENT
The category "Professional development" is the second of six categories of
information which was collected by means of a questionnaire (cf. Appendix
C).
Respondents were asked to express their opinion as to whether they were
keeping abreast of changes in the field of optometry and in which way they
were doing this. In addition, information was obtained to determine if there
were enough opportunities to keep abreast and whether they were
experiencing any problems. Respondents also had to indicate which
factors were playing a role to motivate them to take part in CPD, as well as
to whether the existing available CPD activities addressed their needs.
Respondents' opinion was furthermore obtained as to how they were
going to obtain the acquired points for CPD, especially with a view to
maintain their registration as optometrists. They also had to give an
indication as to what kind of CPD activities they preferred to take part in.
Further information was collated with regard to whether respondents would
be interested in specialising in the field of optometry; if they were of the
opinion that formal post-graduate qualifications should form the basis of
such a specialisation programme; and whether formal qualifications should
represent the expanded scope of privileges which would recognise a
broader skills base.
The data in the second category, namely "Professional development", will
now be represented and discussed. That will be followed by the
description and discussion of data in the following category, namely "Post-
graduate/Post-diploma studies".
204
TABLE 6.5(a): RESPONDENTS' OWN PERCEPTION AS TO
WHETHER THEY WERE KEEPING ABREAST OF
DEVELOPMENTS IN THE FIELD OIF OPTOMETRY
PRACTICE
(Question 2.1)
Yes
No 18.6
DESCRIPTION
Table 6.5(a) shows that 81.4% of the respondents felt that they were
keeping abreast of developments in the field of optometry practice. The
balance of 18.6% felt that that was not the case.
DISCUSSION
This data show a high level of positive self-opinion and can only be tested
via a set of self-evaluation criteria still to be formulated. Such a system will
make CPD with evaluation the more meaningful option in the future. The
CRISIS model as discussed in Chapter 4 could form a basis for this. Few
professionals will admit that they do not keep abreast. It is therefore
important that the reasons for the affirmative answers are carefully
evaluated.
205
TABLE 6.5(b): RESPONDENTS' WAYS OF KEEPING ABREAST
OF DEVELOPMENTS IN THE FIELD or
OPTOMETRY
(Question 2.2)
Reading magazines/newsletters
Reading journals/publications 31.6
Via short courses 25.4
Attending conferences/congresses 20.6
Via seminars/lectures 16.7
Attend meetings/discussion groups 14.0
Via electronic mediallnternetlDSTV 12.7
Via general CPD 5.7
Further formal studies 4.8
By doing extra clinical work 1.8
Reading text books 0.9
By presenting lectures 0.9
Via the use of new technology in the field 0.4
DESCRIPTION
Table 6.5(b) shows the manner in which respondents, who answered
affirmatively in Table 6.5(a), were keeping abreast of developments. The
majority (39.9%) listed magazines and newsletters as the main medium
206
they used. This was followed by 31.6% who reported the reading of
journals and publications to be the manner in which they kept up to date.
The next group consisted of those who indicated attending short courses
(25.4%); conferences and congresses (20.6%); seminars and lectures
(16.7%); and meetings and discussion groups (14.0%).
Electronic media/lnterneUDSTV were reported by 12.7% of the
respondents as their preferred medium. General CPD (5.7%) included
responses like "All opportunities" and ensuring that care was up to date
and of a clinical nature. Only 4.8% of the respondents used formal studies
as a means to keep abreast. Extra clinical work (1.8%); reading textbooks
(0.9%); presenting lectures (0.9%); and the use of new technology (0.4%)
made up the rest of the responses.
DISCUSSION
The respondents favoured the use of printed media (71.5%) to keep up to
date. By adding electronic media (12.7%) and other home-/practice-based
activities such as reading textbooks and the use of new technology, it is
clear that the vast majority preferred the convenience of their
homes/practices and this is the area which the providers of CPD will have
to concentrate on. It remains to be seen if the habit of flocking to a
congress or a seminar will lose its appeal, as the exhibition of products
and technology and social activity cannot be ignored.
However, without an evaluation instrument, the success of the informal
CPD activities will remain vague.
207
TABllE 6.S(a): RESPONDENTS' VIEWS ON ADEQUATE
OPPORTUNITIES TO STAY INFORMED IN THE
FIELD OF OPTOMETRY
(Question 2.3)
No 35.0
"Yes" and" No" 0.8
DESCRIPTION
Of the total number of respondents, 64.3% felt that there were adequate
opportunities to stay informed in the field of optometry. The total
percentage of the respondents who answered in the negative amounted to
35.0%, while 0.8% were unsure.
DISCUSSION
A large group was of the opinion that there were adequate opportunities.
However, the number of those who felt the opposite, was alarmingly high.
\ This is perhaps because compulsory CPD is in its first five-year cycle and
! not all providers have formulated and communicated their programmesyet. The challenge would be to research why one-third felt negative and to
:,1
{ address their reasons.
,I)
il
J
Il
1
j
{
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I,~ J
208
TABLE 6.6(b): RESPONDENTS' REASONS !FOR CONFIRMING
THAT THERE WERE SUFFICIENT
OPPORTUNITIES TO KEEP INFORMED IN THE
!FIELD OIF OPTOMETRY
(Questoon 2.4)
Easy access to magazines
Easy access to Internet 19.0
Attend seminars and conferences 14.0
Attend short courses 12.0
Easy access to local and international journals 10.0
Self-motivation 6.0
Sufficient opportunities, but lack of self-motivation 4.0
Attend product launches 3.0
Enough opportunities, but lack international exposure 3.0
Adequate opportunities, but mainly in major centres 2.0
Attend study groups 2.0
Sufficient opportunities, but there is a need for more 2.0
formal post-graduate courses
Because the UFS is introducing optometry 1.0
Sufficient opportunities, but more clinical workshops 1.0
are necessary
209
DESCRIPTION
In Table 6.6(b) the responses of those who felt that sufficient opportunities
existed, are reflected. Easy access to magazines (21.0%), the Internet
(19.0%) and journals (10.0%) was the main reason.
Attending seminars (14.0%), short courses (12.0%), study groups (2.0%)
and product launches accounted for the second major grouping of
reasons. Although they felt there were sufficient opportunities, 3.0% of the
respondents felt that international exposure was lacking, while 2.0% also
felt that opportunities were sufficient, but indicated that they were too far
from major centres. A further 2.0% felt that, although there were sufficient
opportunities, more formal courses were needed.
1.0% felt that the introduction of a new programme at the UFS would
create more opportunities. A further 1.0% also felt that, although
opportunities were sufficient, the content should be more clinical and more
hands-on. 6.0% of the respondents felt that the main reason for them
reporting adequate opportunities was the fact that they were self-
motivated. However, 4.0% felt the same about the opportunities, but
lacked the self-motivation to make use of them.
DISCUSSION
Of the 250 respondents who felt that opportunities were adequate, only
100 offered reasons for saying so. The respondents who felt there were
sufficient opportunities, stated the main reason to be easy access, a
willingness to attend congresses/seminars, etc., and their own self-
motivation. There was also a group who felt that, although there were
sufficient opportunities, they had problems with self-motivation, lack of
clinical content, distance from the delivery site, and a lack of formal
210
courses. The providers of ePD need to take note of the reasons for the
positive responses and expand on them.
TABLE 6.6(c): RESPONDENTS' REASONS IFOR STATING THAT
OPPORTUNITIES TO STAY INFORMED IN THE
IFIELD OIF OPTOMETRY WERE NOT SUFFICIENT
(Question 2.4)
Poor communication
Too far from major centres 19.8
Lack of self-motivation 18.7
More clinical workshops 9.9
Poor journals locally 6.6
Not sufficient opportunities, currently prefer short 5.5
courses
Need formal post-graduate courses 5.5
Not enough international exposure 4.4
Too expensive 3.3
Professional bodies disorganised 2.2
Self-motivation 1.1
Too scientific 1.1
Not sufficient opportunities, best option is on the 1.1
Internet
211
DESCRIPTION
In this table, the reasons are reflected why respondents felt that
opportunities were not sufficient. A major reason was poor communication
(20.9%), followed by distance (19.8%), as well as a lack of self-motivation
(18.7%).
Other reasons were the lack of clinical workshops (9.9%); poor local
journals (6.6%); the need for formal post-graduate courses (5.5%);
insufficient international exposure (4.4%); high costs (3.3%); while 2.2%
felt that the professional bodies were disorganised. Although some
respondents (5.5%) felt that the opportunities were insufficient, they
preferred to attend current short courses. "Too scientific" was a reason
provided by 1.1% of the respondents. A small group (1.1 %) felt that there
were insufficient opportunities, but it depended on their own self-motivation
whether they could create their own. Another small group (1.1%) reported
insufficient opportunities, but felt the Internet was the solution.
DISCUSSION
Of the 136 respondents who felt opportunities were inadequate, 91 offered
reasons for saying so.
It is clear from the data that respondents who felt. that there were
insufficient opportunities, blamed it on facts like "Poor communication",
"Not offered in smaller centres" and "A lack of self-motivation". Another
factor which was highlighted, was that clinical workshops were lacking.
Although there are short courses on offer, it is clear that the respondents
wanted more international exposure and formal post-graduate course
work. Other reasons were costs, poor organisation and content that were
too scientific.
212
One may therefore assume that it will be fairly easy to remedy the major
complaints, whilst others will be self-limiting. Providers of CPD need to
concentrate on addressing these major reasons for not recognising
opportunities when planning, promoting and delivering CPD activities.
TABLE 6.7(a): RESPONDENTS EXPERIENCING STUMBUNG-
BLOCKS IN PROFESSIONAL DEVELOPMENT
(QUJestoOD1 2.5)
Yes
No 48.0
"Yes" and" No" 0.5
DESCRIPTION
When replying to the question whether respondents experienced
stumbling-blocks in professional development, 51.5% answered in the
affirmative, 48% in the negative, while 0.5% were unsure.
DISCUSSION
The reasons for the high positive ("Yes") responses are explored in Table
6.7(b), as it is clearly of concern that more than half of the respondents felt
that this concept, core to lifelong learning, presents stumbling-blocks.
213
TABLE 6.7(b): STUMBLING-BLOCKS EXPERIENCED BY
RESPONDENTS IN TERMS OF THEIR
PROFESSIONAL DEVELOPMENT
(Question 2.6)
Cost
Loss of income 26.6
Distance 22.3
Poor scheduling 9.3
No broader scope privileges 9.2
Lack of self-motivation 8.2
No formal post-graduate courses 7.1
Disagree with course content 4.4
Opposition from Ophthalmology 4.4
Poorly structured 3.3
Commercial/franchises unethical 2.2
Not enough international input 1.6
DESCRIPTION
Table 6.7(b) offers information with regard to the reasons why respondents
felt they were experiencing stumbling-blocks in their professional
development. Cost at 28.8%; loss of income at 26.6%; and distance at
23.3% all relate to a negative financial impact. Poor scheduling (9.3%);
214
lack of scope privileges (9.2%); and a lack of self-motivation (8.2%) carried
a similar weight as the first reason.
Lack of formal post-graduate courses were provided as a reason by 7.2%
of the respondents; 4.4% disagreed with the current course content of
short courses; while opposition from Ophthalmology was given as a
reason by another 4.4%.
Some 3.3% felt that courses were poorly structured and 1.6% felt that
these courses needed more international input. The final grouping of 2.2%
felt that the commercialisation of the profession made professional
development irrelevant.
DISCUSSION
The financial implications were raised by 77.7% of the respondents. The
second-largest problem was due to organisational issues and the balance
due to regulatory matters.
The challenge for providers would be to reduce costs or add value to CPD,
organise better and make the profession aware of the regulatory process.
This, in other words, entails addressing the "What's in it for me?" concept.
215
TABLE 6.8: FACTORS WHiCH MOTiVATE RESPONDENTS TO
ENGAGE IN CONTiNUING PROIFESSIONAl
DEVELOPMENT (CPD)
(Question 2.7)
To offer better standard of care 33.6
To acquire a broader scope 27.8
If there is sponsorship 11.6
If there is regulation making it compulsory 10.8
If there is financial reimbursement for new skills 9.7
If there is variety 8.9
If there is recognition internationally 6.2
Self-motivation 2.7
If there is introduction of new technology 2.7
If it is part of an academic career 1.9
If it creates public sector posts 1.5
If there is recognition via certification/qualification 1.2
If you punish those who contravene advertising laws 0.8
216
DESCRIPTION
The respondents felt that the major motivating factor to engage in CPD
was to be able to offer a better standard of care (33.6%). To acquire a
broader scope was a factor reported by 27.8%. Respondents felt that if the
following needs/conditions were addressed, they would be more inclined
to engage in CPD activities, namely sponsorship to attend (11.6%);
compulsion (10.8%); remuneration for new skills (9.7%); variety in content
(8.9%); international recognition (6.2%); self-motivation (2.7%); furthering
an academic career (1.9%); creation of public sector posts (1.5%);
recognition via certification/qualification (1.2%); and punishment of
unethical behaviour (0.8%).
DISCUSSION
From the data it is clear that about 60.0% of the respondents saw broader
scope and better standards of care as being of paramount importance.
Financial factors related to higher fees for broader skills, as well as
sponsorship to reduce the cost of CPD, were also regarded as being
important. Most of the remaining factors echoed the previous opinion.
From this and other related responses to questions, it is clear that the
challenge for CPD providers would be to reduce costs and address the
other concerns for CPD to be judged meaningful and of value to the
respondents.
217
TABLE 6.9(a): RESPONDENTS' PERCEPTION AS TO WHETHER
CURRENT CPD ACTIVITIES MET TIHIEIRNEEDS
(Question 2.8)
Yes 64.4
No 33.7
"Yes" and "No" 1.9
DESCRIPTION
A majority (64.4%) of the respondents felt that current CPD activities met
their needs. A total of 33.7% felt their needs were not met and 1.9% were
not sure.
DISCUSSION
Although close to two-thirds of the respondents indicated that current CPD
activities met their needs, more than a third felt that their needs were not
met at all. The reasons for their responses are reflected in Tables 9(b) and
9(c). It is important to note that many of the reasons had specific
conditions attached to the original "Yes" answer. With that in mind, one
may assume that the response is actually an overwhelming "No".
218
TABLE 6.9([0): RIESPONDIENTS' REASONS !FOR STATING THAT
CURRENT PROFESSIONAL DEVELOPMENT
ACTIVITIES MET THEIR NEEDS
(Questioll1 2.9)
.:.:.
Activities offered during CAS courses are sufficient 25.8
In general, current activities on offer are sufficient 25.8
Yes, but actually too soon to comment 10.8
Yes, but content must be more relevant 10.8
Yes, but content must be more practical/clinical 5.4
Yes, but content must lead to broader scope 5.4
Yes, but must have better scheduling 5.4
Working at or situated near an academic institution 3.2
Yes, but more international content must be included 2.2
Yes, but the distance to centres offering CPD is 2.2
inconvenient
Help to give better care (improvement of care) 2.2
Yes, but content must be compiled in such a way that 1.1
it will make . lisation sible
DESCRIPTION
This table offers information regarding the main reasons for the affirmative
responses in Table 6.9(a). A fairly large group (25.8%) felt that activities
offered during CAS courses fulfilled their needs. A group similar in size did
not indicate a specific course, but also felt current activities which were
offered, fulfilled their needs. Those who felt it was too soon to express an
219
opinion amounted to 10.8%, while 24.9% indicated that their affirmative
responses were conditional to the following: 10.8% wanted content to be
more practical; 5.4% wanted the content to lead to a broader scope; 2.2%
wanted more international participation; and 1.1% preferred content to be
structured in such a way that it would lead to specialisation.
More than 7.0% indicated that current CPD activities met their needs, but
that certain logistics could be improved by way of better scheduling of
opportunities (5.4%) and by reducing the distance (2.2%) from where the
activities were being offered. A group of 3.2% provided involvement with
an academic institution or that they lived/practised near an academic
institution as a reason. A smaller group of 2.2% felt that their needs were
met because it helped them improve patient care.
DISCUSSION
The data in the above table indicate that respondents were generally
satisfied that current activities met their needs. Providers need to expand
on the activities preferred most, but need to note the conditions that were
raised regarding content, end goal and logistics. Ideally, all CPD should
have a positive impact on patient care.
220
TABLE 6.9(c): RESPONDENTS' REASONS FOR STATiNG THAT
CURRENT PROIFESSIONAl DEVELOPMENT
ACTIVITIES DID NOT MEET THEIR NEEDS
(Question 2.9)
Programme content not relevant
Not enough clinical training is on offer 12.0
Too soon to comment 12.0
Distance to venues too far 11.1
Too costly 9.3
Poor scheduling of activities 9.3
CPD activities on offer do not lead to broader scope 5.6
Although activities on offer did not meet needs, 5.5
r"""c;:,nrll ...". c'ntc;:, were enrolled for CAS courses
CPD activities on offer do not lead to specialisation 3.7
In need of distance education programmes 3.7
Programmes do not have international recognition 2.8
Do not receive enough information 0.9
Activities on offer did not meet needs, but Internet, 0.9
SAOA information and readi hel
DESCRIPTION
The fact that current CPD activities did not meet respondents' needs is
presented in this table. More relevant programme content topped the list
with 23.2%, followed by 12.0% who reasoned that a more clinical
orientation was required. Some 5.6% felt that CPD activities did not lead to
221
a broader scope; 3.7% reasoned that CPD did not offer opportunities to
specialise; 2.8% argued the fact that there was not sufficient international
content; and 3.7% would rather take part in distance education.
Organisational and logistical stumbling-blocks were given as reasons by
30.6% of the respondents who felt current CPD activities did not meet their
needs. This particular group was divided into 11.1% who reported distance
to be the main reason; 9.3% blamed poor scheduling; and 0.9% the lack of
information received.
Although 6.4% of the respondents were not satisfied with current CPD
opportunities, 5.5% did enrol for the CAS courses and 0.9% made use of
the SAOA, the Internet and journals, as they needed to earn ePD points.
12.0% of the respondents felt it was too early to express a reason, but did
indicate that current opportunities did not meet their needs.
DISCUSSION
Although the reasons motivating both the "Yes" and the "No" responses
are remarkably similar, the only difference is that some of the affirmative
responses contain reasons which are conditional. However, respondents
felt that the CAS type course was the strongest reason for saying "Yes".
This would indicate that the provider should consider this type of CPD as
the anchor "tenant" of CPD; act on the criticism; and offer other activities of
a different nature peripherally to the anchor programme.
It is interesting to note that CAS courses all require the candidates to be
evaluated prior to qualification. In the USA moves are afoot to bring this
kind of CPD to continuing education (CE), namely CE square (CE2) where
222
the second "E" stands for evaluation. This is also an element in the
CRISIS model.
TABLE 6.10: RESPONDENTS' WAYS OIF ACQUIRING CPD
POINTS IN ORDER TO MAINTAIN A LICENCE TO
PRACTISE
(Question 2.10)
Attending conferences/seminars 51.5
Short courses (CAS) 36.3
Articles/journals/Internet 35.2
All opportunities 11.7
Practical sessions 8.7
Study groups 7.9
No idea 5.4
Community clinics 5.4
Lecturing 3.8
Formal study 1.1
Disagree with concept 0.8
Articles on CD 0.3
223
DESCRIPTION
The way in which respondents aimed to acquire CPD points varied, but
more than half (51.5%) felt they would attend conferences and seminars;
36.3% would attend short courses like the CAS; and 35.2% would read
articles, journals or make use of the Internet. A smaller group of 11.7% felt
they would use all opportunities; 8.7% would attend practical workshops;
7.9 % chose study groups; 5.4% had no idea; 5.4% reported that they
would work in clinics; 3.8% would lecture; 1.1% would take part in formal
studies; 0.8% disagreed with the concept; and 0.3% indicated that they
would make use of articles on COs.
DISCUSSION
The responses indicate a traditional trend, possibly because CPD is new
and all avenues had not yet been explored and experienced by the
respondents. Regulators and providers will need to spend more time on
developing and promoting all spheres of CPD. It is interesting to note that,
according to Table 6.5(b), 71.5% of the respondents preferred printed
media, yet here their main intention was to attend congresses/seminars
(51.5 %).
224
TABLE 6.11(a): CPO ACTIVITIES PREIFERRED BY RIESPONDENTS
(Question 2.11)
Informal activities to acquire points (e.g. study groups,
reading professional journals)
Formal activities which do not necessarily lead to a 40.6
formal qualification (e.g. seminars, congresses)
Formal activities which lead to a formal qualification 19.4
All of the above 34.3
DESCRIPTION
Table 6.11 (a) reflects the CPD activities which respondents indicated they
preferred best. These were divided into "Informal activities" (46.6%);
"Formal activities" (40.6%); "Formal activities which lead to formal
qualifications" (19.4%); and "All of the above" (34.3%).
DISCUSSION
The first group obviously preferred the convenience and low cost of
informal activities, whilst the second group preferred a more traditional
form of CPD. Although the third option was only preferred by about 20.0%,
one could argue that those in the last group could easily be persuaded to
elect a formal qualification if it met certain criteria that would be attractive
to them, such as the reasons given to questions probing the shortcomings
of short courses and CPD.
225
The challenge for providers will be to balance formal and informal activities
in a manner that will satisfy all the different groups by providing relevant
activities that could form part of formal studies and could be presented in
an educational model which could be evaluated for the different
competencies and criteria to satisfy regulations at institutions.
This response stands in contrast to the previous table where the preferred
intention to earn points would be to attend congresses and seminars. It is
therefore indicative that something is either wrong with current informal
CPO activities on offer or that the social attraction of congresses and trade
exhibitions is stronger than the respondents wished to admit.
TABLE 6.11(b): RESPONDENTS' RIEASONS WHY THEY
PREIFERRED TO PARTICIPATIE IN CERTAIN CPD
ACTIVITIES
(Questioll1l 2.12)
Want informal activities (study groups/journals), 29.7
because they are home-based/attract people who
think in a similar manner; variation
Formal qualifications require commitment; recognise 21.7
specialisation; more employable
Want formal activities (seminars/congresses) because 12.6
they are structured/shorter time span
All of the above (with conditions) 36.0
226
DESCRIPTION
According to this table, 29.7% of the respondents preferred informal
activities, as they are home-based, inexpensive and convenient; bring
similar thinking persons together; and provide for variation. Formal
qualifications were preferred by 21.7%, as they require commitment,
recognise speciality skills and make the individual more employable. Some
12.6% preferred formal activities, as they are more structured and happen
over a shorter period of time, while 36.0% did not indicate any specific
preference.
DISCUSSION
This discussion will cover the reasons as reflected in Table 6.11 (b) as to
why respondents chose the activities in Table 6.11 (a).
From the data it is clear that respondents preferred informal activities
mainly because they are home-based/inexpensive, convenient, etc.
In general, it is evident that the respondents would have preferred to
exercise personal options without being reminded of the formal or informal
nature of a course. It remains the challenge for providers to offer courses
in such a way that practitioners may choose to make it part of a formal
qualification.
The concept of creating "currency" that could be used at any stage to "buy
into" a formal qualification is in line with the current principles of higher
education.
227
TABLIE 6.12{a): RESPONDENTS' DESIRE TO SPECIAUSIE iN AN
OPTOMETRY FIELD
(Question 2.13)
No 46.3
"Yes" and "No" 0.3
DESCRIPTION
In this table 53.5% of the respondents indicated that they wished to
specialise in a field in optometry. A small number of 0.3% were unsure and
46.3% answered negatively.
DISCUSSION
It is clear from the data that there is a strong desire for specialisation and it
would be interesting to measure this desire in other Health Professions. It
also indicates that undergraduate training may be so broad that speciality
skills cannot be mastered in four years' time and respondents felt that
different niche markets existed in the field of optometry. This response
dictates the major type of post-graduate qualification which institutions
may wish to offer.
228
TABLE 6.12(b): THE EXTENT TO WHICH RESPONDENTS AGREED
THAT FORMAL POST-GRADUATE
QUALIFICATIONS SHOULD FORM THE BASIS OF
SUCH SPECIALISATION
(Question 2.14)
Yes 92.6
No 7.4
DESCRIPTION
According to this table respondents agreed by a vast majority (92.6%) that
formal post-graduate qualifications should form the basis of specialisation.
Only 7.4% disagreed.
DISCUSSION
The large positive response in Table 6.12(a) indicates a specific direction
with regard to the nature of post-graduate qualifications, which will
recognise specialisation.
It is a well-known fact that the public often have to visit several
practitioners when they experience a particular problem before they reach
someone with the necessary skills. This is wasteful and the public should
be afforded the opportunity to identify practitioners with speciality skills.
The post-graduate route which institutions may wish to follow is clear.
229
TABLE 6.12(c): RESPONDENTS' REASONS WHY TIHEY FIELT
THAT A FORMAL POST-GRADUATE
QUALIFICATION SHOULD FORM THE BASIS OF
SPECIALISATION
(QlJIestoo01l2.15)
Need to differentiate skills in specific fields
Undergraduate not sufficient 27.0
Ensures a certain standard of education and care 20.7
The only option 9.0
Yes, but not to Ph.D. level 5.4
An international trend 2.7
Yes, but broader scope parameters needed first 1.8
DESCRIPTION
More than 75.0% of the responses could be divided into three categories,
namely a need to differentiate skills in specific fields (33.3%);
undergraduate education not being sufficient (27.0%); and ensuring a
certain standard of education and care (20.7%). 9.0% of the respondents
felt it was the only option. An international trend was provided as a reason
by 2.7% and 1.8% felt that legislation should first be in place. Although
5.4% were in agreement with the concept, they were against specialisation
at the Ph.D. level.
230
DISCUSSION
From the data it is clear that the respondents favoured formal
qualifications. Those who mentioned legislation as a negative factor, did
not understand that one needs to educate before one can legislate.
Similarly, new trends and structures in higher education can address the
Ph.D. fear and will assure quality.
TABLE 6.12(d): RESPONDENTS' VIEW THAT A FORMAL POST-
GRADUATIE QUALIFICATION SHOUllD NOT FORM
THE BASIS OF SPECIAUSAT~ON
(QuestooD1l 2.15)
.:f
Experience/knowledge more important than a piece of
paper
We need to refer to one another 15.4
Broader scope parameters needed first 15.4
Undergraduate qualification not sufficient/first expand 7.7
Rather develop better clinical guidelines 7.7
Field much too narrow/too much overlap 7.7
DESCRIPTION
In this table the reasons for not electing post-graduate training as a basis
for speciality are reflected. 46.2 % felt that experience was more important
than a piece of paper; 15.4 % wanted a broader scope prior to education;
231
and 7.7% felt the field was too narrow or that there was too much
overlapping to separate a speciality. Another 7.7% suggested that the
undergraduate programme should rather be expanded and the same
number would rather see better clinical guidelines being developed.
DISCUSSION
In response to the reasons, it is important to note the following: It is a fact
that "practice makes perfect" and any speciality course without clinical
modules will fail to deliver the career outcomes required. Qualification-
based recognition will facilitate inter-professional referrals and education
will always precede expansion. The introduction of appropriate post-
graduate training will indirectly allow the undergraduate programme to be
reviewed in order to provide a better base for specialisation, whilst more
attention is given to the immediate needs such as public sector
employment and primary health care requirements. Clinical guidelines
have the desired effect when integrated during formal qualifications and
serve as a reminder/reference thereafter.
TAlBlE 6.13(a): RESPONDENTS' AGREEMENT THAT FORMAL
QUALIFICATiONS SHOULD REPRESENT
EXPANDED SCOPE PRIVilEGES
(Question 2.16)
Yes
No 6.4
232
DESCRIPTION
The vast majority of the respondents (93.6%) agreed that formal
qualifications should present an expanded scope. A small minority of 6.4%
disagreed.
DISCUSSION
This response is more or less in line with the responses to higher
qualification and specialisation. However, this stronger positive response
indicates that an expanded scope needs to be underpinned by accredited
and recognised education and training.
Educators and regulators will need to co-ordinate their efforts, in addition
to recognising the needs of the profession, the public and the workplace.
233
TABLE 6.13{b): RESPONDENTS' MOTIVATION AS TO WHY
fORMAL QUALIFICATIONS SHOULD REPRESENT
EXPANDED SCOPE PRIVILEGES, WHICH
RECOGNISE A BROADER SKILLS BASlE
(Question 2.17)
Post-graduate qualifications serve no purpose 48.0
otherwise
As a public need will be addressed 11.3
Public recognition will be ensured 10.2
For primary care disease management 9.6
Control over competency will be ensured 7.3
There must be financial benefits 4.5
Need to recognise medical skills 2.3
To bring us in line with international skill levels 1.7
Will allow for diversity 1.7
Not sure what "scope privileges" means 1.1
As long as clinical exposure is included 1.1
Practice management skills are needed 0.6
However, Ophthalmology will be upset 0.6
234
DESCRIPTION
Nearly half (48.0%) of the respondents felt that a higher formal
qualification would serve no purpose if there was no scope broadening
accompanying it. Addressing a public need (11.3%) and recognition by the
public of the broader skills (10.2%), were placed in second and third
positions. Primary management of eye disease was reported by 9.6% of
the respondents and 7.3% felt it would ensure competency. A smaller
group of 4.5% felt positive, but required financial reward for the new skill
while 2.3% felt it should be aimed at recognising medical skills. Other
reasons were: "International standard" (1.7%); another 1.7% felt that it
would allow for diversity; 1.1% were not familiar with the term "scope
privileges"; another 1.1% agreed, provided that clinical exposure was
included; 0.6% indicated "Agree, but more management skills are
needed"; while 0.6% were of the opinion "However, Ophthalmology will be
upset" .
DISCUSSION
The first five subcategories, totalling 86.4% of the responses, related to
expanding the formal educational base of the profession, the care it
mobilises and the increased respect from the public. The other responses
entailed conditional approval for the concept, ranging from financial
rewards, shortfalls in current programmes, and political differences based
on ignorance of the public need.
From the data, one may assume that almost half of the respondents would
not have embarked on post-graduate training unless it recognised a
broader scope. If one adds related reasons such as "address a public
need", "ensure public recognition", "primary care management" anc
"international skills level", this scope-based motivation increases. It follows
235
that post-graduate courses will need to include a broader skills base if they
are to attract 93.0% of the respondents.
TABLE 6.13(c): RESPONDENTS' MOTIVATION AS TO WHY
FORMAL QUALIFICATIONS SHOULD NOT
REPRESENT EXPANDEID SCOPE PRIVILEGES
WHICH RECOGNISE A BROADER SKILLS BASE
(Question 2.17)
Must be CPO-based 25.0
Must have financial benefits 18.8
Will divide the profession 12.5
Rather extend undergraduate course 12.5
Rather co-manage with Ophthalmology 6.3
Only if recognised overseas 6.3
Will be too exclusive 6.3
Will not ensure control over competency 6.3
Will ignore experience 6.3
DESCRIPTION
This table (n=16) represents the group who felt formal qualifications were
not required as a basis for an expanded scope. A quarter (25.0%) felt they
could be CPO-based; 18.8% required that there had to be financial
benefits before embarking on this "formal" route; 12.5% felt it would divide
236
the profession; and the same number felt the undergraduate course
should rather be extended. All the other categories measured 6.3%. These
categories were: "Rather co-manage with Ophthalmology"; "Only if
recognised overseas"; "Will be too exclusive"; "Will not guarantee
competency" and "Will ignore experience".
DISCUSSION
The majority of this relatively small group of respondents were of the
opinion that CPD-based activities were sufficient to propose a broader
scope. This might be the case in acquiring new skills, but care should be
taken that the necessary background is present so that splinter skills are
avoided. Once the background is in place, new technology will drive new
skills via a suitable CPD category. The reason which requires "Tariffs first"
does not recognise that one needs the competencies first. By the nature of
the new direction in higher and health education, the undergraduate
programmes will be "extended" but priorities like clinical and community-
based training will have to be addressed first. None of the reasons
address a structured way by which the 2000 current practitioners can be
reskilled.
Division in the profession is currently present, but mainly based on
commercial activity. The need for the recognition of a skills level is evident
from the data in this study. Although the balance of the responses were
initially negative, the reasons given were in fact more positive than
negative. These respondents may also not be aware of the various post-
graduate exits (qualifications) which are available and may well change
their opinion once this aspect has been explained to them.
237
6.6 SUMMATIVE CONCLUSION ON CATEGORY 2: PROFESSIONAL
DEVELOPMENT
It is encouraging that the data in this category favour the formal post-
graduate route with strong CPO links, which will underpin an expanded
scope and standard of care for the profession. Constructive criticism of
CPO content, as well as stumbling-blocks in practice and in achieving CPO
points, has been highlighted and should be taken note of by those
delivering CPO as well as formal qualifications.
The fact that there are currently very few plans afoot to address the
appropriate need for formal recognition of speciality skills or an expanded
scope, should receive serious attention by the teaching institutions and is
indicative of a wrong direction or a comfort zone, which reflects a certain
degree of apathy not warranted in a post-apartheid South Africa.
Communication links between teaching institutions and the profession are
obviously not what they should be.
Figure 6.2 provides a graphic presentation of some of the aspects of the
main findings on Category 2.
238
FIGURE 6.2: A GRAPHIC PRESENTATION OF SOME OF THE
ASPECTS OF THE MAIN FINDINGS ON CATEGORY 2:
PROFESSIONAL DEVELOPMENT
a) Respondents' perceptions with regard to professional development
90 • Keeping abreast ofdevelopments in optometry
80 practice: 81.4% (n=393)
~ 70
Ol • Adequate opportunities to stay
'0
§ 60 informed: 64.3% (n=389)
a.
til
~ 50
ë
~ 40 o Respondents experiencing
(Il stumbling-blocks in professiona
~ 30 development: 51.5% (n=392)
s~ 20
• ePD activities meet
10 respondents' needs: 64.4%
o~----~~~~----------~~~~ (n=374)
CPD activities
b) Type of CPD activities preferred by respondents (n=397)
• Informal activities: 46.6%
50
45
~ 40
Q)
"0 35 • Formal activities which doc
8. not lead to formal30 qualification: 40.6%
~
ë 25
Q)
Cl 20 o Formal activities which.!c!l lead to a formal
~ 15 qualification: 19.4%
Q)
o, 10
5 • All of the above: 34.3%
0
CPO activities
239
c) Respondents' view with regard to specialisation in the field of
optometry
• Respondents desiring to
specialise in an optometry
100 field: 53.5% (n=387)
90
.cl!l
80
Q)
"c0
70 • Respondents agreeing that
a0. 60 formal post-graduateCl)
~ qualifications should form
0 50 the basis of such
Q)
Ol specialisation: 92.6%
ro 40
ë (n=202)
Q)
~ 30
Q)
Q_ o Respondents agreeing that
20 formal qualifications should
10 represent expanded scope
privileges: 93.6% (n=375)
0
Respondents' view
240
6.7 MAIN FINDINGS OF THIS CATEGORY
The following are the main findings of this category:
o A large group of respondents (± 81.0%) were of the opinion that they
were keeping abreast of developments in the field of optometry. Of
these respondents, ± 70.0% favoured reading materials.
o 64.0% of the respondents were of the opinion that there are adequate
opportunities to stay informed. Only 2.0% of this group identified the
fact that there is no formal post-graduate courses. This is due to the
fact that applicable clinical post-graduate courses have not been
successfully developed.
o From the reasons offered by respondents it is clear that content and
the logistics of CPO needs attention.
o As half of the respondents experienced stumbling-blocks in
professional development, it is important to address the main reasons
for this, i.e. casts and logisties.
oAbout 60.0% of the respondents saw a broader scope and better
standards as the main motivation for engaging in CPO.
o Two out of every three respondents were of the opinion that activities
offered during CPO opportunities met their needs.
o Of those who felt that activities offered did not meet their needs, the
main reasons provided were irrelevant content and lack of clinical
training.
e From the responses in this category it appears that there is a golden
thread between all different forms of activities which will make CPO
relevant.
e The respondents wanted freedom of choice as far as formal vs.
informal activities were concerned.
e More than half of the respondents wished to specialise and 90.0% of
them agreed that a sound post-graduate qualification should form the
241
educational basis. The main reasons for these answers are those of
recognition of competency and the lack in undergraduate training.
o ± 94.0% of the respondents agreed that a formal qualification should
represent broader a scope.
242
6.8 RESULTS Of CATEGORY 3: POST-GRADUATE/POST-
DIPLOMA STUIDIES
The category "Post-graduate/Post-diploma studies" is the third of six
categories of information that was collected by means of a questionnaire
(cf. Appendix C).
In this category respondents had to indicate whether they had investigated
post-graduate possibilities in the field of optometry in South Africa and,
should the opportunity arise, whether they would embark on post-graduate
studies. If the respondents answered this question in the negative, they
were asked to ignore questions 3.3 to 5.8 and continue with question 6.1.
If their answers were positive, the next question required a reason to be
provided for not pursuing post-graduate studies at present. Respondents
also had to provide a reason for wishing to pursue post-graduate studies
and were asked whether they would like to receive information or enrol for
the programme, should a formal post-graduate programme meet their
needs. Information was also requested as to the field of optometry in
which they would prefer to acquire a post-graduate qualification, as well as
an explanation for their answers. In the last place, respondents were
asked whether they were experiencing any inadequacies or shortcomings
in their current practice of the profession.
The data in the third category, namely "Post-graduate/Post-diploma
studies", will now be represented and discussed. That will be followed by
the description and discussion of the data in the following category,
namely "Further studies to obtain a formal qualification".
243
TABLE 6.14: RESPONDENTS WHO DID INVESTIGATE POST-
GRADUATE POSSIBILITIES IN OPTOMETRY IN
SOUTH AFRICA
(Question 3.1)
Yes 63.6
No 36.4
DESCRIPTION
In this table 63.6% of the respondents reported that they had investigated
post-graduate possibilities in South Africa. The balance of 36.4% had not.
DISCUSSION
The higher number (250 individuals) who did investigate, indicates a high
level of interest in South African post-graduate opportunities without much
marketing/communication promoting the subject. It is therefore clear that a
well-motivated market, which is currently not catered for, exists.
"s " ,
244
TABLE 6.15( a): RESPONDENTS WHO WISHED TO EMBARK ON
POST -GRADUATE/POST -DIPLOMA STUDIES IF
THE OPPORTUNITY AROSE
(Question 3.2)
No 34.6
DESCRIPTION
This response reflects that 65.4% of the respondents would like to take
part in post-graduate studies should the opportunity arose. The balance of
34.6% did not wish to do so.
DISCUSSION
This information correlates well with Table 6.14 and indicates a high level
of motivation to look for opportunities, as well as the desire to take part in
those opportunities should they arise. Thus the stage is clearly set for the
right kind of programmes.
245
TABLE 6.15(b): RESPONDENTS' MOTIVATION/REASONS WHY
THEY DID NOT PURSUE POST -GRADUATE/POST-
DIPLOMA STUDlIES AT PRESENT
(Question 3.3)
Time constraints/distance
Were doing/had done CAS/OD 26.7
None available/not informed 15.6
Financial constraints 10.6
Not motivated 9.4
Not internationally recognised 5.0
Programme not suitable/accredited/too much 3.9
research
No broader scope opportunities 1.7
Correspondence 0.6
DESCRIPTION
This table reports the reasons why the respondents were currently not
engaging in post-graduate studies.
The first group (26.7%) felt time and travel constraints were their biggest
problem. The same number (26.7%) reported that they had in the recent
past pursued or were at that stage pursuing formal studies offered by a
private institution. Those who felt they were uninformed, came to 15.6%
and the cost factor was a problem for 10.6% of the respondents. "No
246
motivation" was reported by 9.4%, while 5.0% felt all such qualifications
had to be internationally recognised. Content not to their liking or too much
research was offered as a reason by 3.9%. Legislation must first be in
place was offered as a reason by 1.7% and 0.6% wanted courses to be of
a correspondence nature.
DISCUSSION
The fact that 48 of the respondents (26.7%) had in the recent past or were
at that stage engaged in some form of study, is encouraging and
minimises the other reasons of time/travel constraints; not being
interested; high costs; and lack of motivation. Careful planning with regard
to the nature and the structure of post-graduate qualifications should,
however, address all these concerns.
247
TABLE 6.~6: RESPONDENTS' REASONS WHY THEY WISHED
TO PURSUE FORMAL POST-GRADUATE STUDIES
IN THE !FUTURE
(Questnon 3.4)
Broaden skills base
Self-developing/academic career 22.7
Specialisation 9.4
International recognition 9.4
Research/develop new products 2.0
Undecided 0.5
DESCRIPTION
This table reflects that 56.2% of the respondents wanted to increase their
skills base via formal post-graduate studies. Self-development and an
academic career were mentioned as a reason by 22.7%, whilst 9.4%
wanted to specialise and a similar group wanted international recognition.
Only 2.0% were interested in research and the development of new
products, while 0.5% were undecided.
DISCUSSION
This data confirm the clinical reasons behind the desire to engage in
formal post-graduate education. The fact is also confirmed that a vast
majority had at that stage placed broader skills; self- and academic
development; specialisation; and international recognition far above
248
research and the development of new products. This is of concern, but
may only reflect a development phase in the profession in South Africa
whereby a broader skills base will stimulate research and new solutions to
problems in the field. Providers should concentrate on the initial need
and evaluate its changes, but build in the basic element of research as
well.
249
TABLE 6.17: POSITIVE RESPONSES TO THE OFFERiNG OF A
POST-GRADUATE PROGRAMME
(QuestioD1 3.5)
Would like to receive information 59.0
Would like to enrol for the programme 12.3
Would like both options 28.7
DESCRIPTION
Table 6.17 reports that 59.0% of the respondents would like to receive
information about the offering of a post-graduate programme; 12.3%
would enrol; while 28.7% would like both options.
DISCUSSION
This data confirm the high level of interest in post-graduate programmes.
Careful thought should, however, go into the marketing of post-graduate
programmes. It is clear that the majority would first like to receive
information in order to study the content carefully. According to Prof. L.
Botes, the Head of Developmental Studies at the UFS, the ratio
information: enrolment is very much in line with other post-graduate
training programmes at this university. (Written communication from Botes
dated 7 May 2003.)
250
TABLE 6.18: RESPONDENTS' PREFERRED AREA TO OBTAIN
A POST-GRADUATE QUAUFICATION iN THE
FIELD OF OPTOMETRY
(Question 3.6)
Primary care (diagnosis and treatment)
Contact lenses 17.1
Paediatrics 13.8
Vision therapy and sport vision and binocular vision 12.2
Low vision 6.1
All of the above 3.3
Iridology 2.2
Do not know 1.7
Myopia control 0.6
Management 0.6
DESCRIPTION
Table 6.18 represents details of the areas in the field of optometry in which
respondents would prefer to acquire a post-graduate qualification. The
diagnosis and treatment of disease led the field with 42.5%. This was
followed by contact lenses (17.1%); paediatrics (13.8%); vision therapy,
sports vision, binocular vision (12.2%); low vision (6.1%); all areas (3.3%);
Iridology (2.2%); uncertainty (1.7%); myopia control (0.6%); and
management (0.6%).
251
DISCUSSION
The data reflect the similar trend in other questions exploring the priorities
of the respondents. The area of the diagnosis and management of ocular
disease was by far the most important area preferred for post-graduate
qualification. This, as well as the other areas, indicates a need as well as
an opportunity for teaching institutions. However, it also reflects shortfalls
in the undergraduate training and the reasons for that should be analysed.
252
TABLE 6.19: THE INADEQUACIES/SHORTFALLS IN THE
PROFESSIONAL PRACTICE ENVIRONMENT
WHICH! RESPONDENTS EXPIERIENCED
(QuestioD1 3.7)
Diagnose and treat disease
No areas of concern 20.1
Practice management/ethics 9.0
Binocular vision/paediatrics/sport vision 7.6
General problems 7.6
Contact lens skills 6.9
Low vision 5.6
No recognition for post-graduate qualification (re- 4.2
imbursements)
DESCRIPTION
The diagnosis and treatment of ocular disease ranked as the biggest
(38.9%) inadequacy experienced by the respondents. This was followed
by practice management/ethics (9.0%); binocular vision/paediatrics/sport
vision (7.6%); general problems (7.6%); contact lens skills (6.9%); low
vision (5.6%); and no reimbursement for new skills (4.2%). The balance
(20.1 %) of the responses reported no areas of concern.
253
DISCUSSION
The data in Table 6.19 are not only representative of the shortfalls in
professional practice, but also indicate the same in undergraduate training,
as well as opportunities in speciality post-graduate training.
6.9 SUMMATIVE CONCLUSION ON CATEGORY 3: POST-
GRADUATE/POST-DIPLOMA STUDIES
The data collated in this category clearly indicate a willingness to embark
on post-graduate studies. The reason for wanting to do so, as well as
reasons for not being engaged in such studies, is also earmarked. What is
furthermore clear, is that certain specific areas of post-graduate study
were identified by respondents as being of paramount importance, which
more or less corresponds with the problems which they experienced in
practice.
The evidence mounts against an undergraduate programme which is not
measured against the needs of the workplace or the public. It might be
that the undergraduate programme is overcrowded with areas which
require more clinical exposure, areas which may be obsolete, or which
may need to be dealt with at a post-graduate level.
A remedy that follows the guidelines of Health and Higher Education
Policy will need to be looked at if these needs/shortfalls are to. be
addressed.
Figure 6.3 provides a graphic presentation of some of the aspects of the
main findings on Category 3.
254
FIGURE 6.3: A GRAPHIC PRESENTATION OF SOME OF THE
ASPECTS OF THE FINDINGS ON CATEGORY 3: POST-
GRADUATE/POST-DIPLOMA STUDIES
a) Respondents who did investigate post-graduate possibilities in
optometry in South Africa (n=393)
.Yes: 63.6%
.No: 36.4%
b) Respondents who wished to embark on post-graduate/post-diploma
studies (n=393)
.Yes: 65.4%
.No: 34.6%
c) Positive responses to the offering of a post-graduate programme
(n=244)
oWould like to receive
information: 59%
• Would like to enrol for the
programme: 12.3%
• Both: 28.7%
255
d) Respondents' preferred area to obtain a post-graduate qualification in
the field of optometry (n=181)
• Primary care (diagnosis and
treatment): 42.5%
• Contact lenses: 17.1%
o Paediatrics: 13.8%
.cl!l
al • Vision therapy, sport vision,
"'C
Co binocular vision: 12.2%c..
Cl)
~ • Low vision: 6.1%
• All of the above: 3.3%
• lridology: 2.2%
o Do not know: 1.7%
o Myopia control: 0.6%
Preferred area
OManagement: 0.6%
256
6.10 MAIN FINDINGS OF THIS CATEGORY
The following are the main findings of this category:
o Two out of three respondents were interested in post-graduate studies.
Their main reasons were a broader skill base and self-development or
an academic career.
o The preferred areas to obtain a post-graduate qualification are
diagnosis and treatment of ocular disease, contact lenses, paediatrics,
binocular/sport vision and low vision.
e The biggest shortfall experienced in practice is the diagnosis and
treatment of ocular disease.
257
6.11 RESULTS OF CATEGORY 4: !FURTHER STUDIES TO
OBTAIN A FORMAL QUALIFICATION
The category "Further studies to obtain a formal qualification" is the fourth
of six categories of information that was collected by means of a
questionnaire (cf. Appendix C).
Respondents had to indicate how they would like to study (i.e. full-time or
part-time); what form of study they would prefer (i.e. a lectured course, a
research course or a combination); whether they would be able to make
use of online technology for part of their course work; whether they would
be able to attend lectures or modules on campus for a short period of time
and, if so, how often. Respondents had to indicate where they would
prefer to do the practical (clinical) sessions of the course and they were
requested to provide an explanation for their answers. They also had to
indicate which qualification they would like to obtain and provide reasons
for their answers. In addition, respondents had to indicate if they were
aware of any post-graduate opportunities in South Africa and, if so, they
were asked to indicate if such opportunities fulfilled their needs, motivating
their replies. Related to this question, they were required to state if they
were aware of post-graduate programmes available in other countries. If
they answered in the affirmative, they had to indicate if these fulfilled their
needs and motivate their responses. In the last question respondents
were asked if they would prefer the programme they had enrolled for in
South Africa to have international recognition.
The data in the fourth category, namely "Further studies to obtain a formal
qualification", will now be represented and discussed. That will be
followed by the description and discussion of data in the following
category, namely "Detailed Information on Post-graduate/Post-diploma
programmes" .
258
TABLE 6.20: FORMAL STUDY TIME SCHEDULES PREFERRED
BY THE RESPONDENTS
(Question 4.1)
Part-time studies 97.2
Full-time studies 2.8
DESCRIPTION
In Table 6.20 the respondents indicated that 97.2% would prefer part-time
study when attempting formal post-graduate studies. Only 2.8% preferred
full-time studies.
DISCUSSION
The responses are indicative of the fact that the majority were practising
full-time and possibly had families - a fact which would make full-time
studies impossible. Time and financial constraints will therefore need to be
recognised by providers.
259
TABLE 6.21: COURSE-STRUCTURE (COURSE TYPE)
PREFERRED BY THE RESPONDENTS
(Question 4.2)
Combination of a modular-lectured course and a 50.6
research study
Modular-lectured course 46.6
Research study 2.8
DESCRIPTION
The above table reflects the preference for course structure. Most of the
respondents (50.6%) preferred a combination of what was offered. This
was closely followed by a modular-lectured course (46.6%). Only 2.8%
preferred a research study.
DISCUSSION
Although about half of the respondents indicated that a combination of
modular lectures and research would be preferred, a very similar number
excluded research by preferring lectures only. The balance was made up
of those who wanted research only and what appears to be a preference
for a correspondence course. Providers should therefore tailor post-
graduate studies to offer lectured modules - whereafter the respondents
may exit and then attend a combination of lectures and research.
260
TABLE 6.22: THE RESPONDENTS' ABILITY TO USE ONlINE
TIECHNOLOGY AS !PART OIF THE COURSEWORK
DELIVERY
(Question 4.3)
Yes
No 10.2
Not sure 0.4
DESCRIPTION
Table 6.22 reflects that 89.4% of the respondents were able to receive
part instruction via the Internet. A small group of 10.2% indicated that they
would not be able to do this and 0.4% were unsure.
DISCUSSION
With a total response of n=245 one can assume that only about two-thirds
of the respondents were connected to the Internet at the time. This
number will grow with the general trend, but may remain a problem for
some and needs to be considered in any planning.
261
TABLE 6.23: RESPONDENTS' AVAILABILITY TO ATTEND
LECTURES ON CAMPUS FOR A SHORT PERIOD
OF TIME
(QuestioD1 4.4)
No 7.3
Not more than two days in three months 0.4
DESCRIPTION
According to this table, most of the respondents (92.3%) indicated that
they could spend short periods on campus. Only 7.3% felt that it was
impossible and 0.4% mentioned that this period had to be limited to not
more than two days in a three-month period.
DISCUSSION
It is interesting that this figure is only slightly higher than the number with
Internet access, but clearly indicates that respondents were not against
attending short lecture periods on campus. It is also noticeable that the
difference between those who were able to use online technology and
those who could come to the campus for short periods, is small, i.e. 3.0%.
One may assume that the negative answers came from those in very
remote parts of the country. A more precise timeframe was explored in the
question which followed. Providers should note this.
262
TABLE 6.24: FREQUENCY OF RESPONDENTS' ABILITY TO
ATTEND lECTURES
(Question 4.5)
1x year
2x year 32.0
3x year 22.0
4x year 24.9
2 - 4 weeks continuously per year 11.2
DESCRIPTION
According to this table, most of the respondents (32.0%) indicated that
they could attend a short period, i.e. a maximum of four days twice a year
on campus. This was followed by 24.9% who saw four times per year as
reasonable, whilst 22.0% felt they could attend three times per year. The
once a year option was preferred by 10.0%, while 11.2% preferred two to
four weeks continuously once a year.
DISCUSSION
It is clear from the responses that a short period on campus up to three
times a year was not a problem for about half of the respondents.
Providers may therefore tailor post-graduate programmes accordingly.
263
TABLE 6.25(a): INDICATION OF THE REPONDENTS'
PREFERENCE WITH REGARD TO THE PLACE
WHERE THE PRACTICAl/CLINICAL SESSIONS OF
THE POST-GRADUATE COURSE SHOULD TAKE
!PLACE
(Question 4.6)
Teaching institutions
Hospital 29.8
Accredited site/practice 29.8
DESCRIPTION
This table indicates that 40.4% of the respondents would prefer clinical
sessions to be offered at teaching institutions; 29.8% preferred hospital
sites; and a similar number preferred any accredited site or practice.
DISCUSSION
Respondents' reasons for this preference are accounted for in Table
6.25(b), but it is clear that all the options carry sufficient weight and should
therefore be explored.
264
TABLE 6.25(b): RESPONDENTS' MOTIVATION/REASONS WHY
THE PRACTICAl/CLINICAL SESSIONS SHOULD
BE HELD IN THESE LOCATIONS
(Question 4.7)
Convenience/cost containment
Public sector patient base 23.9
Supervision 17.4
DESCRIPTION
Here the respondents (58.7%) reported convenience and costs as their
main reasons for choosing the site they did. It was followed by the public
sector patient base (23.9%) and supervision that would be available
(17.4%).
DISCUSSION
Although teaching institutions were preferred, respondents saw the
expanded clinical opportunities that the other sites would offer. One of
their concerns might be that adequate supervision would not be available
outside the teaching institution, as hardly any such site is currently used
for optometry training. However, they had therefore not been exposed to
the wealth of experience that can be shared by clinically-orientated
teachers who might have experienced clinical cases never seen in
teaching institutions. This negative perception can be addressed by
accrediting protocols and criteria - then all sites could be developed.
265
TABLIE 6.26(a): THE PERCENTAGE OF RESPONDENTS WHO
PREFERRED A CERTAIN TYPE/TYPES OR A
COMBINATION OF POST-GRADUATE
QUAlIlFlCATIONS
(QlUlestion 4.8)
Certificated short courses 31.0
Post-graduate diploma 28.6
Ph.D. 26.5
Advanced diploma 20.0
OD 0.8
DESCRIPTION
Table 6.26(a) offers information about the type of post-graduate
qualification that respondents would prefer. A Master's degree was on top
of the list with 34.7%; followed by certificated short courses at 31%; a
Post-graduate diploma at 28.6%; a Ph.D. at 26.5%; an Advanced diploma
at 20%; and the Doctor of Optometry degree at 0.8%.
266
DISCUSSION
If one looks back at the course structure which was preferred by the
respondents in question 4.2, it is clear that the structured M. degree with a
research component would be the most favoured post-graduate
qualification. However, one should be mindful that respondents might not
have known the difference between post-graduate and advanced diplomas
and if one adds these two groups, it will be the most favoured qualification.
This should not necessarily impact negatively on the Master's degree, as a
post-graduate diploma exit is possible as part of structured Master's
programmes. Providers should therefore ensure that post-graduate
programmes are structured in this way.
TABLE 6.26(b): OTHER TYPES OF POST -GRADUATE
QUALIFICATIONS THAT RESPONDENTS WOlIJlID
LIKE TO OBTAIN
(Question 4.9)
Internationally recognised qualification
Clinically-based qualification rather than research 22.2
Applicable qualifications which recognise 22.2
special isation
Separate qualifications which offer structured or 16.7
research degrees
267
DESCRIPTION
This table reflects the small number (18) of respondents who indicated that
they would prefer a qualification not offered as indicated in the previous
table. Here the majority (38.9%) preferred a qualification which would have
international recognition, followed by a clinical qualification which excluded
research (22.2%). A similar figure represents those who wanted a
qualification which recognised a speciality, while 16.7% wanted to be sure
that structured and research qualifications were offered separately.
DISCUSSION
It is interesting to note that only seven individuals placed international
recognition as a priority, which indicates that most respondents favoured a
South African qualification. Speciality recognition should evolve from the
proposed structures and should therefore not be a concern. However, it
remains evident that respondents wanted to make sure they would not be
forced to do research as part of the qualification. This was also clear from
the responses in the previous table.
It should be noted that he principles of the NQF also state that South
African education should be of an international standard.
268
TABllE 6.27(a}: RIESPONDENTS' AWARENESS OF POST-
GRADUATE OPPORTUNITIES IN SOUTH AFRICA
(QuestioIl14.10)
Yes 77.8
No 22.2
DESCRIPTION
This table indicates an awareness of post-graduate opportunities in South
Africa. Those who answered affirmatively amounted to 77.8%, with the
balance of 22.2% not being aware.
DISCUSSION
The positive figure is relatively high, as the opportunities were few. It is
also proven, however, that the respondents had taken the time to
investigate this, as the dissemination of information had been limited.
Providers should be encouraged by this trend.
269
TABLE 6.27(b): RESPONDENTS' VIEWS WITH REGARD TO POST-
GRADUATE OPPORTUNITIES IN SOUTH AFRICA
WHICH FUllFlLLED THEIR NEEDS
(Question 4.11)
Yes
No 65.2
Have not really gone into the course work 1.6
"Yes" and "No" 1.1
DESCRIPTION
Those who answered "Yes" to the previous question were asked if the
opportunities had fulfilled their needs. An affirmative response was
reported by 32.1 %; a negative response by 65.2%; a small number of
6.0% had not looked at the content of courses; and 1.1% were not sure.
DISCUSSION
The high number of respondents who recorded a negative response
indicates that post-graduate qualifications to date have failed to address
their needs. The reasons for a positive response were further explored in
the next question. The providers should, however, be concerned and use
the information in this study to tailor post-graduate programmes.
270
TABLE 6.27(c): RESPONDENTS' REASONS AS TO WHY POST-
GRADUATE OPPORTUNITIES IN SOUTH AFRICA
FULFILLED THEIR NIEEDS
(Question 4.~2)
CAS adequate
Research-based important 28.6
Do not know 10.7
Not appropriate to personal needs 10.7
Yes, but inadequate information/poor organisation 3.6
Yes, but too much research 3.6
Offering what I need 3.6
DESCRIPTION
28 individuals responded to this question. The main reason why the
respondents felt the current opportunities fulfilled their needs, was the fact
that they had completed or were taking part in a Certificate of Advanced
Study course. This first subgroup represents 39.3% of the responses. The
next subgroup (28.6%) felt that the research-based nature of the
opportunities was most important. This was followed by a subgroup of
10.7% who did not know why they felt fulfilled. A similar group felt that
these opportunities fulfilled their needs, but not a personal need. Although
3.6% responded positively, they had some criticism in that they felt the
opportunities did not provide them with enough information or were poorly
organised. A similar number were positive, but felt there was too much
271
research, while the last subgroup of 3.6% reasoned that opportunities in
general met their needs.
DISCUSSION
It is obvious that the two major subgroups represented respondents who
were involved in a formal post-graduate modular programme and who
were involved in a research programme.
The relatively small response is indicative of the plateau phase which the
profession is experiencing. Only when one or two institutions have
established an example of successful clinical post-graduate studies, will
the true meaning of post-graduate qualifications become apparent and
allow the profession to question whether such examples meet their needs.
272
TABLE 6.27(d): RESPONDENTS' REASONS WHY POST-
GRADUATE OPPORTUNITIES IN SOUTH AfRICA
DID NOT FULFil THEIR NIElEDS
(QUJestion 4.12)
Not appropriate to personal needs 28.3
Inadequate informationl poor organisation 14.1
Do not know 12.9
Not recognised internationally 11.8
Research-based important 11.8
CAS standard too high 7.1
No, but CAS adequate 4.7
Not practical enough 4.7
Too much research 4.7
DESCRIPTION
The reasons why the 85 respondents (n=8S) were not satisfied with
current post-graduate opportunities are reflected here. The biggest group
of 28.3% felt that the opportunities did not fulfil their personal needs;
14.1% felt it was due to poor communication and organisation; 12.9% did
not know; 11.8% felt international recognition was needed; a similar group
felt the importance of research was ignored; 7.1% felt the standard of the
CAS was too high; 4.7% indicated that the CAS was adequate, although
they had initially answered in the negative; 4.7% felt there were not
273
enough practical sessions; and a similar group reported too much
research.
DISCUSSION
Not all the respondents referred to the same course and it was therefore
difficult to link the reasons to a specific opportunity on offer. These
responses will therefore have to be viewed in a general context as
represented in Tables 6.27(a) through to 6.27(d).
The overall impression is that, although respondents were for the most
aware of post-graduate opportunities, the latter were for various reasons
not aimed at their needs. This is an aspect which will need to be taken into
account when designing a post-graduate programme and which need
further evaluation.
TABLE 6.28(a): RESPONDENTS' AWARENESS Of POST-
GRADUATE STUDIES IN OTHER COUNTRIIES
(Question 4.13)
No 36.6
DESCRIPTION
According to this table, 63.4% felt they were aware of post-graduate
studies in other countries. Those who were not, amounted to 36.6%.
274
DISCUSSION
These responses were similar to the responses to the awareness of South
African opportunities, indicating that respondents had taken the time to
investigate opportunities further afield, as South African opportunities did
not fulfil their needs or vice versa.
TABLE 6.28(b): RESPONDENTS' VIEWS AS TO WHIETHIER !POST-
GRADUATE !PROGRAMMES IN OTHIER
COUNTRIES fUlFllllED THEIR NEEDS
(Questioll1 4.14)
No
Yes 29.9
Uncertain 3.2
DESCRIPTION
A large subgroup of 66.9% felt that post-graduate programmes in other
countries did not fulfil their needs; 29.9% felt they did; and 3.2% were
unsure.
DISCUSSION
These answers followed a similar trend to the responses regarding South
African programmes and indicated that institutions in other countries
seemed to fail as badly as South African institutions in offering appropriate
275
post-graduate programmes. However, the effect of cost cannot be ignored
in the international context.
TABLE 6.28(c): RESPONDENTS' VIEWS AS TO WHY POST-
GRADUATE PROGRAMMES IN OTHER
COUNTRIES FULFILLED THEIR NEEDS
(Question 4.~5)
International recognition
Variety of CAS programmes 20.0
Only M. or Ph.D. degrees available in South Africa 12.0
Not sure 12.0
Costs 8.0
DESCRIPTION
Almost half (i.e. 48.0%) gave the main reason for being satisfied with
opportunities in other countries as being that of international recognition.
The next most popular reason was that 20.0% of the NEWENCO-
accredited CAS courses had enough variety; followed by the fact that only
M. and Ph.D. degrees are available in South Africa (12.0%). A similar
number were not sure and 8.0% felt that, although their needs were
fulfilled, the cost aspect was the major problem.
276
DISCUSSION
It is clear that the respondents preferred courses to have international
recognition and one can place 68.0% of the responses under this heading.
It is also clear that non-clinical M. and Ph.D. degrees offered at the time
were forcing a certain group to look elsewhere for post-graduate
opportunities.
TABLE 6.28{d): RESPONDENTS' VIEWS AS TO WHY POST-
GRADUATE PROGRAMMES IN OTHER
COUNTRIES DID NOT FULFIL THEIR NEEDS
(Question 4.15)
Costs 66.0
M. degree or Ph.D. available in South Africa 12.8
Not interested 12.8
International recognition limited 6.4
Variety of CAS programmes not sufficient 2.1
DESCRIPTION
A group of 66.0% felt that the cost of post-graduate programmes in other
countries was the main reason why such programmes could not fulfil their
needs. The availability of M. and Ph.D. degrees in South Africa was a
reason offered by 12.8%. A similar group indicated "Not interested"; 6.4%
felt that the international recognition was too limited; and 2.1 % wanted
more variety in the CAS programmes.
277
DISCUSSION
Cost remains the major factor that detracts from international programmes.
This is particularly true after the recent fall in the value of the South African
Rand.
TABLE 6.29: RESPONDENTS' IDESIRE fOR INTERNATIONAL
RECOGNITION OF SOUTH AFRICAN
PROGRAMMES
(Question 4.16)
Yes
No 2.5
"Yes" and" No" 0.4
DESCRIPTION
The vast majority (97.1%) of the respondents felt that South African
programmes should be recognised internationally. A small subgroup of
2.5% did not concur, while 0.4% did not know.
DISCUSSION
From the data it is clear that the respondents wished for South African
programmes to enjoy reciprocity at institutions in other countries. The
responses in addition indicate a desire to be educated at an international
278
level, which is also one of the objectives of higher education in South
Africa.
Providers should therefore ensure that standards are of an international
level and reciprocity is sought with the countries of choice. It may even
encourage other African students to enrol for programmes in South Africa.
6.12 SUMMATIVE CONCLUSION ON CATEGORY 4: IFURTHER
STUDIES TO OBTAIN A FORMAL QUALIFICATION
From the data collated in Category 4, it is evident that the respondents
were willing to pursue post-graduate studies on a part-time basis by
attending four-day modules three to four times a year and that they wished
to attend clinical training at a convenient site where there would be
sufficient supervision. Most of the respondents had explored local and
international post-graduate opportunities, but found them to be mostly
unacceptable. Most of the reasons related to the cost of international
qualifications and the fact that local qualifications were not tailored to the
personal needs of the respondents.
Most of the respondents would prefer a South African Diploma or Master's
degree of a clinical nature should they acquire a post-graduate
qualification. Such a local qualification had to have international
recognition.
Figure 6.4 provides a graphic presentation of some of the aspects of the
main findings on Category 4.
279
FIGURE 6.4: A GRAPHIC PRESENTATION OF SOME OF THE
ASPECTS OF THE FINDINGS ON CATEGORY 4: FURTHER STUDIES
TO OBTAIN A FORMAL QUALIFICATION
a) Time schedules preferred by respondents for formal study (n=250)
• Part-time studies: 97.2%
Full-time studies: 2.8%
b) Course structure (course type) preferred by the respondents (n=249)
• Combination of a modular-lectured course
and a research study: 50.6%
• Modular-lectured course: 46.6%
o Research study: 2.8%
c) Respondents' ability to utilise online technology as part of coursework
delivery (n=245)
.Yes: 89.4%
.No: 10.2%
o Not sure: 0.4%
d) Respondents' availability to attend lectures on campus for a short
period of time (n=246)
DYes: 92.3%
DNa: 7.3%
o Not more than two days in
three months: 0.4%
280
e) Respondents' preference with regard to the place where the
practical/clinical sessions of the post-graduate course should take
place (n=188)
• Teaching institutions: 40.4%
• Hospital: 29.8%
o Accredited site/practice:
29.8%
f) The percentage of respondents who preferred a certain type/types or a
combination of post-graduate qualifications (respondents could choose
more than one option) (n=245)
• Master's degree: 34.7%
35
-1/1 30 • Certificate short courses:c:: 31.0%Cl)
"e0 25
0 o Post-graduate diploma:
0-
1/1 28.6%
..e.. 20
0
Cl) • Ph.D: 26.5%
- 15Cl10eCl) 10
u... • Advanced diploma: 20.0%
Cl)
Cl.. 5
0 000: 0.8%
Type of qualification
g) Respondents' awareness of post-graduate opportunities in South Africa
(n= 248)
.Yes: 77.8%
ONo: 22.2%
281
h) Post-graduate opportunities in South Africa which fulfil the
respondents' needs (n= 187)
OYes: 24.4%
No: 72.0%
o Have not gone into
course work: 1.6%
• "Yes" and "No": 1.1%
i) Respondents' awareness of post-graduate studies in other countries
(n=243)
.Yes: 63.4%
.No: 36.6%
j) Post-graduate programmes in other countries which fulfil the
respondents' needs (n=145)
• Yes: 29.0%%
.No: 66.9%
o Uncertain: 3.2%
k) Respondents' desire for international recognition of South African
programmes (n=241)
.Yes: 97.1%
ONo: 2.5%
• "Yes" and "No": 0.4%
282
6.13 MAIN FINDINGS OF THIS CATEGORY
The following are the main findings of this category:
o Almost all the respondents preferred part-time post-graduate time
schedules.
o Only 2.8% preferred a research only study.
o 89.4% of the respondents were able to take part in the electronic
delivery of lectured modules. At the same time they were willing to
attend lectures on campus for short periods of four days, two to four
times per annum.
e Clinical training within institutions, hospitals or other accredited sites
are all possibilities.
e An optional series of qualifications are preferred.
o Eight out of 10 were aware of post-graduate opportunities in South
Africa. However, two-thirds were of the opinion that the opportunities
did not fulfil their needs.
o Almost all the respondents wanted international recognition for their
post-graduate studies. However, the cost factor of courses in other
countries is a negative factor.
283
6.14 RESULTS OF CATEGORY 5: DETAilED INFORMATION ON
POST -GRADUATE/POST -DIPLOMA PROGRAM MES
The category "Detailed Information on Post-graduate/Post-diploma
programmes" is the fifth of six categories of information which was
collected by means of a questionnaire (cf. Appendix C).
In this category a list of some of the programmes was provided and
respondents had to indicate their personal preference of the programme
they would like to follow. They were also given the opportunity to indicate
programme content that was not on the list provided and were then asked
to elaborate on their answers. Subsequently the respondents were asked
to specify the duration of a specialisation programme. In addition, they
were asked to indicate what the nature of such a programme should be
(e.g. practical/clinical work, theory, etc.); whether it should include elective
modules for enrichment in related fields; and if it should be aimed at
broadening the respondents' scope of practice. Finally, the respondents
were requested to elaborate on their answers.
The data in the fifth category, namely "Detailed Information on Post-
graduate/Post-diploma programmes", will now be represented and
discussed. That will be followed by the description and discussion of data
in the following category, namely "Awareness of the public need".
284
TABLE 6.30(a): RESPONDENTS' PREFERENCE WITH REGARD
TO THE CONTIENT OF A POST-GRADUATE
PROGRAMME
(QuestioD1 5.1)
Diagnostic agent privileges
Therapeutic agents 61.9
Contact lenses 60.3
Surgical co-management 56.8
Business management skills 50.6
Binocular vision 50.2
Public health 43.2
Low vision 39.7
Industrial/environmental optometry 31.9
Sports vision 31.1
Other 8.2
DESCRIPTION
The respondents indicated the popularity of specific fields that they would
like to see in post-graduate programmes. Diagnostic agents (82.1 %) and
therapeutic agents (61.9%) occupied the first and the second positions.
These were followed by contact lenses (60.3%); surgical co-management
(56.8%); business management (50.6%); and binocular vision (50.2%).
Topics that scored less than 50.0% were public health (43.2%); low vision
285
(39.7%); industrial/environmental optometry (31.9%); sports vision
(31.1 %); and other topics not listed (8.2%).
DISCUSSION
The respondents clearly favoured topics which were aimed at improving
clinical skills such as the diagnosis and treatment of ocular disease; better
skills in contact lens practice; surgical co-management; and business
management skills. In a simplistic way the list prioritises the needs in the
profession, in addition to identifying the shortcomings of undergraduate
programmes. Providers should therefore evaluate these topics at both
under- and post-graduate level.
286
TABLE 6.30(b): OTHER CONTENT SUGGESTIONS WITH REGARD
TO POST-GRADUATIE PROGRAMMES
(Question 5.2)
Diagnose and treat ocular disease 44.2
Paediatrics 23.3
Nutrition/lridology 9.3
Ethics/practice management 9.3
HIV/AIDS 7.0
Neurology of vision 2.3
Contact lenses 2.3
All of the above/a combination of topics 2.3
DESCRIPTION
Topics which were described under "Other" featured as follows: The
diagnosis and treatment of ocular disease at 44.2%; paediatrics at 23.3%;
nutrition and Iridology at 9.3%; ethics and practice management also at
9.3%; HIV/AIDS was next with 7.0%; neurology of vision at 2.3%; and
contact lenses at 2.3%. A similar number, namely 2.3%, chose a
combination of all the topics in Table 6.30(a).
DISCUSSION
Most of the suggested topics would by nature fall into one of the fields in
the previous table, i.e. diagnose and treat ocular disease; paediatrics;
287
practice management; neurology of vision; and contact lenses. One can
therefore assume that only nutrition, Iridology and HIV/AIDS would be
offered in addition to the initial topics. Iridology, on the other hand, is not a
proven scientific practice and will need objective evaluation. This data
again call for introspection at undergraduate level and will help in the
planning of post-graduate levels.
288
TABLE 6.31: RESPONDENTS' RECOMMENDATIONS ON THE
DURATION OF A SPECIALISATION PROGRAMME
(Question 5.3)
Maximum two years 39.9
One year or less 29.5
Do not know/as long as it takes 12.4
One week per category 6.2
Two to four years 5.2
Four years 3.1
Two to three days per category 1.6
Two to four weeks per category 1.6
Two months per category 0.5
DESCRIPTION
In the above table the respondents indicated the time they would be willing
to devote to a post-graduate programme. A maximum of two years was
preferred by 39.9%. This was followed by 29.5% who felt it should be no
longer than one year; 12.4% had no specific timeframe; 6.2% chose one
week per category; 5.2% indicated two to four years; 3.1% indicated four
years; 1.6% indicated only two to three days per category; a similar
number felt two to three weeks per category was sufficient; and 0.5%
chose two months per category.
289
DISCUSSION
Most of the responses could be catered for within the structure of a two-
year 240-credit modular course work M. degree with the possibility of a
diploma exit after one year of 120 credits.
This structure was proposed by the University of the Free State and
approved by SAQA.
TABLE 6.32: RESPONDENTS' PREFERRED STUDY MODE
(Question 5.4)
Contact sessions (including different activities) 28.3
Self-study 23.5
Lectured sessions 21.9
Self-study and lectured sessions 7.6
Self-study and contact sessions 6.4
Contact sessions and lectured sessions 5.6
All the above combinations 6.8
290
DESCRIPTION
Table 6.32 reflects the study mode the respondents preferred. Contact
sessions led the field with 28.3%. This was followed by self-study with
23.5%; lectured sessions with 21.9%; self-study and lectured sessions
with 7.6%; self-study and contact sessions with 6.4%; contact and lectured
sessions with 0.8%; and a combination of all the above with 4.8%.
DISCUSSION
It is not clear if the respondents confused lectured and contact sessions as
they might include practical demonstrations and research guidance
sessions. One may assume that the contact and the lectured sessions
were seen to be more or less the same and if these two responses are
combined, one looks at a total of 50.2%. This will then be followed by self-
study (23.5%) and the rest of the combinations. The table which follows,
provides more information.
The final structure of a post-graduate programme will depend on how
these combinations can be implemented in a practical way.
291
TABLE 6.33: CLINiCAL/THEORY/RESEARCH PREFERENCE OF
THE RESPONDENTS
(Questnon 5.5)
Combination of practical/clinical; theory and 67.1
research
Combination of practical/clinical and theory 21.1
Practical/clinical work 9.5
Research 1.2
Combination of theory and research 0.8
Combination of practical/clinical and research 0.4
Theory 0.0
DESCRIPTION
This table offers information on the "blend" of clinical/theory/research
preference reported by the respondents. Theory received no response; a
combination of practical/clinical and research received 0.4%; theory and
research received 0.8%; research only received 1.2%; practical/clinical
only received 9.5%; practical/clinical and theory received 21.1 %; and
practical/clinical, theory and research received 67.1 %.
DISCUSSION
The combination with the strongest support matches the structure of the
proposed M. Optometry degree at the UFS. It also indicates that research
292
is not excluded if it forms part of a combination and should be encouraged
by providers.
TABLE 6.34: !PREFERENCE FOR THE INCLUSION OF
ELECTIVE MODULES
(Question 5.6)
Yes
No 6.0
DESCRIPTION
94.0% of the respondents felt that elective modules had to be included in
post-graduate programmes, while 6.0% did not feel that it was of
paramount importance.
DISCUSSION
It is clear that the respondents wanted an "own choice" module as a part of
post-graduate studies. This makes sense, especially in the light of a
research dissertation that will be required in a structured Master's
programme. This will also match the clinical/theory/research blend they
preferred according to Table 6.33.
293
TABLE 6.35(a): RESPONSES TO THE BROADENING OF SCOPE
Of PRACTICE
(Question 5.7)
Both "Yes" and "No" 1.2
No 0.4
DESCRIPTION
According to this table, 98.4% of the respondents felt that post-graduate
programmes should be aimed at broadening the scope of the profession.
Only 1.2% were unsure and 0.4% were negative about this.
DISCUSSION
The respondents were convinced that education should underpin new
skills and that the main reason for post-graduate studies in optometry
should be aimed at an expanded skills base. Providers need to co-
ordinate their educational efforts with other stake holders in the field, such
as Ophthalmology and the regulatory bodies.
Their reasons for making this statement are depicted in the next table:
294
TABLE 6.35(1:»: RESPONDENTS' REASONS/MOTIVATION AS TO
WHY A POST-GRADUATIE PROGRAMME SHOULD
BE AIMED AT BROADENING THIE SCOPE OF
PRACTICE
(Questoon 5.8)
Reduce costs to patient/increase care 33.6
Speciality skills recognised 29.5
Only reason for post-graduate studies 10.7
Bring primary care to areas Ophthalmology cannot 9.8
cover
Understanding of multi-system abnormality 6.6
Scope needs to grow with new advances 4.9
Create employment opportunities 2.5
Bring financial reward 1.6
Do not know 0.8
DESCRIPTION
The respondents reasoned that a post-graduate qualification should
underpin a broader scope in the following order of importance: It will
reduce costs to patient and increase care (33.6%); it will recognise
speciality skills (29.5%); it is the only reason for post-graduate studies
(10.7%); it brings primary care to areas that Ophthalmology cannot cover
(9.8%); it will help in the understanding of multi-system abnormality
(6.6%); scope needs to grow with new advances (4.9%); creating
295
employment opportunities (2.5%); bringing financial reward (1.6%); and do
not know (0.8%).
DISCUSSION
The responses were realistic and focused on better, expanded and
affordable care backed by education and new technology/procedures.
Financial reward and employment would be spin-offs which would
naturally follow the expanded scope and were clearly not the priority.
Providers should be encouraged by this response, which is also of great
value to professional associations and regulatory bodies, as it gives insight
into the motivation for a broader scope and higher clinical standards.
6.15 SUMMATIVE CONCLUSION ON CATIEGORY 5: DETAILED
INIFORMATION ON POST -GRAIDUATE/POST -DIPLOMA
PROGRAMMES
Data collated in this category pinpointed the areas in which the
respondents wished for post-graduate training. One obtains a good
perception with regard to timeframes, modes of study and combinations of
lectures, self-study, theory, as well as clinical and research content which
were preferred. The importance of the inclusion of elective modules as
well as the educational basis for scope expansion was highlighted. The
reasons for scope expansion concentrated on Public Health issues, which
cannot be argued against.
Figure 6.5 provides a graphic presentation of some of the aspects of the
main findings on Category 5.
296
FIGURE 6.5: A GRAPHIC PRESENTATION OF SOME OF THE
ASPECTS OF THE FINDINGS ON CATEGORY 5: DETAILED
INFORMATION ON POST-GRADUATElPOST-DIPLOMA
PROGRAMMES
a) Respondents' preferred content of a post-graduate programme (more
than one option could be chosen) (n=257)
D Diagnostic agent privileges: 82.1%
Therapeutic agents: 61.9%
o Contact lenses: 60.3%
o Surgical co-management: 56.8%
• Business management skills: 50.6%
• Binocular vision: 50.2%
o Public health: 43.2%
o Low vision: 39.7 %
• Industrial/environmental optometry:
31.9%
o Sports vision: 31.1%
ContenUField • Other: 8.2%
b) Preferred study mode by respondents (n=251)
• Contact sessions: 28.3%
o Self-study: 23.5%
• Lectured sessions: 21.9%
• Self-study and lectured
sessions: 7.6%
o All combinations: 6.8%
• Self-study and contact
sessions: 6.4%
• Contact and lectured sessions:
5.6%
297
c) Clinical/theory/research preference of the respondents (n=251)
Practical/clinical/research/theory:
67.1%
• Practical/clinical/theory
combination: 21.1%
Practical/clinical: 9.5%
• Research: 1.2%
o Theory/research: 0.8%
o Practical/clinical/research
combination: 0.4%
• Theory: 0.0%
d) Preference for the inclusion of elective mode (n=249)
OYes: 94.0%
ONo: 6.0%
e) Responses to the broadening of scope of practice (n=246)
.Yes: 98.4%
• "Yes" & "no": 1.2%
No: 0.4%
298
6.16 MAIN FiNDINGS OF THIS CATEGORY
The following main findings are present in the category:
o Respondents have a clear opinion on the content of a post-graduate
programme.
o Duration of qualifications must relate to the type of qualification.
e A combination of educational strategies is preferred.
o Post-graduate studies must include a combination of practical! clinical
training, theory and research.
o Most respondents prefer the inclusion of electives in post-graduate
studies.
o Virtually all the respondents required that post-graduate studies should
be aimed at a broader scope.
299
6.17 RESULTS OIFCATEGORY 6: AWARENESS Of THE PUBLIC
NEED
The category "Awareness of the public need" is the last of the six
categories of information that was collected by means of a questionnaire
(cf. Appendix C). It is by far the most comprehensive category of the
questionnaire.
This category started off by requesting the respondents' detailed opinion
concerning the public need with regard to aspects like accessibility,
affordability and equity in eye care, as well as the public's current need
regarding eye care with specific reference to the management of ocular
disease in, for example, glaucoma, diabetes, cataract, etc. The
respondents furthermore had to indicate which role, in their opinion, the
optometrist could play in the standard of care, as well as the role post-
graduate education can play in the improvement in eye care delivery and
standard of care. They had to indicate if they saw themselves as part of
the community they served; the role the State should play in the provision
of eye care; as well as the number of optometrists the State should
employ. In both these cases the respondents were asked to substantiate
and motivate their answers. Subsequently the issue regarding whether
the profession should develop a Private/Public Sector Partnership was
broached and the respondents' opinion regarding compulsory community
service for optometry graduates, which is earmarked for 2007, was
requested. Respondents furthermore had to indicate if they thought the
latter should be implemented sooner; if in their opinion a National Health
Service was an option for South Africa; and, in the last instance, they had
to indicate if they thought post-graduate education and training would have
a positive impact on addressing the needs of the public. It has to be
emphasised that the respondents were not merely asked to exercise a
300
choice, but in all the instances they had to elucidate, define and motivate
their answers.
The data in the sixth category, namely "Awareness of the public need", will
now be represented and discussed.
TABLE 6.3S(a): RESPONDENTS' DETAILED OPINION ON THE
PUBLIC'S NEEDS REGARDING ACCESSIBILITY
(Question S.1a)
Distribution problem 55.0
Do not know 15.0
Too little government responsibility 10.6
Generally not catered for 3.9
Current specialised care not accessible 3.3
Too little health promotion 3.3
Great need 2.8
Depends on income 2.8
Must be more convenient 2.2
Optometry more in rural areas than Ophthalmology 0.6
More accent on disease management needed 0.6
301
DESCRIPTION
Accessibility of eye care by the public was judged by respondents to be a
problem, as the distribution of practitioners was to blame (55.0%). 15.0%
offered no opinion; 10.6% felt the government did not recognise its
responsibility; 3.9% felt that the poor was generally not catered for; 3.3%
felt it was due to insufficient health promotion; 2.8% indicated that there
was a great need; 2.8% focused on those who could pay vs. those who
could not; 2.2% felt that access had to be more convenient; 0.6% felt that
optometry was more accessible than Ophthalmology in rural settings; and
a similar number felt that disease management should receive more
attention.
DISCUSSION
In a sense all responses recognised a problem with regard to the
accessibility of eye care. The major reason for this was that they felt
practitioners were too concentrated in the urban setting. It is also clear
from the other responses that the respondents felt that, coupled with
government initiatives and a redistribution of optometrists, the problem
could be addressed.
Suggestions regarding the siting or location of practices were put forward,
but may clash with constitutional rights. The answer lies in the government
taking more responsibility for eye care by employing optometrists. At the
same time undergraduate education needs to be structured so that
graduates are prepared for the public sector.
Community-based education and public sector clinical rotations are vital
elements prior to the effective implementation of community service. The
aforementioned educational and service delivery structures will expose
practitioners to rural settings and will hopefully prompt some of them to
302
consider private practices in these settings, especially if incentives are
provided.
TABLE 6.36(b): THE RESPONDENTS' DETAILED OPINION ON THE
PUBUC'S NEEDS REGARDING AFFORDABIUTY
(Question 6.1b)
Too expensive/commercial
Right to Sight more affordable 20.5
State aid needed 16.5
Most important 11.4
Full range possible 9.7
Optometry more affordable that Ophthalmology 4.6
Medical aid benefits too low 2.8
Do not know 2.3
Suppliers too expensive 2.3
DESCRIPTION
This table reflects the respondents' opinion regarding the affordability of
eye care. At the top of the list was the statement that it was too expensive
and commercial (30.1 %). The next group of 20.5% felt that current efforts
such as the Right to Sight campaign made a positive difference, while
16.5% felt the State needed to contribute more. A group of 11.4% felt that
this was a most important area, while 9.7% felt that it was possible to
303
deliver care to all income groups. A smaller group of 4.6% highlighted the
fact that optometry is more affordable than Ophthalmology; 2.8% felt
medical aid benefits were too low; 2.3% did not know; and the same
number blamed suppliers who were too expensive.
DISCUSSION
It is clear from the responses that something needs to be done to make
eye care more affordable to the majority of South Africans, whether it be
via subsidisation, multi-skilling or by offering clinic options in private
practice.
The Professional Board may have to revisit advertising rules in order to
increase public awareness of basic eye care and the cost thereof. Similarly
the Optometry Association may wish to expand its efforts to make the
Right to Sight available in each and every practice. The government
cannot continue to ignore its responsibility to provide basic optometry
services. Although this is part of the primary care package, very little has
been done to implement this service.
It is clear that a national campaign - approved by the Professional Board,
the SAOA and the Minister of Health - should be launched in order to
make eye care more affordable and to drive commercialism out of eye
care so that the neglected majority may benefit.
304
TABLE 6.36(c): RESPONDENTS' DETAILED OPINION ON THE
PUBLIC'S NEEDS REGARDING EQUITY
(Question 6.1c)
Standard of care must be equitable
Gross disparities exist 26.6
Do not know 24.8
Price drives this 6.4
Good equity 4.6
State aid needed 2.8
Misleading advertising causes the public to have 0.9
misconceptions
DESCRIPTION
In reply to the question whether respondents felt eye care was equitable,
33.9% agreed that the standard of care had to be equitable between all
sectors of society; 26.6% recognised gross disparities; 24.8% did not
know; 6.4% felt that you get what you pay for; 4.6% felt there was good
equity; 2.8% indicated that State aid was needed; and 0.9% felt that
misleading advertising caused the public to believe that all eye care was
equal.
305
DISCUSSION
The declining number of responses between Tables 36(a) to 36(c)
indicates a lack of information on this subject, as the public health issues
are not a priority as far as the profession is concerned. Until recently,
Public Health has hardly been taught at undergraduate level. This void is
made worse by the fact that there is very little public sector exposure in
training and very few public sector posts. However, it is clear that the
respondents were aware, like the first two indicators, that eye care is not
equitable.
Only through a partnership among the leading institutions, the profession
and the government will the building-blocks be put into place for more
equity in eye care delivery.
306
TABLE 6.37(a): RESPONDENTS' DETAILED OPINION ON THE
PUBUC'S CURRENT NEEDS REGARDING EYE
CARE WITH SPECiFIC REFERENCE TO THE
MANAGEMENT OF OCULAR DISEASE IN
DIABETES
(Question S.2a)
Heath promotion/optometry education lacking 37.3
Mandatory six to 12 months examinations by optometrists 13.6
Dire need 12.4
Under-diagnosed/-treated: Optometrists to diagnose 11.9
Need for co-management interdisciplinary 11.3
Not in optometry field 5.1
Do not know 5.1
Hospital/State responsibility 2.8
People are well informed 0.6
DESCRIPTION
This table describes the respondents' views regarding the public need in
the management of diabetic eye care. The majority (37.3%) felt that the
public as well as the profession lack knowledge. Mandatory examinations
by optometrists every six to 12 months was the suggestion of 13.6%. A
further 12.4% felt there was a dire need; 11.9% felt that it was mainly
under-diagnosed and treated; 5.1% felt it was not in the field of optometry;
307
the same number did not know; 2.8% felt it was a State/hospital
responsibility; and 0.6% felt people were well informed.
DISCUSSION
The overall impression one formed from the data was that the respondents
felt that there was a great need and that the profession could play a bigger
role. The need to educate the profession as well as the public was
accentuated. This again points to the shared responsibility that rests on
the shoulders of teaching institutions, the government and the profession.
308
TABLE 6.37(b): RESPONDENTS' DETAILED OPINION ON THE
PUBLIC'S CURRENT NEEDS REGARDING EYE
CARE WITH SPECIFIC REFERENCE TO THE
MANAGEMENT Of' OCULAR DISEASE IN
RETINOPATHY
(Question 6.2b)
Regular dilated examinations
Public ignorantlGPs not aware 18.9
Do not know enough about the disease 15.4
Co-management 14.7
Immense need but poorly managed 11.2
Do not know the need 5.6
Not in optometry field 4.2
Nutritional issue 2.1
State hospitals slow to respond to help offered by 2.1
optometrists
Specialists unaffordable 0.7
DESCRIPTION
This table depicts the respondents' opinion regarding the public need with
specific reference to diabetic retinopathy. The biggest group (25.5%) felt
that the standard of care to follow is regular dilated examinations; 18.9%
felt that the public were ignorant and general practitioners unaware; 15.4%
indicated they did not know enough about the disease; 14.7% felt it should
309
be co-managed; 5.6% could not express an opinion; 4.2% felt it was not in
the field of optometry; 2.1% felt it was a nutritional issue; and 0.7%
mentioned that specialists were unaffordable.
DISCUSSION
Although the majority of the respondents were aware of a need and felt
that optometrists should play a bigger role, an unacceptable number
showed little insight into the disease and the threat it poses. Its prevalence
makes it a primary care issue that needs to be diagnosed, monitored and
co-managed by an optometrist if blindness is to be avoided.
Countries like the UK and the USA have specific policies on eye
examinations of diabetics. Regulation with regard to health promotion,
education and training, as well as clinical care is required in this regard.
310
TABLE 6.37(e): RESPONDENTS' DETAilED OPINION ON THE
PUBLIC'S CURRENT NEEDS REGARDING IEYE
CARE WITH SPECIFIC REFERENCE TO THE
MANAGEMENT Of' OCULAR DISEASE IN
GLAUCOMA
(Question S.2e)
Co-management
Immense need but poorly managed 22.3
Public ignorance 21.0
Do not know enough about disease - optometry 9.6
education required
More regular follow-up gonioscopy 7.0
Average need 3.2
State hospital service poor 3.2
Not in optometry field 2.6
Financial re-imbursement needed 1.9
Do not know the need 0.6
DESCRIPTION
This table reflects the responses with regard to the management of
glaucoma. 28.7% of the respondents felt that the answer to the problem
lay in co-management. The next group (22.3%) felt that the disease was a
big problem and was being poorly managed. Public ignorance was
reported to be the biggest problem by 21.0%; 9.2% felt they did not know
311
enough about the disease; 7.0% sited regular follow-up and gonioscopy to
be the answer to the problem; 3.2% felt that there was an average need; a
similar group mentioned that the State hospital service was poor; 2.6% felt
it was not in the field of optometry; 1.9% would like financial reward before
they became involved; and 0.6% did not know.
DISCUSSION
The reduced number of responses throughout these questions is
indicative of the lack in training, especially in the public sector where these
diseases are so destructive and where they cause blindness. The
responsibility for this needless blindness rests on the shoulders of society
in general and its instruments of governance.
The professions of ophthalmology and optometry are to blame for the fact
that14.0% of blindness is due to this disease (RSA DoH 2000:4).
312
TABLE 6.37(dI): RESPONDENTS' DETAILED OPINION ON THE
PUBLIC'S CURRENT NEEDS REGARDING EYE
CARE WITH SPECIFIC REfERENCE TO THE
MANAGEMENT OF OCULAR DISEASE IN
CATARACT
(Question 6.2d)
Huge surgery backlogs in state hospitals
Affordable via co-management 23.9
Optometry gatekeeper role important; immense need in 17.4
detection
Too many misconceptions on the side of the public 11.6
No big need/do not know 5.8
Not optometry field 5.2
Right to Sight project helps 3.9
Not enough research on causes 1.9
Cataract technicians required 1.3
DESCRIPTION
The respondents recognised the surgical backlog in hospitals, as 29.0%
sited this as the biggest problem. Co-management to reduce costs and an
increase in the surgery rate were suggested by 23.9%, while 17.4% felt
that the gatekeeper role of optometry was of major importance. A group of
11.6% felt that there were too many misconceptions by the public with
regard to this disease; 5.8% felt there was no big need or they were not
313
sure; 5.2% indicated that it did not fall in the field of optometry; 3.9% felt
that the Right to Sight surgery project did help; 1.9% would like to see
more research into the causes and 1.3% felt that technicians should be
trained to do cataract extractions.
DISCUSSION
Cataract is a relatively easy abnormality to diagnose and manage. It
appears from the data that the majority of the respondents were well
aware of the need in this regard and the reasons for the dire surgical
need. Human and financial resources are required to address this need,
but public misconceptions about the outcome of modern surgery remain a
problem which needs to be addressed as well.
Although various remedies are proposed for Africa, the most obvious
approach is that of the effective use of an eye team, which can result in
surgeons being free to do what they are good at. The starting point would
be in the public sector where nurses, optometrists and surgeons must
function as a team guided by the Prevention of Blindness Policy. In South
Africa 66.0% of blindness is caused by cataract (i.e. 5 000 people for a
population of one million) (RSA DoH 2000:4).
314
TABLIE 6.37(e): RESPONDENTS' DETAILIED OPINION ON THIE
PUBLIC'S CURRENT NEEDS REGARDING EYE
CARE WITH SPECIFIC REFERENCE TO THIE
MANAGEMENT Of OCULAR DISEASIE IN
iMPAIRED (lOW) ViSION
(Question 6.2e)
..:}
Do not know enough to offer service 33.1
Needs not addressed 24.5
Must be more affordable 20.5
Public awareness of services lacking 11.9
Average need 4.0
No not know 2.7
State assistance needed 2.7
Medical aid benefits too low 0.7
DESCRIPTION
The respondents' opinion on the need for low vision care is reflected in this
table. A third (33.1 %) felt they did not know enough to offer a service;
24.5% recognised that the needs of the low vision patient are not
addressed; 20.5% felt that such care had to be made affordable; 11.9%
were of the opinion that the public were unaware of help that could be
provided; 4.0% reported an average need; 2.7% did not know; a similar
number felt the State should provide financial assistance; and 0.7%
indicated that medical aid benefits were too low.
315
DISCUSSION
Attending to the needs of the visually impaired is often time-consuming
and carries little financial reward. The respondents felt that they were ill
equipped to offer this service, which is financially not viable unless more
training, financial aid and promotion of the service were offered.
It is clear that more education and research are needed in this field and, to
be effective, a certain level of specialisation would be required. The
literature in Chapter 1 provides evidence that millions world-wide are
suffering from low vision.
316
TABLE 6.38: RESPONDENTS' VIEWS ON THE ROLE THE
OPTOMETRIST CAN PLAY IN THE IMPROVIEMENT
OFTHE STANDARD OF CARE
(Question 6.3)
Important role but no clear standards/clinical guidelines
lrnprove role through education/research 19.3
Broader scope needed in order to play bigger role 17.5
Improved standards via public sector posts/clinics for the 15.8
indigent
Preventative role to play 10.2
Marketing and information role 10.2
Need to be more passionate about profession 7.0
Improved standards via co-management 4.2
Unlikely to improve with so many chain stores around 2.8
Correction of refractive errors only 0.7
Improved role if medical aids are done away with 0.7
Improved standards when medical aids pay more 0.7
Improved standards via more commercial activity 0.4
Improve standards by seeing representatives to keep up to 0.4
date
317
DESCRIPTION
Table 6.38 reflects the respondents' opinion on how optometrists can play
a role in the improvement of the standard of eye care. The biggest group
(28.4%) felt that optometrists can play an important role, but that they
lacked clear clinical guidelines; 19.3% felt that standards of care would
improve via education and research; 17.5% indicated that optometrists can
only improve standards via a broader scope; 15.8% felt this could be
achieved via public sector posts and indigent clinics; 10.2% felt that the
profession had a preventative role to play; a similar number saw the
improvement in standards of care made possible via marketing and
promotion; and 7.0% merely wanted optometrists to be more passionate
about their profession. Improvement of standards via co-management was
the answer offered by 4.2%, while 2.8% felt that too many chain stores
prevented improvement in standards. A small group of 0.7% felt that
optometrists should see to refractive errors only; the same number felt that
standards would only improve if medical aids were done away with; while
a similar number of 0.7% felt that standards would improve when medical
aids paid more! A very small number of 0.4% felt that more commercial
activity would improve standards and a similar number indicated that
standards would be improved by seeing representatives.
DISCUSSION
The majority of the respondents (85.2%) expressed the opinion that
optometry could play an important role in the improvement of eye care
standards via improved clinical training, guidelines, skills, co-management,
and public sector involvement. Although the other comments should also
be noted, it is clear that the educational backbone of care improvement
through self-improvement is of paramount importance.
318
TABLE 39: RESPONDENTS' VIEW ON THE ROLE POST-
GRADUATE EDUCATION CAN PLAY IN EYE CARE
DELIVERY AND STANDARDS
(Question 6.4)
Will improve both delivery and standards
Do not care/too old to give an opinion 3.4
Experience more important/no role 3.4
Too concentrated in urban settings - not much effort 1.3
Will upset Ophthalmology 1.3
Will drive the profession 0.8
Will be too costly 0.4
Should be aimed at closing gaps in undergraduate 0.4
education
Must first be promoted with the public 0.4·
DESCRIPTION
A vast majority (88.6%) of the respondents felt that post-graduate
education would improve both service delivery, as well as standards of
care. Some 3.4% of the respondents felt they were too old or did not care
about the subject; the same number felt that experience was more
important; 1.3% felt that post-graduate education would be too much
effort; or that the competition/concentration of optometrists in urban areas
would increase and enhance the effect of post-graduate education. 1.3%
319
also indicated that post-graduate education would upset Ophthalmology,
as it would threaten their turf.
A smaller group of 0.8% indicated that post-graduate education would
drive the profession; 0.4% felt the undergraduate programmes should
accommodate what is currently seen as post-graduate education; and
0.4% felt it should be promoted with the public or it would not have the
desired effect. A similar group felt that post-graduate education would be
too costly.
DISCUSSION
This data correlate well with the data of Table 6.38 where one could
assume that 85.2% based their responses on educational enhancement
and that they almost stated the obvious, namely that improvement in
standards of care and delivery of service can only be achieved by the
expansion of undergraduate training via post-graduate programmes.
320
TABLE 6.40(a): RESPONDENTS' PERCEPTION OF BEING PART
OF THE COMMUNITY THEY SERVED
(Question 6.5)
No 6.6
DESCRIPTION
The majority (93.4%) of the respondents felt that they were part of the
community they served. The balance (6.6%) did not.
DISCUSSION
This is a very high positive response and about half of the respondents
practise in urban, commercial settings. The reasons for their responses
are reflected in Table 6.40(b).
321
TABLE 6.40(b): RESPONDENTS' REASON/MOTIVATION WHY
THEY SAW THEMSELVES AS PART Of THE
COMMUNITY THEY SERVED
(QlI.Oestion 6.5)
Live in, involved with and socialise in the community 39.9
Take part in and contribute to community projects 15.4
Do more than just refractive work 12.2
Visit rural clinics/schools 11.5
Not a commercial practice 5.1
Serve the entire community at affordable levels 4.5
Highly respected for my opinion 1.9
First contact with those who seek help 1.9
Work for NGO 1.9
Live in small town 1.3
PatienUpractitioner relationship continues beyond 1.3
practice visit
Cannot isolate yourself 1.3
Does not matter where you live 0.6
Live in different town 0.6
Employed by group/locum 0.6
322
DESCRIPTION
The main reason why respondents saw themselves as part of the
community they served was the fact that they lived, were involved and
socialised in the community (39.9%). The next most popular reason was
that they took part in community projects (15.4%). This was followed by
12.2% who reported that they did more than just refractive work; 11.5%
reported that they visited clinics and schools; and 5.1% reasoned that they
were not a commercial practice.
Other reasons were the following: 4.5% helped patients budget and saw
those who could not afford to pay. "First contact with those who seek eye
care" was provided as a reason by 1.9%; 1.3% provided the reason of a
small town; 1.3% reported that their patient/practitioner relationship
continued beyond the practice visits; and 1.3% reasoned that no-one was
an island and they therefore naturally formed a part of the community they
served. 1.9% reasoned that they were highly respected for their opinion,
and the same number worked for an NGO. Although they lived in a
different town, 0.6% saw themselves as part of the community they
served, while the same number felt it does not matter where you live.
0.6% also reasoned that working as a locum or for a group made them feel
part of the community.
DISCUSSION
The majority of the reasons centre around the fact that human
relationships and attitudes which are structured in the practice continue
beyond professional contact. The respondents therefore felt they were
more sensitive to the needs of the community and how to address those.
323
Although a large percentage answered "Yes" in the previous table, Table
6.40(a), a much smaller group offered reasons for saying so.
TABLE 6.40(c): !RESPONDENTS' REASONS/MOTIVATION WHY
THEY DID NOT SEE THEMSELVES AS !PART Of
THE COMMUNITY THEY SERVED
(Question 6.5)
Have little non-professional contact 41.2
See only those who can afford to pay 17.7
Live in different town 11.8
Employed by groupIlocum 11.8
Work in town 5.9
Do not wish to share personal issues 5.9
Background differs 5.9
DESCRIPTION
This table reflects the reasons why the respondents did not see
themselves as part of the community they served. 41.2% reported that
they had little non-professional contact; 17.7% saw only patients who
could afford the service; 11.8% lived in a different town; and 11.8% were
employed by a group or did locum work. Although 5.9% lived and
socialised in the community, they did not see themselves as part of that
community. As they "worked in town", 5.9% similarly indicated that they did
324
not wish to share personal issues. A final group of 5.9% felt that their
backgrounds were different.
DISCUSSION
The reasons why the respondents did not feel part of the community they
served, mainly focus on little non-professional contact for either personal
reasons, logistical reasons, cultural reasons or temporary employment.
TABLE 6.41: RESPONDENTS' VIEWS ON THE ROLE THAT THE
STATE SHOULD PLAY IN THE PROVISION OF EYE
CARE
(Question 6.6)
Improve current service 31.9
Employ optometrists/broaden scope 25.8
Subside spectacles at clinics/hospitals 19.2
Pay/endorse private practitioners for certain work 7.7
National health plan 6.2
Health/eye care promotion 3.9
State incapable of improving 3.1
Do not know 1.2
Stop listening to professors of Ophthalmology (barrier) 1.2
325
DESCRIPTION
Table 6.41 reflects respondents' views regarding the role they saw the
State should play in the provision of eye care. A fairly large number
(31.9%) argued that the State should improve the current services. The
next group (25.8%) felt that the State should employ optometrists and/or
broaden their scope. This was followed by the following answers:
"Subsidise spectacles" (19.2%); "Pay private practitioners for certain work"
(7.7%); "Implement a national health plan" (6.2%); and "Perform more
health/eye care promotions" (3.9%).
A smaller group of 3.1% felt that the State was incapable of improving;
1.2% had no suggestions; and a similar group stated that the State should
stop listening to the professors of Ophthalmology.
DISCUSSION
The first six subcategories dealt with more commitment by the State in the
form of providing more resources (human and financial) and Health
Promotion. Although small, the last group's comment is worth discerning,
as the State historically based policy and designed policy around
Ophthalmology departments within a system which supported separate
development. Today the demographics of Ophthalmology do not reflect
successful transformation and, although the argument is often used that
apartheid no longer exists, the legacy of a 40-year old system may well
take more than a decade to rectify.
326
TABLE 6.42(a): RESPONDENTS' VIEWS/RECOMMENDATIONS ON
THE NUMBER OF OPTOMETRISTS THAT THE
STATE SHOULD EMPLOY FOR THE (WHOLE)
COUNTRY
(Question 6.7)
100-250 optometrists 16.0
Enough to match need 14.5
Two per provincial hospital 11.1
Do not know 10.7
Every hospital 9.9
Four to seven optometrists per district 8.0
1000-1500 optometrists 7.6
None 4.6
All who qualify 3.4
1:20000 3.4
As many as the State can afford 3.1
1:50000 3.1
Five per province 2.3
150 per year 1.2
Five per hospital 0.8
1:6000 0.4
327
DESCRIPTION
Table 6.42(a) reflects the number of optometrists that the respondents felt
the State should employ. The most popular was a total of between 100
and 250 optometrists (16.0%). This was followed by "Enough to match the
need" (14.5%); "Two per provincial hospital" (11.1%); while 10,7% did not
know. "Every hospital" accounted for 9.9% of the responses; "Four to
seven per district" (8.0%) followed; "1000-1500" followed (7.6%); while
4.6% elected none. "All that qualify" accounted for 3.4%, as did a ratio of
one optometrist for every 20 000 members of the population. "As many as
the State can afford" was next (3.1%), while a similar group elected a ratio
of 1:50 000. 2.3% felt five per province was the ideal figure, followed by
150 per year at 1.2%. 0.8% recorded five per hospital and 0.4% a ratio of
1:6000.
DISCUSSION
This is clearly a subject which needs more research in order to get to the
best ratio - a ratio that might vary in different parts of the country.
However, the respondents did not shy away from this, as the majority felt
that one should start somewhere. Although the ideal district should
represent 250 000, there are much smaller districts in South Africa, as well
as much larger ones (1.5 million).
The Prevention of Blindness Policy mentions a ratio of 1:250 000 (RSA
DoH 2000:5). The logical route to follow is to train all optometrists via the
public sector; create at least the ±160 posts as per the 1:250 000 ratio;
and rotate graduates through those posts within a community service
structure, provided that sufficient supervisory posts are also in place.
328
Supervisor posts would be ophthalmologists or senior optometrists
employed by the State and, if undergraduate training is in line with public
sector needs, supervision may only be required for three months. Medical
officers, nurses and voluntary community workers should make up the rest
of the team.
TABLE 6.42{b): RESPONDENTS' REASONS !FOR THE
RECOMMENDED NUMBER OF STATE-EMPLOYED
OPTOMETRISTS
(Question 6.8)
Current system cannot cope 49.3
Hospitals/clinics are widespread 12.3
Do not know/more research 11.0
Too many optometrists reduce standard of care/do not 9.6
want to work in public sector
Need the correct ratio 5.5
We can do it without State 3.4
Graduates must do community service 3.4
Estimation probably not enough, but let's start 2.7
somewhere
500 patients per annum per optometrist 2.1
Follow tender system 0.7
329
DESCRIPTION
The table reflects respondents' reasons for the recommended numbers of
State-employed optometrists. About half (49.3%) felt that the current
system could not cope. The geographic spread of hospitals and clinics
was given as a reason by 12.3%; 11.0% felt that they could not comment
as more research was needed; 9.6% reasoned that an oversupply
reduced the standard of care and most optometrists did not want to work
in the public sector.
5.5% suggested that the correct ratio would need to be formulated, while
3.4% reasoned that the profession could do it without the State. A further
3.4% mentioned compulsory community service as a solution, while 2.7%
estimated a number that they felt might not be enough, but reasoned they
just had to start somewhere. 2.1 % motivated their answer by calculating
that every employee should be able to see 500 patients per annum.
Finally, 0.7% responded by saying that a tender system should be
followed.
DISCUSSION
The wide range of responses in Table 6.42(a) forms a base for the wide
range of responses in Table 6.42(b). However, most responses were
based on the fact that the current public sector system cannot cope and
that hospitals and clinics have a better geographical spread in terms of
service delivery. A large group was realistic in that a correct ratio is
required and this ratio may even change per district as the demographics,
health needs and the socio-economic nature of a particular district change.
330
TABLE 6.43(a): RESPONSE TO THE SUGGESTION OF
PRIVATE/PUBUC SECTOR PARTNERSHIP TO
ASSIST THE STATE IN ADDRESSING THE EYE
CARE NEEDS IN SOUTH AFRICA
(Question 6.9)
Yes
No 12.6
Do not know 0.8
DESCRIPTION
In response to the question as to whether a public/private sector
partnership in eye care was needed, 86.7% of the respondents answered
affirmatively; 12.6% were against such a suggestion and 0.8% were
unsure.
DISCUSSION
Although there is policy with regard to this topic, few such partnerships
have been formed in the Health Sector. The Professional Association,
Regulatory Bodies and teaching institutions should investigate this option.
331
TABLE 6.43(1b): RESPONDENTS' MOTIVATION fOR THEIR
BELIEFS THAT THE PROFESSION SHOULD
DEVELOP A PRIVATE/PUBLIC SECTOR
PARTNERSHIP TO ASSIST THE STATE iN
ADDRESSING THE EYE CARE NEEDS OF SOUTH
AFRICANS
(Question 6.10)
c
Public sector needs too big/standards poor 28.9
A civil duty (better managed) 15.7
Few can afford medical aid/private care 12.7
Formalise employment on a sessional basis 11.5
Positive move by optometry 8.4
Private sector better equipped (organised) 7.2
Would not like to see profession as part of political 5.4
turmoil in government (poor management)
Will assist in a better understanding of optometry 4.8
Will gain clinical experience 1.8
Private sector not aware of need 1.2
Competition will reduce high costs of optometry 1.2
services
Create work for private sector 0.6
Build on existing projects like Right to Sight 0.6
332
DESCRIPTION
Table 6.43(b) reflects the reasons why respondents reacted positively to a
public/private sector partnership. 28.9% reasoned that the public sector
was too big with poor standards. 15.7% reasoned that it was a civil duty
which would be better managed via this partnership.
12.7% focused on the fact that the majority could not afford medical aid or
private care. 11.5% felt that such partnership would create formal
employment, while 8.4% saw the positive public relations in such
partnership. 7.2% felt that the private sector would be better equipped or
organised; 5.4% mentioned poor management and that they would not like
to see the profession as a part of political turmoil in the government; 4.8%
felt it would assist in the better understanding of optometry; 1.8% felt that
clinical experience would be gained; the same percentage, namely 1.2%,
felt that the private sector were not aware of the need and that competition
would reduce the high costs of optometry services. Likewise two groups
(both 0.6%) expressed the opinion that it would create work for the private
sector and that it would build on existing projects like Right to Sight.
DISCUSSION
Most of the respondents realised the shortfalls in the public sector; their
own civil duty; the employment, educational and promotional opportunities;
and the fact that the poor cannot afford care. Poor organisation and
remuneration in the public sector and a fear of competition from the public
sector were furthermore mentioned. The profession should see this as but
one element in building a network of eye care services which will be
available all over the country.
333
TABLE 6.43(c): RESPONDENTS' MOTIVATION FOR THEIR BELIEF
THAT THE PROFESSION SHOULD NOT DEVELOP
A !PRIVATE/PUBLIC SECTOR PARTNERSHIP TO
ASSIST THE STATE IN ADDRESSING THE EYE
CARE NEEDS OF SOUTH AFRICANS
(Question 6.10)
Rather employ optometrists formally 36.0
Would not like to see profession as part of poor 28.0
management in government
Competition will become greater 12.0
State remuneration poor 8.0
Do not know 8.0
No assurance of financial management 4.0
Should be part of clinical experience/training 4.0
DESCRIPTION
In this table the majority of the respondents (36.0%) expressed the opinion
that optometrists should rather be employed formally; 28.0% indicated that
they would not like to see the profession as part of poor management in
the government; 12.0% felt that competition among optometrists would
become greater; 8.0% indicated that State remuneration was poor; and
the same percentage (8.0%) did not know. "No assurance of financial
management" was indicated by 4.0% and the same number of
respondents (4.0%) felt that it should be part of clinical experience/training.
334
DISCUSSION
The main reason why respondents felt anti-private/public sector
partnership was that formal employment was preferred. However, a group
about the same size did not want to have any part in what they perceived
to be a chaotic structure. A few felt financially threatened, whiled others
saw it as part of training anyway. Without involvement in the public sector
the profession is incapable of constructive input.
TABLE 6.44(a): RESPONSES TO THE iNTRODUCTiON Of
COMPULSORY COMMUNITY SERVICE
PROPOSED fOR 2007
(Question 6.11)
Yes
No 12.5
"Yes" and "No" 1.8
DESCRIPTION
A large majority (85.7%) indicated that they were in favour of compulsory
community service for optometrists. A small group of 1.8% were unsure,
while 12.5% were against the concept.
335
DISCUSSION
The profession of optometry and its teaching institutions have been in
favour of a type of internship for many years, but failed to come up with
any proposal in this regard. Now that the State has started with its own
initiatives, the profession as a whole should be proactive and make it
happen. Such a proposal should include all elements, such as
undergraduate training, post-graduate training, CPD, Public-Private-
Partnerships, and voluntary and compulsory community service.
336
TABLE 6.44(b): RESPONDENTS' REASONS WHY THEY WERE OF
THE OPINION THAT COMPULSORY COMMUNITY
SERVICE IS A GOOD IDEA
(Question 6.12)
A good way to gain experience/serve the community 77.6
wider
To understand the diverse problems of the population/ 15.3
part of training
A way to pay civil rent 3.6
Ensures that all optometrists take part/creates more 2.0
possibilities/opportunities
Provided there is a public sector career path 1.0
As long as the State can pay/protect them 0.5
DESCRIPTION
An overwhelming majority (77.6%) of the respondents indicated that it
would be a good way to gain experience or serve the broader community,
while 15.3% felt that it would help to understand the diverse problems of
the population or that it was a part of training. 3.6% indicated that it was a
way to pay civil rent; 2.0% felt that it ensured that all optometrists took part
or that it would create more possibilities or opportunities; 1.0% specified
that there had to be a public sector career path; and 0.5% emphasised
that the State had to pay and protect them.
337
DISCUSSION
The data confirm that most of the respondents understood the importance
of clinical training for a clinical profession and the community-based
learning that should take place.
It is obvious that the profession and the State will benefit by virtue of the
fact that the broader population will be served; training opportunities will
be expanded; and formal employment will create supervisory, managerial,
research and service delivery opportunities for the profession.
TABLE 6.44{c): RESPONDENTS' REASONS WHY THEY WERE OIF
TIHIEOPINION THAT COMPULSORY COMMUNITY
SERVICE IS NOT A GOOD IDEA
(Question 6.12)
Can do this in private practice 27.3
Must be voluntary 27.3
Rather focus on public sector during training 21.2
State cannot accommodate/pay/protect them 12.1
State must employ and pay permanent staff 12.1
338
DESCRIPTION
27.3% of the respondents felt that they could perform this service in
private practice, while the same number (27.3%) expressed the opinion
that it had to be voluntary. 21.2% indicated that the focus should rather be
on the public sector during training, while two groups of the same size
(12.1 %) expressed a sentiment pertaining to the State, namely that the
State cannot accommodate/pay/protect graduates and that the State
should rather employ and pay permanent staff.
DISCUSSION
The majority of this group clearly did not grasp the importance of
community-based education and training and obviously did not really want
to become involved in the sustainable public sector role of the profession.
Opinion should change once all optometrists have experienced Public
Health as part of education and training.
339
TABLE 6.44(d): RESPONDENTS' REASONS WHY THEY WERE
NOT SURE ("YES" AND "NO") AS TO WHETHER
2007 (EARMARKED FOR POSSIBLE
COMPULSORY COMMUNITY SERVICE) WAS A
GOOD IDEA
(Question 6.12)
Can the State accommodate/pay/protect them? 57.1
A good way to gain experience/serve the community 28.6
wider
State must employ and pay permanent staff 14.3
DESCRIPTION
The concern of a large group (57.1 %) was whether the State could
accommodate, payor protect them, while 28.6% felt that it was in the
interest of community service or a way of gaining experience. 14.3%
indicated that the State had to employ and pay permanent staff.
DISCUSSION
A certain amount of uncertainty is understandable, but again - without
involvement - the system can neither be implemented nor improved.
340
TABLE 6.45: RESPONDENTS' VIEWS ON THE EARLIER
IMPLEMENTATION OF COMPULSORY
COMMUNITY SERVICE (EARLIER THAN 2007)
(Question 6.13)
Positive
Negative 41.5
Do not know 0.8
Proper structures first 0.5
DESCRIPTION
More than half (57.1 %) of the respondents felt that compulsory community
service should be implemented prior to 2007, while 41.5% were against an
earlier date. A small group of 0.8% were not sure and 0.5% indicated that
they would like to see proper structures first.
DISCUSSION
The positive responses (57.1%) were fewer than those in Table 6.44(a),
where 85.7% were in favour of compulsory community service. It is difficult
to find any other reason for this other than a perception that the State
would not be ready for this or that appropriate training was not in place.
It is clear that the Professional Bodies, the teaching institutions and the
State need to plan together to ensure effective implementation.
341
TABLE 6.46(a): RESPONSES TO THE SUGGESTION THAT A
NATIONAL HEALTH ASSURANCE SCHEME IS AN
OPTION FOR SOUTH AFRICA
(Questio01l 6.14)
Positive 61.2
Negative 35.7
"Yes" and "No" 0.6
Do not know 2.2
Too complex 0.3
DESCRIPTION
According to this table, 61.2% were positive; 35.7% were negative; 0.6%
harboured both positive and negative feelings; 2.2% were uncertain; and
0.3% felt the issue was too complex.
DISCUSSION
One would think that a National Health Plan would be to the benefit of
everybody and it is therefore somewhat surprising that 35.7% of the
responses were negative. This may be due to a fear that the current
medical aid system is not satisfactory and that a national system may pay
less and later. The profession should act proactively to design its own
version of a plan which involves all in the profession and the optical
industry.
342
TABLE 6.46(b): RESPONDENTS' MOTIVATION FOR THE
IMPLEMENTATiON OF A NATIONAL HEALTH
INSURANCE SCHEME IN SOUTH AFRICA
(Question 6.15)
Majority cannot afford care or medical aid/system
cumbersome
Current State efforts not adequate 12.1
Improved accessibility 9.1
Could work, doubt ability of the State 6.1
Yes, but we will end up indirectly paying for this 5.1
Yes, but need more information 5.1
Can incorporate a broader scope of treatment 3.0
Yes, but can be done on a private basis 2.0
Yes, but AIDS will deplete funds 1.0
DESCRIPTION
A very large percentage (56.6%) indicated that the majority could not
afford care or a medical aid or felt that the current system was too
cumbersome; 12.1% felt that current State efforts were not adequate,
while - with reference to the State - 6.1% doubted the ability of the State.
"Improved accessibility" was put forth as a reason by 9.1 %; two groups of
the same size (5.1%) felt positive, but had reservations, namely that the
profession would end up paying for it and that they needed more
information; 3.0% felt it could incorporate a broader scope of treatment;
and another two groups were also positive. One of these two groups
343
(2.0%) said it could be done on a private basis, while the other one (1.0%)
felt that AIDS would deplete funds.
DISCUSSION
The respondents realised that many individuals are so poor that not even
the cheapest "clinic price" in private practice would be affordable, nor
would a viable practice be sustained.
Although in favour of the implementation of a National Plan, many
negative conditions were aired, most of them based on reasonable doubt.
Proactive planning, design and creative thought need to come from the
profession if it wishes to play a part in such a National Plan.
344
TABLE 6.46(c): RESPONDENTS' MOTIVATION AS TO WHY A
NATIONAL HEALTH INSURANCE SCHEME
SHOULD NOT BE IMPLEMENTED IN SOUTH
AFRICA
(Question 6.15)
Could work, doubt ability of State 31.5
Too expensive to run 15.1
Medical insurance fraught with problems 13.7
State cannot pay for this - we will have to 11.0
National Health plans standards usually poor world- 9.6
wide
AIDS will deplete funds 9.6
Can be done on a private basis 5.5
No, do not believe it can work 2.7
Will reduce our income 1.4
DESCRIPTION
According to this table, the respondents did not have a great deal of
confidence in the State, as 31.5% doubted the ability of the State and
11.0% felt that the State could not pay for this. 15.1% felt it would be too
expensive to run; 13.7% pointed out the problems present within medical
insurance; 9.6% indicated that National Health plans world-wide leave
much to be desired; a group of a similar size (9.6%) reiterated that AIDS
will deplete funds; 5.5% felt it could be done on a private basis; 2.7%
345
doubted its ability to work; and 1.4% were of the opinion that it would
reduce their income.
DISCUSSION
A fairly large group doubted the capacity of the State to implement such a
programme. Outsourcing is a possibility, but has also proved not to be
without problems.
It is clear that the best system world-wide needs to be looked at and
adapted to South Africa's needs and that the profession and the industry
should plan upfront.
TABLE S.47(a): RESPONSES TO THE QUESTION WHETHER
POST-GRADUATE EDUCATION WOULD IMPACT
POSIT~VEl Y ON THE NEElDS OIFTHE PUBUC
(Question 6.16)
Yes 86.4
No 12.8
Do not know 0.8
DESCRIPTION
In response to the question whether the respondents were of the opinion
that post-graduate education would impact positively on the public's
needs, 86.4% answered in the affirmative, 12.8% in the negative and 0.8%
were not sure.
~~------------------------------------------------------
346
DISCUSSION
These affirmative responses correlate with those in Table 6.39, where
88.6% of the individuals responded positively to the question whether
post-graduate education could play a role in eye care delivery and
standards. Although this view on the public need is that of optometrists
and might be biased, it remains a perception to value, as the respondents
were convinced that new skills learned via post-graduate studies would
help to address public needs, which they obviously encountered on a daily
basis.
This should be viewed in a positive light by providers of education, the
Professional Bodies and the DoH.
347
TABLE 6.47(b): RESPONDENTS' REASONS WHY A POST-
GRADUATE EDUCATION WOULD HAVE A
POSITIVE IMPACT ON THE NEEDS OF THE
PUBLIC
(6.17)
Improved eye care standards and scope 50.8
Improved specialised care 9.6
Improved public image 8.6
Will make certain procedures more accessible and 7.1
affordable
Only if it is needs-based 6.1
Knowledge = power + wisdom 4.6
Research brings development 4.5
Must have compulsory community (public sector) 4.1
service as part of it
Specialised fields lacking 2.5
Yes, but only small positive impact 1.0
Will add to professionalism 0.5
Provided that not too many take part 0.5
DESCRIPTION
A large group (50.8%) indicated "Improved eye care standards and scope"
as the reason; "Improved specialised care" was indicated by 9.6%; and
"Improved public image" by 8.6%. 7.1% felt that certain procedures would
348
be more accessible/affordable; 6.1% expressed the reservation that only if
it was needs-based; 4.6% indicated that "Knowledge = power + wisdom";
another reservation expressed was that compulsory community service
should be a part thereof; 4.5% indicated "Research brings development";
2.5% felt that specialised fields were lacking; 1.0% felt that it would only
have a small positive impact; 0.5% were of the opinion that it would add to
professionalism; and another group of the same size (0.5%) were reserved
in that they felt not too many should take part.
DISCUSSION
This large group realised the needs and opportunities in primary eye care
in South Africa and that education will play a major role in attending to
these needs and utilising the opportunities. It also stands to reason that
undergraduate training will ultimately benefit from prioritisation which will
follow once higher qualifications are underway. In other words, a new
focus will develop at undergraduate level aimed at public health care,
immediate public needs and the public sector career path with managerial
opportunities, as well as research possibilities. One could easily reason
that everyone stands to gain from post-graduate studies, i.e. the public,
the State, the profession and the industry.
349
TABLE 6.47(c): RESPONDENTS' REASONS WHY A POST-
GRADUATE EDUCATION WOULD NOT HAVIE A
POSITIVE IMPACT ON THE NEEDS OF THE
PUBLIC
(Question 6.17)
Unless it has a compulsory community (public sector)
service as part of it
Post-graduate education does not make you more 19.4
accessible, affordable
Review undergraduate education and public sector 16.1
partnerships
Will not maintain, standards not guaranteed 12.9
Speciality skills training often ignores basic needs 12.9
Preventative care more important 6.5
Speciality fields not yet recognised 3.2
Will impact positively more on education than training, 3.2
not the need of the blic
Majority will not benefit 3.2
More research needed 3.2
DESCRIPTION
According to this table, 19.4% specified that post-graduate education
should have a compulsory community service as part of it; another 19.4%
felt that this kind of education does not make the optometrist more
accessible or affordable; 16.1% felt that undergraduate education and
public sector partnerships should be reviewed; according to 12.9%
350
standards would not be guaranteed; and another 12.9% felt that speciality
skills often ignore the basic needs. 6.5% felt that preventative care was
more important; 3.2% indicated that speciality fields were not yet
recognised; another 3.2% were of the opinion that it "Will impact positively
more on education than training, not the need of the public"; a third group
of 3.2% indicated that the majority would not benefit; and a fourth group of
3.2% felt that more research was needed.
DISCUSSION
It appears from the responses that this group was unaware of the changes
that higher education will be undergoing in the coming years. Most of the
concerns will be addressed via this new direction.
If the teaching institutions are serious about implementing the new Health
and Higher Education Policies, every concern in the above table will be
addressed. Understanding new Policies in Health and Education is vital,
as some in leadership positions in the profession are sill ignoring these
Acts. The challenge is to first educate leadership, followed by informing
the profession and ensuring that undergraduate programmes teach all the
relevant concepts.
351
6.18 SUMMATIVE CONCLUSION ON CATEGORY 6: AWARENESS
or THE !PUBLIC NEED
Measuring the public need from the perspective of the respondents gave
the researcher an idea of the awareness of the public need. In some of
the open-ended questions, fewer respondents provided an answer than in
the other five categories. Although fewer answered, one still gains
valuable perspectives which can be applied. What is encouraging is that
the respondents believed that their profession can contribute to better eye
care for all.
In order to put the major causes of blindness into context, it is important to
note that over the age of 40 years, the prevalence of glaucoma is 1-2% (in
Africa the prevalence could be double this rate) (Cook 2001). A recent
study on a primarily Black population found that Black participants tended
to have thinner corneas (Nemesure 2003:240-244). In the Ocular
Hypertension Treatment Study (OHTS) it was confirmed that thinner
corneas resulted in an error of intra-ocular pressure measurement that
was lower than in "normal" corneas (Fingeret 2002). Although the
Barbados study did not find a relationship between intra-ocular pressure
and corneal thickness in that population, other studies have reported a
positive relationship. These findings may therefore hold particular
challenges for the management of the disease in Africa as "under-
treatment" may be a significant factor.
It can be assumed that diabetic retinopathy will become the major cause of
blindness in South Africa once current major causes have been
addressed. The New Jersey 725 study enrolled 725 African Americans
with Type 1 diabetes and concluded that diabetic retinopathy in African
Americans with Type 1 diabetes is common, being found in almost two-
thirds of the patients studied (Ray 2000:97-104).
352
The effect of cataract on blindness in developing countries is well known
with up to 66.0% of blindness in South Africa due to this condition. A major
contributing factor to the high percentage of blindness is the cataract
surgical rate expressed in operations/million/year. The rate is about 200 in
Africa, 500-1500 in Latin America, 2000 in India, 3000 in Europe and 5000
in the United States of America (Thylefors 1998: 1 of 3). Many optometrists
are not aware of these needs, as CPD, post-graduate programmes and
the clinical exposure in the public sector have not been developed to serve
as a conduit for optometrists ' participation. The inherited fragmented
health care system is slowly changing, but lack of innovative management
in the public sector will make any sound policy implementation very
difficult, with problems that range from infrastructure to financial
management to service delivery. However, it is here where the greatest
challenge and opportunities for the profession lie. In fact, the opportunities
are so great that post-graduate education is but a small part thereof and
would hopefully play a catalyst role in improved undergraduate training
and service delivery to the majority. After all, it is for this majority that the
profession is jointly responsible. This responsibility starts with the first year
of training, extending to the last page of a Ph.D. thesis to every tax rand
paid by those in private practice.
To conclude, what is needed is committed leadership within academia, the
profession and the DoH to put all available resources together to
understand the overall need; to design or alter current structures
appropriately; and to implement a sustainable education- and training-
based service which the public can utilise. Communicating a structure
plan is of paramount importance.
Figure 6.6 provides a graphic presentation of some of the aspects of the
main findings on Category 6.
353
FIGURE 6.6: A GRAPHIC PRESENTATION OF SOME OF THE
ASPECTS OF THE FINDINGS ON CATEGORY 6: AWARENESS OF
PUBLIC NEED
a) Respondents' detailed opinion on the public needs regarding
accessibility, affordability and equity [Only the main opinions are
provided - also see Tables 6.36 (a),(b),(c).]
Accessibility (n=180)
60 • Distribution problem:
55.0%
-CJ)c: 50 • Do not know: 15.0%a>
"0
c:
0
o, 40 o Too little government
CJ)
a>
L- responsibility: 10.6%
'+-
0 30
-a> • Generally not cateredOl<Il 20 for: 3.9%c:ao>
L- • Current specialised care
a>
CL 10 not accessible: 3.3%
o Too little health
0 promotion: 3.3%
Opinion on public's needs
Affordability (n=176)
• Too expensive/commercial:
30.1%
• Right to sight makes it more
affordable: 20.5%
o State aid needed: 16.5%
• Most important: 11.4%
o Full range possible: 9.7%
o Optometry more affordable than
Opinion on affordability Ophthalmology: 4.6%
354
Equity (n=109)
• Standard of care
35 must be equitable:
-en 33.9%30c • Gross disparities(!)
"0 exist: 26.6%
c 25
0aen. o Do not know: 24.8%
..~
20
...
0
(!) 15
Cl • Price drives this:
$c 6.4%
ê 10
(!) o Good equity: 4.6%
Q.. 5
0 o State aid needed:
Opinion on equity 2.8%
b) Respondents' detailed opinion on the public's current needs
regarding eye care with specific reference to the management of ocular
disease in diabetes, retinopathy, glaucoma, cataract, impaired (Iow)
vision [Only the main opinions are provided - also see Tables 6.37 (a) -
(e).]
Diabetes (n=177)
• Health
promotion/optometry
40 education lacking: 37.3%
-en 35 • Mandatory six - 12c months examinations by
(!)
"0 30 optometrists: 13.6%
C
8en. 25 o Dire need: 12.4%
..~...
0 20
(!)
-Ccol 15 • Under-diagnosed/c
(!) -treated: Optometrists to
~ 10 diagnose: 11.9%
(!)
Q..
5 • Need for eo-
management
0 interdisciplinary: 11.3%
Opinion of respondents
355
Retinopathy (n=143)
• Regular dilated
examinations: 25.2%
-CIlC<I> • Public ignoranUGPs
-0
C not aware: 18.9%
o
c.
CIl
~
...... o Do not know enougho
<I> about the disease:
-Cl(Il 15.4%C<oI>.... • Co-management:
o<I,> 14.7%
• Immense need, but
Opinion of respondents poorly managed:
11.2%
Glaucoma (n=157)
• Co-management: 28.7%
.cel • Immense need, but poorly
<I> managed: 22.3%
"C
Co
c.
CIl
.~... o Public ignorance: 21.0%o
<I>
Cl
.£c9
<I>
~ • Do not know enough
<I> about disease/optometry
o, education required: 9.6%
• More regular follow-up
gonioscopy: 7.0%
Opinion of respondents
356
Cataract (n=155)
• Huge surgery backlogs in
30 state hospitals: 29.0%
2
c 25 • Affordable via eo-
Q) management: 23.9%
"0
e
0
0.. 20
(Jl
Q) o Optometry gatekeeper
..L...... 15 role important; immense0
Q) need in detection: 17.4%-Ol(Ile 10 • Too many misconceptions
Q)
o on the side of the public:
L..
aQ..). 5 11.6%
• No big need/do not know:
0 5.8%
Opinion of respondents
Impaired (Iow) vision
• Do not know enough to
35 offer service: 33.1 %
-f/)e 30
Q) • Needs not addressed:
"e0 25 24.5%
0
0..
f/)
Q) 20
..L...... o Must be more
0
-Q) 15
affordable: 20.5%
Ol
(Il
e
Q) 10
o • Public awareness of
L..
Q) service lacking: 11.9%
a... 5
0 • Average need: 4.0%
Opinion of respondents
357
c) Respondents' view on the role the optometrist can play in the
improvement of the standard of care [Only the main views are provided
- also see Table 6.38 (n=285).]
• Important role but no clear
standard/clinical guidelines: 28.4%
• Improve role through
education/research: 19.3%
c(JJ: o Broader scope needed in order to play
Q)
"0 bigger role: 17.5%
C
8.. • Impoved standards via public sector
(JJ
~ posts/clinics for the indigent: 15.8%
'0
Q)
Ol • Preventative role to play: 10.2%
.cl!!
Q)
t?
Q) Marketing and information role: 10.2%
o,
Need to be more passionate about
profession: 7.0%
o Improved standards via eo-
View of respondents
management: 4.2%
d) Respondents' view on the role post-graduate education can play in
eye care delivery and standards [Only the main views are provided -
also see Table 6.39 (n=237).]
• Will improve both delivery
and standards: 88.6%
.cl!l
• Do not care/too old to give
Q) opinion: 3.4%
"0
oC
Cl.
(JJ
-~ o Experience moreo important/no role: 3.4%
Q)
Ol
c(I:l • Too concentrated in urban
~ settings - not much effort:
Q)
a, 1.3%
• Will upset Ophthalmology:
1.3%
View of respondents
358
e) Respondents' perception of being part of the community they
served (n=366)
.Yes: 93.4%
.No: 6.6%
f) Respondents' reasons why they saw themselves as part of the
community they served [Only the main reasons are given - also see
Table 6.40 (b) (n=156).]
• Live in, involved with and
socialise in the community:
40 39.9%
35 • Take part in and contribute toen
ë community projects: 15.4%
al
'0 30
c:
0 o Do more than just refractive
ean. 25 work: 12.2%
-~0 20
al • Visit rural clinics/schools:
Cl
(Il 15 11.5%
ë
oal 10
(ij • Not a commercial practice:
0.. 5 5.1%
0 Serve the entire community at
Reasons of respondents affordable levels: 4.5%
359
g) Respondents' view on the role that the State should play in the
provision of eye care [Only the main views are given - also see Table
6.41 (n=260).]
• Improve current service:
35 31.9%
Cf)
ë 30
Q) • Employ
"C
c: 25 optometrists/broaden
0a. scope: 25.8%
Cf)
-Q...). 20 o Subsidise spectacles at0 clinics/hospitals: 19.2%
Q) 15
Ocol
ë
Q) 10 • Pay/endorse private
o.... practitioners for certain
Q)
0.. 5 work: 7.7%
0 • National health plan: 6.2%
View of respondents
h) Response to the suggestion of private/public sector partnership to
assist the state in addressing the eye care needs in South Africa
(n=366)
.Yes: 86.7%
• No: 12.6%
Do not know: 0.8%
i) Responses to the introduction of compulsory community service
proposed for 2007 (n=384)
.Yes: 85.7%
.No: 12.5%
"Yes" and "No":
1.8%
360
j) Responses to the suggestion that a national health assurance
scheme is an option for South Africa (n=325)
o Positive: 61.2%
• Negative: 35.7%
• "Ves" and "No":
0.6%
• Do not know:
2.2%
o Too complex:
0.3%
k) Responses to the question whether post-graduate education would
impact positively on the needs of the public (n=374)
.Ves: 86.4%
No: 12.8%
Do not know: 0.8%
361
I) Respondents' reasons why a post-graduate education would have a
positive impact on the needs of the public [Only the main reasons are
provided - also see Table 6.47(b) (n=197).]
• Improved eye care standards
and scope: 50.8%
• Improved specialised care:
9.6%
o Improved public image: 8.6%
Ol
Ol • Will make certain
~ procedures more accessible
Ol
~ and affordable: 7.1%
eO,l
• Only if it is needs-based:
6.1%
In Knowledge = power +
Reasons of respondents wisdom: 4.6%
362
6.19 MAIN FINDINGS IN THIS CATEGORY
The following main findings are present in this category:
o Respondents do have a detailed opinion on the public need regarding
necessity, affordability and equity.
o Respondents do have a detailed opinion on ocular disease in diabetes,
retinopathy, glaucoma, cataract and low vision.
o Optometry can play an important role in the improvement of the
standard of care.
o The role of post-graduate education will result in improved standards of
care and delivery.
o A large portion of the respondents felt part of the community they
served. However, they did have different views on why they had
reported this.
o Respondents had specific ideas as to what role the State should play
in the provision of eye care.
o Respondents felt that the State should employ optometrist, as the
current structure is inadequate.
o Respondents felt that there should be a public/private sector
partnership to assist in the delivery of eye care, because the needs of
the public sector are big and standards are poor.
o Most of the respondents felt that community service was required, as it
is a good way to gain experience and serve the community.
e A National Health Insurance scheme can contribute by bringing private
care to a larger part of the population.
e Most of the respondents were of the opinion that post-graduate
education would have a positive impact on the public's need.
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CHAPTER "1
A SlIllNflllMJrA~vlE PERSPIECT~VIE OF THIE STUDY
7.~ INTRODUCTION
In this chapter a summative perspective of the study will be provided.
Each chapter will be dealt with and discussed separately. It should be
noted that references to the literature (with singular exceptions) will not be
made again, since it was already done comprehensively in the chapters
being discussed here.
7.1.1 Perspectives 011 Chapter ~
Introductory perspectives to equip the reader with an orientation to the
study were provided in this chapter with the same title. It was noted that
the importance of good health care was being increasingly emphasised,
not only in South Africa, but also world-wide, e.g. by institutions like the
lAPS and the WHO. The National DoH (RSA DoH 1997:38) recognises
the necessity that education and training programmes should be aimed at
recruiting and developing personnel who are competent to respond
appropriately to the health needs of the people they serve. In the
education and training for health professions, the focus has shifted from a
hospital-based/institution-based to community-based education and
training with the emphasis on primary care. Furthermore there has been a
shift from traditional content-based and teacher-centred methods to
outcomes-based and learner-centred methods and approaches. Thus
education and training now have to be delivered within a programme-
based, modular mode; diversification and access to programmes have to
be facilitated; while teaching and learning systems have to be made more
flexible to meet the criteria for qualifications laid down by SAQA (see 1.1).
364
Changes in higher education include education for the health professions,
which include optometry education and training. The needs which exist
nationally as well as internationally were outlined and special reference
was made to the optometry career ladder as accepted by the Professional
Board for Optometry (see Figure 1.1). The importance of equity and
quality in health care delivery was emphasised so that blindness and
related conditions can be treated, not only in South Africa, but especially in
Africa, which is considered to be the region in the world with the greatest
need for human resource development (RSA DoH 2000:33).
The rationale for the study was outlined with special reference to the
WHO's Vision 2020 - The Right to Sight campaign, namely to eliminate
avoidable blindness by the year 2020. The extreme importance of the
weo resolution entitled the Global Vision Care Campaign, which needs to
be taken cognisance of in the education and training of optometrists, was
depicted and its content spelled out (Di Stefano 2001), while
recommendations were also made in this document. Reference was
made to the National Prevention of Blindness Programme developed by
the government. In this Programme various shortcomings of optometry
education and training are recognised and the need to address them, is
acknowledged (RSA DoH 2000). The prominent need for renewal at post-
graduate level furthermore clearly emerged and several countries abroad
were mentioned as examples of locations where education and training
beyond the bachelor's degree have to be pursued. The conclusion was
reached that in South Africa, based on the current undergraduate training,
there is a need for a programme aimed at providing education and training
to learners in order to become competent to render a professional
specialist service in optometry and to contribute to the enhancement of the
discipline through research (see 1.2).
The problem which was identified and addressed in this study, is that a
potential market of optometrists who wish to pursue post-graduate studies
365
exists in South Africa. However, no suitable and clinical-relevant
programmes (opportunities) are offered to address their needs and to
afford them the opportunity to expand their scope and enhance their
knowledge and skills in order to make a more meaningful contribution to
the prevention of avoidable blindness in South Africa (see 1.3).
The overall goal and objectives were outlined, namely to make a
contribution to eye care and the prevention of blindness, as well as to
make a meaningful contribution to education and training in optometry.
The aim was stated, namely to determine the needs of optometrists with
regard to optometric education and training and the opportunities existing
in South Africa, measured against the background of the needs of the
society (from the optometrists' perspective). Thereafter the objectives
were discussed, namely in the first place to enhance competence beyond
graduate level, thereby serving the eye care needs of the population of
South Africa in particular and of the whole of Africa in an indirect way
better. In the second place the objective was to make recommendations
concerning the delivery of relevant and applicable post-graduate studies at
Optometry Schools/Departments. All of these aspects were achieved by
conducting a literature study on optometry education and training in order
to collect information to serve as a background for the empirical study, in
addition to conducting an empirical study among optometrists by means of
a questionnaire survey to determine their needs in respect of post-
graduate studies, as well as obtaining the respondents' views regarding
existing opportunities in this regard (see 1.4).
The methods used and the procedure for the research study were
explained (see 1.5). The study took the form of a needs analysis and was
descriptive and exploratory in nature, as it comprised a literature review
and an empirical investigation, which entailed a questionnaire survey
carried out among optometrists. Furthermore a quantitative design was
employed, but - because open-ended questions had been included - the
366
study had a qualitative dimension as well. Some aspects regarding the
questionnaire were touched on, but neither this nor the respondents were
dealt with in detail here, as these aspects are described fully in Chapter 5
(see 5.4.1; 5.5).
The significance and the value of the study were subsequently pointed out.
The aspects of new and academic challenges which the optometry
profession is faced with, new opportunities, as well as changes taking
place, were mentioned. The needs of optometrists and the possibilities for
post-graduate studies in South Africa were identified, while the
shortcomings which prevent optometrists from reaching the top of the
career ladder, were referred to. Mention was made of the programme for
a master's degree in optometry which had already been registered by the
Faculty of Health Sciences of the UFS. The desire was expressed that
this study would play an important role in addressing specific needs which
had been identified, as well as create opportunities that would be best
suited to address the needs of optometry post-graduate students, not only
in pursuing formal post-graduate studies, but also in CPD with a view to
maintaining registration with the professional board. In the final analysis,
the study would ensure that optometry post-graduate studies in South
Africa would be embarked upon in a scientific way and based on well-
founded evidence. In this way a relevant programme would be ensured.
The recommendation would be made that this study would be followed up
with a Ph.D. study aimed at developing the contents and implementation,
that is, a full curriculum, for such a Master's Programme in Optometry (see
1.6).
In paragraph 1.7 the scope of the study was outlined and it was mentioned
that it had been conducted within the field of Health Professions
Education, while perspectives had also been gained from the field of study
of higher education, as it is related to this field as well. It was pointed out
that the relevant health science for the investigation was that of optometry
367
and therefore attention had been paid to the demands made on and the
requirements of optometry education and training in South Africa from the
profession, as well as health care and higher education authorities. In
addition, international views and perspectives were considered.
Reference was made to the concepts of "needs", "a needs analysis" and
the "target population", but these aspects were not explained in detail
here, as that will be done in Chapter 5 (see 5.4.2; 5.5).
In the last place, the arrangement of the dissertation was explained (see
1.8).
7.1.2 Perspectives 01111 Chapter 2
This chapter is entitled "Factors influencing the design of optometry
education and training programmes". Factors influencing the design of
optometry education and training programmes, as described in literature,
were taken under scrutiny, while the history of the optometry profession
was also attended to. The transformation of the health care system in
South Africa, as well as the transformation of education and training in
South Africa, was discussed.
The chapter started by referring to the changing health scene in South
Africa and world-wide. This as well as prominent trends in health care and
health professions education was discussed (see 2.1). The enabling
competencies and attributes which health care practitioners must begin to
embrace as undergraduates in order to remain effective, were listed.
Hereafter the history of the development of the optometry profession from
its earliest years was briefly outlined (see 2.2).
The next issue to be discussed was the transformation of the health care
system in South Africa and the eye care needs of the South African
population. Two trends which have emerged nationally and internationally,
368
are the primary health care approach and the community-based approach.
Reference was made to different policy documents and legislation as well
as their importance, e.g. the White Paper for the Transformation of the
Health System (RSA DoH 1997) and the National Prevention of Blindness
Programme (RSA DoH 2000:2). The importance of the WHO's Vision
2020 - The right to sight campaign, not only for South Africa, but also
world-wide, was discussed and some alarming facts and figures regarding
blindness and related conditions and consequences were provided. The
aims and goals of this body, which closely resemble those of the National
Prevention of Blindness Programme, were spelled out. In addition, there
was an identification of the resources required and an exposition of the
four areas at which the prevention of blindness will be addressed (see
2.3.2.1; 2.3.2.2).
With reference to PHC, it was pointed out that it is a concept which is
defined differently by different people. In this regard some definitions and
perspectives as provided by different authors were provided. The three
functional levels of PHC, namely the primary level, the secondary. level
and the tertiary level - which can be incorporated into one model - were
mentioned. The objectives of health promotion, as well as the way in which
they will be developed in South Africa according to the White Paper for the
Transformation of the Health System in South Africa (RSA DoH 1997),
were depicted (see 2.3.3).
The important role of statutory and professional bodies was attended to,
since health professionals have to register with these bodies and therefore
have to meet their requirements. The first body to be dealt with, was the
HPCSA, formerly the Medical and Dental Council of South Africa. The
aims and functions of the Council were outlined with special reference to
the function of the laying down of minimum standards of training,
inspection of training, and conducting certain examinations, which - by
implication - means that it also regulates education and training for the
369
profession (see 2.3.4.1). The history of the next body, namely the SAOA,
was briefly discussed and its objectives were outlined (see 2.3.4.2). This
was followed by a discussion of the establishment of the SACOE, which
does not play a major role any longer (see 2.3.4.3).
The next very important aspect to be reviewed, was that of the
transformation of education and training in South Africa. Some of the
challenges and principles for higher education as proposed in the Draft
White Paper on Higher Education (RSA DoE 1997a:9-14) were
highlighted, while curricula and their requirements were also defined.
Reference was made to the Act on Higher Education (RSA 1997) and the
White Paper 3 on Higher Education Transformation (RSA DoE 1997c) with
their stipulations and recommendations regarding the programme-based
approach. In addition, the six programme elements which should be
attended to according to SAQA (1997:15), were also provided (see 2.4.3).
Subsequently OBET, what it entails, its focus, and its enormous challenge
to educators were discussed. A distinction was made between the two
kinds of outcomes, namely critical cross-field education and training
outcomes (briefly critical outcomes) and specific outcomes, whereafter
each kind was discussed. Mention was also made of a third group of
outcomes, i.e. career outcomes. As the critical outcomes have to inform
the specific outcomes, a closer look was taken at critical outcomes and
they were defined according to, infer alia, the Regulations under the SAQA
Act (Act 58 of 1995) (RSA 1998:8). Next specific outcomes, which are
context-specific, were defined and described and their importance was
highlighted. This was followed by a brief description of career or
vocational outcomes, while the three integrated elements of learning
outcomes, namely knowledge and understanding, doing (skills and
abilities), and attitudes and levels were outlined and examples provided.
The conclusion was reached that, as optometry is a dynamic profession
where new knowledge and methods are developed continually, it is of
paramount importance to train students who have the skills to integrate
370
theory and practice; to contextualise their knowledge, skills and attitudes
into real-life situations; and who are equipped to be lifelong learners (see
2.4.3).
The establishment of the NQF, its aims and goals, the dire necessity for
the existence of such a body, as well as relevant legislation were
discussed next. The way in which SAQA is compiled, its functions, the
difficulties confronting it, its role in the registration of programmes and its
limitations were described. The eight qualification levels of the NQF with
its three bands were described and a schematic presentation provided in
Table 2.1. The objectives of the NQF as laid out in the SAQA Act (RSA
1995), as well as the set of principles with regard to qualifications by which
it is underpinned, were listed. The stringent requirements which education
and training programmes have to meet were delineated with specific
reference to optometry education and training programmes.
It was emphasised once again that making recommendations regarding
the delivery of relevant and applicable post-graduate studies in optometry
education and training in which the needs as defined in this study can be
addressed, would be the ultimate goal of the research. Thus educational
strategies were dealt with next. The SPICES model was discussed and
each of its aspects explained, namely the student-centred strategy;
problem-based learning; an integrated approach; the community-based
approach; electives; and a systematically structured curriculum (see
2.4.6).
Finally, this chapter attended to the issue of development trends in
optometry education and some recommendations were made in this
regard (see 2.5).
371
7.1.3 Perspectives on Chapter 3
Chapter 3 is entitled uA selective review of optometric education" and it
starts off by providing a brief history of the profession, which had its origin
abroad. Mention was made of events, leading institutions and legislation
in various countries abroad, e.g. Europe, the former East Block and Asia,
Australia and New Zealand, the USA, Canada, Britain, etc. In South Africa
the profession was officially recognised in the Health Professions Act of
1974 (RSA 1974) and the extreme importance of optometric education and
training came to the fore. Therefore this chapter focuses on this aspect
nationally as well as internationally. The emphasis is on South Africa,
however, since it is the country with the most advanced optometric
education and training system in Africa. Furthermore it is also the country
where optometric education and training, as well as the practice of
optometry, have advanced most rapidly over the past couple of years (see
3.1 ).
An overview of the history of optometric education and training in South
Africa was subsequently provided. Compared to other African countries,
South Africa has the oldest optometric educational heritage. As a
profession, optometry was only recognised in South Africa around 1927,
while formal training started around 1931. The history of the various
institutions with their different courses and student numbers, the influence
of political changes occurring in South Africa and legislation with regard to
optometry education and training were depicted in paragraph 3.2.1.
Specific reference was made to the scope of optometry which was clearly
defined under Regulation No. R.228 in 2001 (RSA DoH 2001: 1). The
current need to train specialist optometrists in South Africa for the private,
state and primary health care sectors clearly emerged and statistics were
provided to substantiate this fact. The objectives which should be pursued
in optometry education and training in South Africa as set out by the
National DoH in its National Prevention of Blindness Programme (RSA
372
DoH 2000:38), were outlined (see 3.2.1). The next step was describing
the programmes offered at the different institutions in order to gain a clear
picture of the education and training of optometrists and dispensing
opticians in South Africa.
The following institutions, their programmes, student numbers and the way
in which they meet legislation, were described:
o The TWR (see 3.2.2).
e UNIN (see 3.2.3).
e UDW (see 3.2.4).
o RAU (see 3.2.5).
ti The CT (see 3.2.6).
o The UFS (see 3.2.7).
NEWENCO and its relationship to the GlO as well as the important role of
the latter were dealt with, while CAS and the different CAS courses were
discussed. A visual representation of post-graduate optometry in South
Africa as depicted in Figure 3.1, was provided (see 3.2.8).
The above exposition was followed by a discussion of optometric
education and training in the rest of Africa (see 3.3). The profession was
introduced to Africa by European immigrants and at present there are
optometric services in western Africa, eastern Africa and southern Africa.
Sadly, though, there are no optometric training programmes in northern
Africa (see 3.3.1). As previously mentioned, the whole of this country is in
dire need of optometry services as a result of the severity of prevalent
circumstances and conditions with regard to (eye) health care. Resulting
from the opening of several new teaching programmes during the past two
decades optometry is, however, now presenting a significant presence in
four African countries, namely Nigeria, Ghana, Tanzania and South Africa.
These four countries have 10 optometric teaching programmes, which
373
vary in scope. Far too few optometrists are, however, produced to meet
the needs of their own countries, let alone make a contribution to the eye
care needs of the countries without optometric training programmes.
Except for South Africa, a brief overview was provided on each of the
countries mentioned, as the literature on this aspect is limited. The history
and the current state of affairs in Ghana (see 3.3.2), Tanzania (see 3.3.3)
and Nigeria, including French-speaking Africa (see 3.3.4), were discussed.
As much information as possible concerning the institutions; the number of
students; the kinds of programmes offered; and, where applicable, the
influence of countries abroad was provided. To summarise, the utter
gravity of the situation was reiterated and it was pointed out that, in
contrast to Africa, the education and health systems - with special
reference to optometry - in the USA seem to be well developed. Therefore
optometrists from Africa mostly receive their post-graduate training in the
USA or through USA programmes. Since this is the case, the next two
countries to be discussed, were America and Canada (see 3.4).
By way of introduction some background information was provided. In the
case of the USA the meaning of concepts such as "doctor of optometry"
and "optometrist" was provided, while their functions and the length of time
involved to qualify to perform these functions were also delineated.
Aspects like admission tests; different kinds of degrees (e.g. OD and MS);
residencies; legislation; the language of instruction; the number of
students; and prominent institutions were furthermore referred to (see
3.4.1 ).
In paragraph 3.4.2 programmes for optometric education and training;
prerequisites for admission (e.g. the OAT); subjects taken; as well as other
relevant aspects pertaining to each of the following institutions were
discussed:
374
o The Ferris State University.
o The Michigan College.
o The Pennsylvania College of Optometry.
o The Pacific University College of Optometry.
Q The University of California at Berkeley.
In conclusion it was pointed out that - in contrast to the training in Africa -
which is mostly (almost exclusively) undergraduate, the training in the USA
is exclusively post-graduate. Furthermore, in the programmes of the USA
the various needs of the population are addressed and students have
opportunities for research. Innovation is taking place in programmes,
while new developments in health and specifically in eye care are
addressed in various residency programmes. In the USA there are even
too many eye care providers, while in Canada the primary vision care
needs of the population of just over 30 million people are taken care of by
approximately 3 300 practising optometrists (Spafford 2001). The
scenario which emerges when one compares these two countries with
Africa, is indeed not only a disheartening one, but it is also distressing and
deplorable.
Subsequently optometric education and training in Europe, the United
Kingdom and Australia were discussed (see 3.5). It would seem that
optometric education and training in Australia and in the UK provide in the
needs of the countries, as the former has three and the latter eight
universities which offer optometric education and training. Europe,
however, seems to be having problems in providing education of a level
that will be acceptable to all the different countries on the continent. An
encouraging aspect in this regard is that guidance and assistance are
provided by the ECOO.
Once again, as was the case with the previous institutions and countries
dealt with, an outline of the state of affairs at each of the various
375
institutions; the duration of courses; subjects; research; etc. was provided.
The first country to be discussed was Australia with its three universities,
namely the University of New South Wales, the University of Melbourne
and the Queensland University of Technology. Special mention was made
of the Department of Optometry and Vision Sciences of the University of
Melbourne, which is research-focused and has a strong graduate school.
Its three higher qualifications, namely the Postgraduate Diploma in Clinical
Optometry, the Postgraduate Diploma in Advanced Clinical Optometry and
the Master of Optometry (by Research or by Research and Clinical Work)
were discussed at length (see 3.5.2.1).
The United Kingdom with its eight universities, namely the City University,
London, Anglia, Aston, Bradford, Cardiff, Glasgow Caledonian, Ulster, and
Manchester UMIST was discussed in paragraph 3.5.2.2. The role of the
GOG was mentioned; it was pointed out that there are two kinds of
opticians, namely "optometrists" and "dispensing opticians"; the difference
between them was explained; programmes, credits and modules at the
University of Bradford were dealt with; while the APL scheme and its value
were also discussed.
The prominent role of the ECOO in Europe was highlighted in paragraph
3.5.2.3. It represents 24 nations and is a confederation of the leading
professional bodies representing 22 countries in Europe, the names of
which were provided. The way in which optometrists are trained in
Europe; the length of courses; the EGOO European Diploma in Optometry;
different kinds of institutions (e.g. technical schools, the university); the
nature of the ECOO; and examinations, including the patient care
examination, were some of the aspects discussed.
The summative perspective provided by the researcher was that the
challenge for South African educators would be to find a model that would
address the immediate public need, whilst allowing for the vertical
376
development within a career path to the highest post-graduate level
possible. Furthermore, it was emphasised that the public need is so
urgent and of such a nature that it demands that the profession plays a
bigger role in the avoidance of blindness (see 3.6).
7.1.4 Perspectives on Chapter 4
Chapter 4 is entitled "Continuing professional development (CPD) in
optometry", which is an integral part of the research study and as such had
to be investigated thoroughly. By way of introduction it was pointed out
that the notion of a "vocation for life" learnt once will have to be
surrendered in favour of the idea of constant, that is, lifelong learning,
especially in the field of health professions. Some reasons why CPD is
essential, were emphasised, e.g. the rapid rate of developments in health
sciences, coupled with the impact of this on health care practice, have
made it impossible to keep up to date with developments relevant to
practice; the knowledge and skills of every individual decay over time and
need to be refreshed and reinforced; from a professional point of view, it
should be mandatory to maintain professional competence; it has been
proven by research that knowledge starts to become obsolete from the
first day of an optometrist's practice and the situation deteriorates over
time so that, by the time an optometrist has been in practice for 20 years,
serious gaps in knowledge and skills exist; primary health care is receiving
increasing emphasis and most practice-based optometrists have little or
no knowledge of community work as well as little experience of detecting
the early presentation of vision failure, the extent of eye disease in
communities, or the impact of disability on relationships in family units,
while in practice they are not always kept informed of the latest
developments in basic care (see 4.1).
The rationale for CPD was outlined in paragraph 4.2. It has to be noted
that CPD has been undergoing tremendous changes recently, in addition
377
to becoming increasingly important for health professions and patients.
The aspects of recertification and reaccreditation, as well as quality
assurance and the reasons for their existence were highlighted. It was
mentioned that one of the major objectives of accreditation and
certification bodies, professional associations/boards and employers, is to
ensure that professionals in health services are kept sufficiently qualified
to keep on practising. As already pointed out, knowledge continually has
to be kept up to date. In South Africa some hindrances exist with regard to
keeping up to date, e.g. long distances which have to be travelled to
centres where courses are offered; a lack of time and funding; etc. Yet no
one can dispute that the necessity of updating courses, completion
courses and other CPO programmes increases with policy changes and
changes in the regulation of practising optometry. There is an increasing
need of CPO programmes in a situation such as the current one in South
Africa, where necessary change in the educational level required in the
profession is brought about and the scope of practice is broadened.
The next aspect concerning CPO which had to be examined, was the
criteria for CPO programmes (see 4.3). Thus far the need for CPO was
already established beyond a shadow of doubt and the conclusion
reached that an undergraduate professional qualification can no longer be
regarded as an adequate lifelong certificate of competence. Furthermore
the traditional approach to CPO will no longer suffice. Thus proactive
action is called for from the side of the health care professions, including
optometry, to ensure that services remain relevant and that the needs of
the community and the public at large are satisfied. Some factors playing
a role when CPO programmes are considered, were listed and attention
was drawn to the fact that sets of educational criteria are required to
maintain as well as encourage quality in all forms of CPO and post-
graduate education and training. This led to an exposition of the CRISIS
criteria as identified by Harden and Laidlaw (1992). With regard to
378
CRISIS, the following important facts were listed (Harden & Laidlaw
1992:3-15):
o The criteria contained in CRISIS were explained.
o As "CRISIS" is an acronym, its meaning was depicted.
Q It is a practical tool, based on 15 years' experience in the production
and evaluation of CPD programmes at the Centre for Medical
Education at the University of Dundee, while the criteria have since
been proven to be suitable for use in other CPD programmes too.
Attention was drawn to certain important facts, i.e. that factors related to
health professionals' decision to attend CPD programmes were identified
by research (e.g. such items as convenience, travel, scheduling,
preferable days, months, and fees); that aspects related to delivery
systems play a role (e.g. programme format, programme amenities, and
programme location); and that additional aspects exist (e.g. the
involvement or participation of the learners, methodology, content, the
subject knowledge and teaching ability of the programme deliverers). It
was acknowledged that CRISIS might seem a simplification in a very
complex world, but it was also pointed out that it did identify the
characteristics of programmes which are successful in achieving the goals
of CPD.
Each of the characteristics of CRISIS as described by Harden and Laidlaw
(1992:3-15) is relevant in designing CPD programmes and in defining the
needs of practitioners with regard to professional development.
Subsequently each of the characteristics of CRISIS was described
individually, namely:
Q Convenience (see 4.3.1) makes voluntary participation easy and
includes the aspects of place (see 4.3.1.1); time (see 4.3.1.2); and
pace (see 4.3.1.3).
379
e Relevance (see 4.3.2) reflects the user's day-to-day role in practice
and is a very important aspect. Various authors give different
connotations to relevance, but currentness and content continually
emerge. Other aspects mentioned are, inter alia, how facts are
applied; that learners must be shown the uses to which knowledge may
be put; it is related to the choice of topic and also to the way or context
in which the content can be put to use; and the importance of a needs
analysis as well as problem areas in connection with different needs
once again came to the fore. In the latter regard Harden and Laidlaw
(1992) provide a graphic representation of the relationship among the
three components of relevance which were depicted in Figure 4.1.
Thereafter each of the five components was explained, while some
methods as identified by Ounn, Hamilton and Harden (1985) that are
available to identify the needs of practitioners with regard to CPO, were
indicated.
o Individualisation allows learners a say in what is learnt and to adapt the
programme to their own needs. As learners come from various
educational backgrounds and differing professional circumstances, it
stands to reason that their needs will therefore differ. A recently
qualified optometrist may be up to date on a subject, but lacking in
experience; more senior colleagues may have the experience, but lack
up-to-date theory and skills. With regard to this aspect, 10 areas into
which the variation in individuals' needs may be divided according to
Harden and Laidlaw (1992:9), were outlined Subsequently strategies
to individualise continuing education programmes in order to increase
the likelihood of success, were delineated (Nel & Nel 1995:8).
ID Self-assessment was discussed in paragraph 4.3.4. Self-assessment
encourages learners to evaluate their understanding of the subject and
to remedy gaps that exist. The numerous ways in which self-
assesssment can contribute to successful CPO were outlined, while
380
Harden and Laidlaw's (1992: 10-11) statement that it is a three-stage
process was described.
o Interest arouses attention and encourages learners to participate (see
4.3.5). Three reasons were provided why continuing education must
be interesting to be successful. According to Nel & Nel (1995:10) and
Harden and Laidlaw (1992: 12-13), a combination of five factors had
been identified to maximise the attractiveness of a programme and the
interest of potential participants, namely relevance; presentation; text
design and lay-out; visuals and colour; and active involvement.
o Speculation recognises controversial and grey areas in the field and
offers a planned programme with coverage of the whole (see 4.3.6.1).
The reasons why areas of speculation and controversy should be
included, were provided, while the areas where speculation may exist,
were mentioned.
e "Systematic" has to do with subject or an identified part of it (see
4.3.6.2). The importance of the fact that CPO needs to be systematic
was emphasised, while it was furthermore pointed out that CPO
programmes should include a well-designed mix of self-directed
learning, seminar participation, instructional experiences and
scholarship.
Subsequently the different types of CPO programmes were discussed in
paragraph 4.4. The fact that the CRISIS criteria do not distinguish among
various types of interventions, was mentioned and three kinds of self-
directed CPO were distinguished, namely:
e Informal, ongoing habitual activities directed to the maintenance of
competence.
o Semi-structured learning experiences which typically have their basis in
immediate patient problems.
Cl) Formal, intentional, planned activities.
381
It was reiterated that traditional approaches to updating knowledge and
skills in a profession would no longer suffice and it was pointed out that it
would be advisable to link CPO activities to departments of optometry and
faculties of health sciences. It was suggested that CPO programmes
could be offered by means of disciplinary congresses, seminars and
workshops, as well as over longer periods, e.g. summer or winter schools.
The importance of building a strong component of distance education into
COE programmes in order to take CPO to the practitioner, was also
mentioned. The criteria which should apply in designing CPD
programmes were summarised in four main points:
o Educational efficiency (educational interface, infrastructure, planning
and support).
I) Availability of resources (financial, human, physical, technological).
e Attitude towards change (the demands and requirements of our times
need to be addressed).
o Interest and needs (needs analyses to be done) (NeI1995:3).
Hereafter a distinction was made between formal programmes and
informal CPO and the ways in which each kind is presented, was
described.
The next aspect to be dealt with, was that of CPD in South Africa (see
4.5). Its establishment and administration were outlined. Reference was
made to the vital role which the Professional Board of Optometry and
Dispensing Opticians plays, while its functions were also outlined (see
4.5.1). Categories of educational and developmental activities and the
aspect of obtaining points were mentioned and elucidated in paragraph
4.5.2. The requirements for obtaining points were clearly defined and the
following categories identified:
G Category 1: Organisational activities.
382
o Category 2: Small-group activities.
o Category 3: Individual activities. These include self-study; individual
learning; research and publications In peer
reviewed/continuing professional development
journals; teaching and/or training activities;
paper/poster presentations/lectures to peers; relevant
additional qualifications;
evaluations/assessments/examinations; supervision of
candidates for higher degrees; community service;
professional ethics; and non-clinical but health-related
activities.
In paragraph 4.5.3 the conditions were outlined which the Board may
impose should deferment or non-compliance of a practitioner occur.
Furthermore it was made clear what is understood by "Providers of CPO
activities" (see 4.5.4), as well as by "Accreditors of CPO activities" (see
4.5.5).
The HPCSA, which is a statutory body established in terms of the Health
Professions Act of 1974 (RSA 1974), was discussed next (see 4.6). The
HPCSA is an umbrella body with 12 professional boards functioning under
its jurisdiction (see 4.6.3). Aspects which were discussed, were among
others, the following:
COl The background of the HPCSA (see 4.6.1).
o Registration of the HPCSA. This features aspects like prerequisites for
practising; benefits enjoyed as a result of registering; and the list of
professionals who register in terms of the Act (see 4.6.2).
• The 12 Professional Boards under the jurisdiction of the HPCSA were
listed (see 4.6.3) and the role of the latter where these Boards are
concerned, was spelled out. In addition, the function of a Professional
Board as it relates to professional practice, was outlined. The way in
383
which regulations pertaining to professional conduct inquiries of the
Professional Boards are discharged in accordance with legal principles
following upon formal complaints lodged against a registered person
and related aspects were also dealt with.
It was pointed out in paragraph 4.7 that, with knowledge becoming so
proliferated, diverse and specialised, it is impossible for any profession, let
alone that of a teacher or being a student, to know or master everything
that has to be learned (Super 1989:708). Reference was made to the
conclusions reached by Grant and Stanton (reported in Eraut 2001 :8)
regarding ePD, namely:
CD The key to the effectiveness of ePD is not to be found in the learning
methods adopted.
• There is not a best learning method and no best approach to learning.
Q Instead, the key to effectiveness is to make sure that the process of
ePD is effectively managed to have the following components:
A stated reason for the ePD to be undertaken.
An identified method of learning, which might be formal or
informal.
Some follow-up after the. ePD for reinforcement and
dissemination of the learning.
By way of conclusion (see 4.8), it was emphasised that the role of
optometrists in the health care of our nation can therefore clearly not be
denied. The profession of optometry has been a leader in the movement to
formalise continuing education through mandatory participation related to
renewal of licensure in the USA (Escovitz & Augsburger 1991:41). South
Africa is now undergoing the same processes and certain questions which
need to be answered with regard to eOE, were put forward, e.g. Do
optometrists participate in continuing education because it is mandatory?
Do other factors enter into the decision to undertake eOE? Are providers
384
of COE addressing the perceived needs of optometrists? What changes
can be made to offer optometrists better opportunities for COE?
Additional issues raised were, among others, the issue of standards; the
structure of COD programmes; the real needs of the potential participants;
the fact that education and health care are interdependent; etc.
Subsequently perspectives on Chapter 5 will be provided.
7.1.5 Perspectives 0011 Chapter 5
The title of Chapter 5, namely "Research methodology", gives an exact
indication as to the content of this chapter. Aspects which were referred to
in Chapter 1, were discussed in detail in this chapter to provide the reader
with the necessary insight into and an understanding of the research
study. By way of introduction (see 5.1) it was reiterated that the research
took the form of a descriptive and an exploratory study, comprising a
literature review as well as an empirical investigation. The data in the
empirical study were collected by means of a questionnaire survey, carried
out among practising optometrists in South Africa to determine their needs
in connection with post-graduate studies, as well as the possibilities
available for optometrists in South Africa to further their studies and
enhance their knowledge and skills as professionals in health care
services. The empirical study therefore took the form of a needs analysis.
The noteworthy terms "needs", "needs analysis" and "target population" as
defined by different authors were clarified in this chapter (see 5.1; 5.4;
5.4.2; Appendix B). The changes which the optometry profession as well
as higher education and training have been undergoing recently, were also
pointed out.
Paragraph 5.2 explained that the aim of the literature review was to
provide reliable data with a view to gaining sufficient background
knowledge on the subject, as well as to generate a number of criteria to be
385
used to determine the needs of optometrists with regard to their education
and training. These criteria were eventually converted into items
contained in a questionnaire used for the needs analysis. The
questionnaire survey constituted the empirical part of the study.
Reference was made to the two main paradigms or models used in
research, namely the quantitative and the qualitative approaches. It was
pointed out that both these approaches had been used in this study, but
that the greatest emphasis had been on a quantitative design, since the
questionnaire had contained open-ended questions as well as other kinds
of questions. In addition, the advantages of a multiple approach were
pointed out, while both the advantages and the disadvantages of the
quantitative and the qualitative approaches were outlined. Since this study
falls into the category of descriptive surveys, this concept as defined by
various authors was explained. Furthermore the concepts "reliability" and
"validity" were stressed, while attention was drawn to the fact that in this
study the reliability of the instrument (questionnaire) had been established
by means of a pilot study, the inclusiveness of the sample, as well as the
response rate. The validity of the findings rests on the in-depth literature
survey, the experience of the researcher, as well as the number of
respondents who had participated in the study.
Subsequently each of the different methods and procedures utilised in this
study was elucidated in detail. The aim and purpose of the literature
review was clearly outlined in paragraph 5.3.1. In this study it was to
establish a background to and a context for the research problem; to justify
the need for the research; and to indicate that the researcher was
knowledgeable about the field of study and the particular area under
investigation (cf. Landman 1988:69). Based on the literature study, a
phenomenological perspective was established, as the focus was on the
meaning of the phenomenon of continuing/post-graduate/further optometry
education and training. This was a search for meanings and, through it,
assumptions in concepts and methods were uncovered (Landman
-----------
386
1988:75). The factors which comprised the focus of the literature study
were mentioned, while the sources of information and the different aspects
which had received special attention in the study, were identified.
The questionnaire (see Appendix C), which had been briefly mentioned in
Chapter 1, was described in detail in paragraphs 5.3.2 and 5.4.1. The
function of the questionnaire was outlined and definitions thereof
according to various authors were provided. It was pointed out that this
method of gathering data is exceptionally suitable for a needs analysis of
national scope, as was required in this study (cf. Wolmarans & Eksteen
1987:39). The questionnaire utilised for this study consisted of six
categories containing approximately 35 questions, which were divided into
77 subsections. Aspects which were delineated were, among other things,
the different categories; the types of items used; the length of time
involved to complete the questionnaire; the way in which the
questionnaires reached the respondents and how the latter could respond;
the cover letter (see Appendix 1); the number of questionnaires sent out
(i.e. four) over a period of 16 weeks; and the list of definitions provided
(see Appendix B). The content of each category was briefly summarised
and a differentiation among the types of items - with a short description of
each kind of item - were provided. The disadvantages of questionnaire
surveys were outlined, but mention was made of the fact that steps had
been taken to counter the difficulties encountered in this regard.
Subsequently the needs analysis was dealt with (see 5.4.2). The
extremely important aspects of "needs" and a "needs analysis" or a "needs
assessment" were once again referred to and definitions according to
different authors were provided (cf. Appendix B). It was pointed out that
this study is concerned with macro-level needs, that is, needs which occur
at national and even international level (e.g. Africa). Furthermore it was
stressed again that an in-depth literature review had been done and a
questionnaire developed to identify the needs of practising optometrists
387
with regard to their education and training; the needs of the society and
other stakeholders; and the opportunities they saw with regard to further
education and training.
Perhaps the most important aspect of all, namely the respondents, was
dealt with in paragraph 5.5. Before this aspect could be discussed, the
term "target population" was defined and its relation to this study
explained. The noteworthy fact that, in most research, the entire target
population is not accessible to the author (Halldorson 1999) was
reiterated, since it had been the case in this study. It was emphasised that
the target population for the questionnaire did not comprise the total
population of optometrists in South Africa. Subsequently the following
aspects were clarified:
ei) The number of addresses obtained (i.e. 1 400) and how they had been
obtained from the GlO.
o The role of the Professional Board and why addresses had not been
obtained directly from this body.
o The attitude of the SAOA and why the researcher did not make use of
this body.
ei) How it came about that the target group to whom questionnaires had
been posted, was eventually 1 131.
e How it occurred that the final number of questionnaires was eventually
576, giving a response rate of 70.2%.
o That, in the end, 397 fully completed questionnaires were used for
statistical analysis, i.e. 68.9% of the questionnaires which had been
returned.
• The exclusion criteria which had been applied (i.e. age; individuals who
already possessed a clinical applicable post-graduate qualification;
illegible handwriting; and duplication which occurred).
Ci) The term "population".
388
o The respondents' needs with regard to post-graduate studies and their
views on possibilities available to them to satisfy these needs.
The ethical considerations [i.e. issues concerning anonymity;
confidentiality; demographic details; and approval of the protocol for the
study obtained by the Ethics Committee of the Faculty of Health Sciences,
the UFS (ETOVS number: 12/02)] were discussed in paragraph 5.6.
In paragraph 5.7 an explanation was provided as to the way in which the
analysis of the data took place by the Department of Biostatistics at the
University of the Free State by using the S.A.S. Programme.
Subsequently an analysis of the chapter was provided before commencing
with Chapter 6 (see 5.8).
7.~.6 Perspectives 01111 Chapter 6
In this chapter the six categories of questions dealt with in the
questionnaire (see Appendix C) were analysed in detail by means of
tables, etc. Each of the six categories of the questionnaire was followed
by a summative conclusion, as well as by the main findings of the content
of that specific category. The main findings, as well as those obtained via
the literature study, enabled the researcher to make recommendations on
post-graduate optometric education in South Africa. (In this regard, see
Chapter 8.)
7.1.7 Perspectives on Chapter 7
This chapter is entitled uA summative perspective of the study" and the
different perspectives regarding each chapter were dealt with separately.
389
7.1.8 Perspectives on Chapter 8
In Chapter 8 recommendations on post-graduate optometric education in
South Africa will be made. These recommendations will be based on the
literature cited, as well as on the findings. Different factors, which are
listed under the following headings and subheadings, will have influenced
these recommendations:
e Points of departure.
o Role-players.
Ei) Post-graduate optometric education and training itself, divided into
three aspects, namely:
Recommendations concerning the programme.
Recommendations with regard to CPD.
Recommendations on clinical competence based on public
needs.
The recommendations on clinical competencies will be extremely detailed,
since they may serve as a basis for the SGB of Optometry and Opticianry.
In order not to confuse the professional competencies with the categories
of the questionnaire, they will be divided into six sections, namely:
o Section A: Clinical responsibilities.
G Section B: Patient history.
o Section C: Patient examination.
e Section D: Diagnosis.
o Section E: Patient management.
G Section F: Recording of clinical data.
Each of these sections will be divided under the headings "Outcomes";
"Performance criteria"; and "Indicators".
390
In the last instance a summative perspective will be provided in which a
framework will be proposed as a starting point for post-graduate education
and training programmes.
7.1.9 Perspectives 001 Chapter 9
This chapter will deal with a summary of the main conclusions and the
limitations of the study. The researcher's opinion is that the overall goal
and objectives of the study have been addressed and realised, while
meaningful recommendations will be made. The main limitations of the
study is that the opinion on the public need was limited, as the
respondents were practitioners; literature and statistical sources of the
South African situation are limited, since epidemiological data are
incomplete and fragmented; while optometry educational development
also stagnated during the apartheid years.
Finally, the conclusion will be reached that - for the recommendations in
this study to be successfully implemented - a model and a detailed
curriculum plan for post-graduate optometric education will be required.
Furthermore the researcher will express the opinion that the profession as
a whole needs a leadership and management model that will ensure
cohesion between all the facets in the eye care field.
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CHAPTIER 8
RIECOMMIENlDAT~ONS ON POST-GRADUATIE OIPTOMIETR~C
EDUCAT~ON ~NSOUTH AIFR~CA
8.1 INTRODUCTION
The overall goal of the study was to make a contribution to eye care and
the prevention of blindness in South Africa. To achieve this, the study
sought to determine the needs of and the opportunities which exist in
South Africa for students in optometry who wish to pursue post-graduate
studies. Post-graduate education was therefore seen as the formal
structure that underpins improved skills which will be more appropriate to
the needs of the majority of the population who were neglected prior to
1994. The educational opportunities were sought in order to improve skills
which would enhance care. The need of society in this regard was
therefore seen as an element in the development of education and formed
part of the study, albeit being a subjective opinion.
As the recommendations are aimed at a post-graduate programme, one
must be mindful of the fact that certain skills will, over time, become part of
undergraduate training during a process of overview, integration and a
shift to primary health care. Similarly certain skills will become speciality
skills and therefore will only be taught at introductory level in the
undergraduate programme with the advanced skills acquired at post-
graduate level.
The needs of the public, the workplace and the profession will determine
the priorities and time frames, provided that these needs are measured on
a regular basis and acted upon by the providers of education and training.
392
8.1.1 Why post-graduate?
It is clear from the results in the research that post-graduate education is
indeed required by the profession. The respondents' views of the public
need are also indicative of the fact that, in the field of eye care, service
delivery is inadequate and speciality skills are lacking. This is particularly
evident in the public sector, responsible for what is estimated to be 75.0%
of the population. Preventable blindness is therefore not successfully
addressed as cataract, glaucoma, diabetic retinopathy and the correction
of refractive errors remain the major contributing factors in South Africa.
According to the National Prevention of Blindness Programme document,
the following disturbing statistics are in force:
"For our planning purposes-
For a population of 1 million-
Prevalence of blindness 0.75%
Number of blind people = 7 500
Causes of blindness - Cataract 66% = 5 000 people
Glaucoma -14% = 1 000 people
Incidence of blindness due to cataract = 1 000 people per year
All other - 20% of blindness" (RSA DoH 2000:4).
One needs to question this current scenario beyond the most obvious
reason of apartheid and separate development. Five other possible
reasons come to mind:
e Limited ophthalmology posts (± 45) and hardly any optometry posts
(± 25) in the public sector (responsible for ± 30 million people).
e Undergraduate training in optometry is still aimed at a first-world
population and takes place mainly outside public sector health facilities.
393
o Undergraduate training in optometry is not measured on an ongoing
basis against a public and workplace need.
o Undergraduate training in optometry is didactically too broad and
therefore limits clinical exposure, which results in insufficient time spent
on clinical and speciality skills.
o The scope of the eye team responsible for eye care in South Africa is
not fully understood due to the lack of research, epidemiology data,
mid-tier workers and proper management. This resulted in a lack of
design models and creative implementation of a structure which can
address needless blindness. Currently the lack in undergraduate
optometrist training and clinical involvement in the public sector forces
others (ophthalmologists) with post-graduate skills to perform many
primary care tasks.
Most of the above reasons can be addressed via curriculum review and
integration which will allow for more time in the undergraduate final year
for clinical training. However, as previously mentioned, public sector
involvement at under- and post-graduate level should result in a
repositioning of the profession in order to play a more useful role. It follows
that certain skills at the undergraduate level will be taught at an
introductory level with a view to enhance them at post-graduate level.
Some may argue that another option would be to expand the
undergraduate programme beyond four years. That will be too costly for
the State and the student and will delay addressing the immediate public
need. Community service will also be delayed and an extended
programme will also be against the current Policy that seeks mid-tier exits.
It is important to note that the courses that are thus taught at introductory
level, will need formal recognition when graduates return to upgrade these
skills beyond the B. Degree. In other words, a structured approach should
394
be followed so that skills which are seen to be speciality skills, need the
basics introduced at undergraduate level for them to be recognised as
sufficient prior learning that will satisfy the admission regulations at post-
graduate level.
8.1.2 lHIowwill this contribute to addressing the need?
Post-graduate education will contribute to addressing the need in at least
six ways:
c As previously explained, post-graduate education will by nature
influence undergraduate training, the major factors being that post-
graduate training will initially be more structured and aimed at
addressing the immediate needs. As undergraduate training becomes
more structured or repositioned to be more appropriate for the public
sector, post-graduate training will shed some of the initial
responsibilities to concentrate more on specialisation. For example,
B. degree optometrists will fulfil the functions of refraction and
diagnosis, whereas M. degree optometrists will be involved in disease
management and specialisation in fields such as contact lenses, low
vision, vision therapy and co-management with Ophthalmology. Both
groups and/or levels will, in turn, improve service delivery, standard of
care and the increased diagnosis and management of potentially
blinding diseases, as well as rehabilitation, health promotion and the
education of nurses, ophthalmic nurses and voluntary community
workers.
G By offering post-graduate specialisation such as in the management
and co-management of glaucoma, keratoconus and irregular corneal
conditions, ocular trauma, cataracts, diabetic retinopathy, low vision
and other common ocular diseases, post-graduate education will
prevent and reduce blindness, in addition to preventing unnecessary
costs and social grants. Other areas of specialisation such as sport
395
vision and vision therapy may be limited to certain centres only, but
should not be excluded from the public sector setting, as it will be of
benefit to other interdisciplinary fields and departments.
o The cascading effect of skills or multiskilling in the eye team will
increase the effect that community workers, nurses, B. degree
optometrist, general medical practitioners, M. degree optometrist, and
ophthalmologist will have in the prevention and reduction of blindness.
In other words, it will move away from the current structure where
highly trained people are used to perform primary care which creates
the backlogs and subsequent preventable blindness which brings
hardship.
e The resultant better-organised and skilled eye team will allow for better
eye health promotion, which will result in less preventable blindness by
the mere fact that the public will be better educated about eye safety
and the importance of compliance in diabetes and glaucoma, as well
as resolving some of the myths surrounding cataract extraction,
amblyopia, strabismus and the progression of diseases like glaucoma,
age-related macular disease and other blinding conditions.
o A better-structured eye team will result in better screening protocols at
schools and in industry which will partner State and private sector
efforts, further helping with the correction of refractive errors and
diagnosis of other potentially blinding disease.
o Research stimulated and accommodated via the structured approach
to the eye care career will result in better epidemiology studies, better
management of service and care structures and should lead to better
disease management protocols. clinical guidelines, surgical
techniques, therapeutic interventions, low vision assistive devices and
rehabilitation services.
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8.1.3 Post-graduate education in optometry and its role 081 post-
apartheid South Africa
Educational policy under a new dispensation creates the opportunity to
structure a career path that allows a new focus in the educational
underpinnings of skills and expanded skills. A direct result of this
structured direction offers effective articulation between under- and post-
graduate training that, coupled with a broader skills base, will entrench the
role of the profession in the field of eye care in South Africa. A post-1994
Health Policy provides the conduit whereby the profession can evolve as a
public utility and reach a much large population, as well as its full potential.
Ultimately, this dual track in policy allows for a stable platform for the
profession to contribute to the improvement of services to eye care,
research and the reduction of preventable blindness. The simultaneous
introduction of primary health care and the "Primary Care Worker"
provides a further opportunity for the profession to play a gatekeeper role
in the public sector and share generic modules in education and training
with others involved in eye care at various levels.
The successful utilisation of these new structures will develop a model for
Africa as South Africa, is the country most likely to take the lead in
optometric education in Africa (home to five of the 10 schools on the
continent).
It is also important to note that in the post-apartheid era restructuring of
systems, which were inherent to the past, brings forth new elements such
as career outcomes and community-based education and training. These
elements are directly or indirectly part of the recommendations in this
study.
397
Ophthalmology protectionist attitudes may delay this development but
cannot be substantiated under these new policies. A protectionist attitude
would have been quite acceptable under apartheid, as equity in health
care was not a priority of the state.
8.2 PREMISES OF POST -GRADUATE OPTOMETRY
EDUCATION
From the perspective of the researcher, it is. obvious that the following
premises are not negotiable in order to establish effective and efficient
post-graduate education and training. Subsequent to this, our
recommendations, the role-players and the points of departure will be
discussed.
The first premise entails that, should a structured approach be followed for
post-graduate education, it will allow for the delivery of eye care in a way
that is more accessible, affordable and equitable for the broader public.
This is also supported by the research in this study and is fundamental to
Health and Higher Education Policy, for example:
o Specialised skills through the post-graduate programmes will bring help
to those who could not be helped before due to distances from tertiary
institutions and private practitioner cost factors.
o It also translates to better health promotion to what was previously only
enjoyed by those who could afford private specialised care.
e The ladder structure allows for a new focus on specific and immediate
eye care needs, supported by an appropriate educational background.
The second premise is that it is also clear from this study that, for
practitioners to engage in post-graduate studies, it should be accessible,
affordable and at an acceptable standard. Elements that will make this
possible are, for example:
398
o Flexible modules as participants in post-graduate studies will need to
be accommodated in part-time studies.
o Close to home or local community-based activities, which will be more
convenient and reduce costs.
o Part self-study, part lectured/contact sessions in order to meet the
findings in this study.
o Recognised by the Professional Board for Optometry, SAQA and
internationally.
o Increased scope parameters which offer increased options in skills and
patient care.
e Post-graduate studies which have CPO links.
o Grow the reach of the profession by extending services to more
people.
In the third place it should be noted that, for the proposed post-graduate
studies in optometry education to be successful, the standard of eye care
should be lifted.
This can, for example, be achieved via:
o The enhanced skills and knowledge which allow more comprehensive
eye examinations and insight into ocular disease, systemic disease
states and treatment modalities.
o The relatively better demographics of the profession that bring
advanced care to a larger population.
e Clinical rotations that allow for interdisciplinary teamwork to develop
and promote the cascade from primary to secondary to tertiary care
and vice versa more efficiently and effectively.
In the fourth place, for post-graduate optometry to be successful, it needs
to uplift the status of the profession and allow for further vertical
development, for example via:
399
o The recognition of advanced post-graduate skills in a specific field.
o The growth of meaningful research in the field of eye care.
El The freedom to choose a recognised speciality area.
o Internationally equitable standards of post-graduate studies.
o The establishment of a secure public sector career path.
In the fifth place, successful post-graduate studies will be measured in
their ability to build faculty capacity in order to perpetuate the continued
growth in research, curriculum review and quality assurance, for example
via:
o Relevant and tailor-made post-graduate courses which cover clinical
skills, professional knowledge, research skills and pedagogical skills.
o The development of leaders in the field of optometry education and the
departmental management of educational, as well as clinical sites.
o The forging of national and international links in education, especially
with reference to the African continent.
o The development of resources in funding and inter-governmental
agreements to educate in and for Africa.
8.3 RECOMMENDATIONS
This section will deal with the recommendations which the researcher
wishes to make. The first aspect which will be discussed, are the points of
departure which influence the recommendations as depicted in Figure 8.1 :
FIGURE 8.1: POINTS OF DEPARTURE WITH REGARD TO THE RECOMMENDATIONS ON
POST-GRADUATE EDUCATION AND TRAINING
ADDRESSING HPCSA
REGULATIONS ACCESSIBILITY
ADDRESSING ~
MANAGEMENT o
SKILLS o
POINTS OF DEPARTURE
ADDRESSING
RESEARCH
PROFESSIONAL
DEVELOPMENT
ADDRESSING HIGHER
EDUCATION AND
HEALTH POLICIES
401
8.3.1 Points of departure
For the recommendations in this study to be effectively implemented, the
following elements are assumed to be in place, or - if not in place - they
should be put in place:
e Post-graduate programmes must be accessible to optometrists by:
recognising prior learning;
structuring that promotes a symbiotic relationship between
CPD and formal post-graduate programmes;
structuring that is modular and part-time based; and
scheduling that is convenient in timing and distance.
o Post-graduate programmes must be affordable by:
after hours scheduling where possible;
being offered partially on the Internet and at as many sites as
possible; and
making use of local educators where possible.
(il Post-graduate programmes must provide for:
personal development opportunities;
elective modules and research opportunities;
professional development;
a vertical career path with horizontal exits; and
recognition of advanced skills or specialities.
(Ij Post-graduate programmes must address the public need by:
offering knowledge and skills that address current public
need;
- offering knowledge and skills that a broader population will
benefit from and, by implication, will be more affordable than
what is currently available;
~-----------------------------------------------------------------------------
402
offering knowledge, skills and research which will result in an
improvement of the current standard of care.
o Post-graduate programmes must address Health and Higher Education
Policy by:
respecting the principles of the Primary and District Health
Care Policy;
respecting the principles of the NQF, the objectives of SAQA
and - besides career outcomes - critical outcomes as well.
e Post-graduate programmes must promote specific and elective
research by:
providing optometrists with fundamental as well as advanced
research skills;
providing study leaders, promoters and examiners at the
appropriate level;
providing technology and scholarships where needed;
providing guidance as to the most appropriate research in
the field of eye care;
providing the right atmosphere for research and recognising
the efforts and achievements of optometrists.
o Post-graduate programmes must offer managerial skills by:
offering fundamental and advanced practice, departmental,
financial, human resource and corporate management skills
where appropriate.
G Post-graduate programmes must take cognisance of the HPCSA
regulations by:
involving the Professional Board in planning, setting of
standards, structuring and quality assurance of these
programmes;
403
informing the Professional Board where regulatory changes
will be required; and
ensuring that the code of ethics will be respected during and
after post-graduate training.
The next section will deal with the role-players who influence
recommendations regarding optometric education and training. Figure 8.2
provides a schematic presentation in this regard:
FIGURE 8.2: ROLE-PLAYERS WHO INFLUENCE RECOMMENDATIONS WITH REGARD TO
OPTOMETRIC EDUCATION AND TRAINING
~
STATE o
~
• Education and
training
• Service
delivery
• Eye care
policy
PROFESSIONAL
BOARD
Regulation
ASSOCIATIONS Quality assurance
INDUSTRY AND INDIVIDUAL Career outcomes
OPTOMETRISTS Standards-setting
• Funding
Research Sustainable
• Recognition career
Marketing development
Public relations
405
8.3.2 Role-players
For post-graduate programmes to be successful, the following role-players
need to be recognised and involved where possible:
Students by:
o joint planning sessions with specific reference to a sustainable and
viable career;
o communicating the development opportunities within a vertical
career path; and
o ensuring competency at each exit level.
Providers of education and training by:
e developing faculty capacity in the post-graduate academic, clinical
and research spheres;
<il recognising limitations; and
o forging links nationally and internationally.
The Professional Board by:
e communicating effectively where regulatory change is needed;
o motivating speciality level registration;
o assisting in developing quality assurance structures;
o offering career outcomes, clinical guidelines and standards,
performance criteria and indicators;
o upholding the code of ethics; and
f) developing and maintaining its role as the ETQA for the profession.
The professional associations and individual optometrists by:
Q) planning a sustainable and viable career path; and
El communicating benefits to the profession and the public by
assisting with the publicising and recognition of broader and/or
speciality skills and knowledge.
The Optical and Pharmaceutical Industry by:
406
o forging working relationships with the profession towards a clear
goal;
o being offered entry into new markets;
o offering scholarships where deserved;
o promoting research opportunities; and
o promoting joint evaluation of new technology, materials and
pharmaceutical agents.
The public by:
o accommodating their expectations in care and cost;
o promoting health and eye care to them;
o communicating broader skills and improved standards of care;
e dispelling myths and preventing blindness; and
e respecting their rights.
The State by:
o establishing new education and training opportunities;
e helping with the implementation of the Prevention of Blindness
Policy and being party to its success;
(!) ensuring the effective implementation of community-based
education and training;
o establishing a network of clinical sites that will articulate with
community service;
e playing a role in the multiskilling of the eye team (including
community workers);
o helping in the improvement of standards of care and service
delivery;
® playing a role in the supply of corrective and low vision devices;
e playing a role in rehabilitation;
Cl) developing the public sector career path for optometrists;
Cl) providing management of public sector eye care structures;
407
o assisting in problem-solving by directing and implementing relevant
research;
o playing a role in correcting the skewed demographics in an
objective and responsible manner; and
o entrenching the role of the profession as a public utility within the
primary health care policy.
Other professions in eye care such as:
Nurses by:
o sharing modules during training;
o assisting in their efforts of screening and health promotion;
o offering training in advanced skills where no optometrist are
available; and
e offering training of community workers.
Medical Officers by:
o playing a gatekeeper role with them in Eye Departments;
o allowing them the time to acquire certain surgical skills to alleviate
the backlog; and
Q sharing relevant modules in programmes.
Ophthalmologists by:
~ offering public sector refractive services which can be taken over by
B. degreed optometrists or trained nurses where required;
e performing a. gatekeeper role as a post-graduate and later an
undergraduate function;
El alleviating fears of loss of income by highlighting the needs of the
public and respecting skill levels;
e assisting in pre- and post operative care;
& assisting in the management of common ocular disease;
408
o managing the non-surgical option in keratoconus;
o playing a major role in the management, education and follow-up of
non-surgical glaucoma patients as well as co-manage surgical
cases in glaucoma;
o taking part in collaborative research in the field of eye care;
o paving the way for effective and ethical private sector group
practice;
o taking over the managerial functions of Ophthalmology
Departments where needed;
o creating time for surgeons to catch up with the surgery backlog; and
o playing a part in restoring public confidence in the public sector.
SAQA by:
o seeking registration for post-graduate programmes;
e upholding the principles of the NQF; and
o respecting and achieving the critical and career outcomes.
The CHE by:
o respecting its ETQA memorandum with the Professional Board; and
e tendering and implementing own quality assurance structures.
The next section will deal with the recommendations concerning post-
graduate optometric education and training. Figure 8.3 provides a
schematic presentation in this regard:
409
FIGURE 8.3 A SCHEMATIC ILLUSTRATION OF THE RECOMMENDATIONS
WITH REGARD TO POST-GRADUATE OPTOMETRIC EDUCATION AND
TRAINING
RECOMMENDATIONS ON POST-GRADUATE
OPTOMETRIC EDUCATION AND TRAINING
• RECOMMENDATIONS CONCERNING THE
PROGRAMME
- Curriculum design, content and organisation
- Teaching, training, learning and assessment
- Student progression and achievements
- Student support, development and guidance
• RECOMMENDATIONS CONCERNING THE
PROVIDER
- Aim, purpose and outcomes
- Student and staff resources
- Staff development and training
- Human and physical resources
- Governance and organisation
- Quality assurance and enhancement
RECOMMENDATIONS ON RECOMMENDATIONS ON
CLINICAL COMPETENCE CONTINUING
PROFESSIONAL
• BASED ON PUBLIC NEEDS DEVELOPMENT
• Clinical responsibilities • RECOMMENDATIONS
• Patient history CONCERNING THE:
• Patient examination
• Diagnosis __ ~. CPD content and design of
• Patient management programmes;
• Recording of clinical data • logistics of CPD
• Etc. • marketing of CPD
• etc.
410
8.3.3 Recommendations with regard to post-graduate optometric
education and training
The following recommendations are made with regard to post-graduate
education and training programmes to be delivered in/by South African
Optometry Schools:
8.3.3.1 Curriculum design, content and organisation
o The post-graduate optometry programme must satisfy the standards of
the NQF level at which the programme is registered.
e The duration of the post-graduate optometry programme must be at
least two years as recommended by the respondents/the researcher/
the HPCSA. The post-graduate programme must give recognition to
post-graduate/CPD studies/activities.
o The notional hours for the post-graduate optometry programme and
concomitant credits must be on a par with what is reasonably expected
of similar programmes in other Optometry Schools.
o That the Optometry School/Department, through its curriculum
responds to demands due to changing demographics, cultural contexts
and the health needs of society.
a That the content and sequencing of the curriculum components (core
curriculum and electives) are described clearly.
IJ That the sequencing of the curriculum components must promote
horizontal and vertical integration of content as well as the integration
of basic and clinical disciplines.
411
o That the curriculum is designed to provide professional post-graduate
education to prepare (and foster) independent, unsupervised practice
and to hone specific clinical skills and competencies.
o That the curriculum must include elective options to provide
opportunities for students to pursue individual academic/clinical
research interests.
o That the curriculum must include opportunities for students to develop
critical thinking skills, scientific thinking and research skills - the
curriculum must prepare students to be lifelong learners.
o The curriculum must be designed to prepare students to have a sound
knowledge and understanding of health (eye) care, the promotion
thereof and the prevention and management of eye disease.
o The curriculum must be designed to deliver post-graduate students
who are proficient in advanced clinical skills, including contact lenses,
treatment and management of ocular disease, vision therapy/sport
vision and paediatrics; interpret the findings, prevent eye disease and
promote health. Professional reasoning and problem-solving as part of
clinical practice must form an integral part of the curriculum.
e Interdisciplinary co-operation between optometry and other health care
professions, as well as between health care and the social welfare
professions must be encouraged in teaching, training and research to
the advantage of the patient.
I) The curriculum must be based on and emphasise ethical aspects.
o The curriculum must be designed to deliver a post-graduate student
who has the appropriate attitudes and behaviour to ensure quality
412
health care, including a commitment with regard to the well-being of the
community, recognition of the importance of primary health care and a
community-orientated approach to health care.
o The programme should develop post-graduates with an attitude to
carry out their responsibility towards patients, colleagues, the broad
public (including the desire to serve humanity, respect for human
rights, recognition of ethical values, a community and primary health
care orientation) and a willingness to adapt to local circumstances and
changing situations.
o The curriculum must be designed to ensure that the students are
sensitive to and have the acquired necessary knowledge and
understanding to be aware of the health needs of the country.
El The curriculum must ensure standards in optometry education with a
view to produce safe practitioners.
o Clear statements on RPL and flexibility between post-graduates and
CPO must be made.
8.3.3.2 Teaching, training, learning and assessment
Q The strategies for teaching, training, learning and assessment
articulate clearly with the aims, objectives and outcomes of the
programme.
o The teaching, training, learning and assessment activities must be
appropriate in terms of the intended learning outcomes, in particular
with regard to the development and assessment of knowledge and
understanding, generic skills, cognitive skills, and specific
practical/clinical skills.
413
o Teaching and learning systems must be grounded in modern
educational theory and the ranges of available technological aids must
be used optimally. Innovative, relevant and situationally applicable
teaching and learning strategies must be employed.
o Content development, as well as the development of teaching, training,
learning and assessment strategies, must be based on and clearly
related to stated outcomes.
o Students must accept responsibility for their own learning: the focus
must be on active study and involvement in the educational process
rather than passive learning. Students must be prepared to become
lifelong learners.
e Self-activity, group work and co-operation in teams must be
emphasised. The use of information technology must be promoted.
o Clinical skills must be developed by using skills laboratories/units,
simulated patients, models for practical procedures, and patients.
o Clinical skills, including skills in patient care, must be acquired under
supervision and assessed thoroughly.
e Clinical training must include ocular trauma, ocular disease, diagnosis
and management, sport vision, low vision, co-management and contact
lenses (primary health care; community-based training; management of
health care in hospitals, private practices and rural practices/clinics).
I:) Learning outcomes must be stated for all parts of the post-graduate
programme and must provide direct guidance for assessment.
Assessments must be consistent with these outcomes and the
assessments must be valid and reliable.
414
o Required outcomes and standards of achievement must be
communicated widely through the programme materials, policies,
publications and other communications.
o The methods used for assessment must be defined and described (that
is, the balance between formative and summative assessments; the
number of examinations and tests; the nature of the examinations and
tests; the balance between oral and written and other types of
examinations and tests; and the nature of clinical testing) and the
criteria for passing levels must have been clearly stated.
E> The Optometry School/Department must ensure the validity and
reliability of the assessment methods by making use of moderators and
external examiners.
8.3.3.3 Student progression and achievement
o Processes must be in place to ensure that students meet the stated
outcomes and satisfy the set standards for achievement.
E> Regular evaluations must take place and pass rates, drop-out and
failure rates must be analysed and the results must be used to improve
retention rates, learning success and the standards of achievement.
o The rates and trends in student progression must be satisfactory at
each stage (end of module/term/year) of the programme and also on
completion of the programme.
o The Optometry School/Department must do follow-up studies on
student achievement, including progression to further study, and
provide evidence of student achievement from external examiners'
415
reports, reports to and from the regulatory authority,
employers/professional practitioners, as well as by means of data
collection and meetings with former students/colleagues.
8.3.3.4 Student support, development and guidance
o The Optometry School/Department must have structures in place for
academic support, development, guidance and counselling.
o The Optometry School/Department must have support services
available for special needs of students (physical, mental, financial,
social, welfare needs).
o The Optometry School/Department must provide students with the
necessary training facilities and amenities that increase effectiveness
of studies.
o The Optometry School/Department must have a policy on health and
exposure to infections and environmental hazards/disease.
Q The Optometry School/Department must have and follow clear
procedures to receive and deal with students' complaints and
grievances and must be able to resolve these appropriately.
8.3.3.5 Aim, purpose and outcomes
o The Optometry School/Department must have a clearly defined
mission and objectives, stating its aim and purpose, and the overall
outcomes of the post-graduate optometry education on the training
programme it offers.
o The Optometry School/Department must regularly review its mission
and objectives and the stated outcomes of its post-graduate
416
programme in consultation with its major stakeholders and the
regulatory authority, and with consideration of needs, demands and
trends in health sciences and higher education in South Africa and the
rest of the world.
o The Optometry School/Department must submit its post-graduate
programme for approval to SAQA for the registration of the
programme.
o The Optometry School/Department must be successful in reaching its
stated aim and in achieving the set of outcomes of the programme as
submitted to and approved by SAQA for registration of the programme.
8.3.3.6 Student and staff resources
o The Optometry School/Department must have a clear recruitment and
admission policy document, explicitly stating the selection criteria for
the programme at undergraduate and post-graduate level.
o The Optometry School/Department must define the size of the student
intake for post-graduate studies, related to the capacity of the School in
terms of resources and facilities; and in accordance-with national health
authority expectations and the needs of the community.
o Members of the academic staff must have the capability and continued
commitment to be effective educators and trainers, recognising that
effective teaching requires knowledge of the discipline, as well as the
necessary clinical skills and competencies.
e The Optometry School/Department must have a policy regarding the
student:staff ratio in each of the modules in the programme (science
disciplines as well as clinical and research fields).
417
8.3.3.7 Staff development and training
o The Optometry School/Department must establish effectiveness-
related standards of performance for all staff, and regularly evaluate
their overall performance.
G Academic staff members must have a commitment to continuing
professional and academic development and the Optometry
School/Department should make available opportunities for the
development of their educational knowledge and skills.
8.3.3.8 Human and physical resources
o The Optometry School/Department must provide an environment which
is conducive to teaching, training and learning, where students and
staff members work together in teaching, learning, research and health
care services, and where new knowledge is generated.
o The academic staff of the Optometry School/Department must be an
expert professional body consisting of competent, committed
individuals who are academically prepared and qualified, and who
accept responsibility for maintaining the highest level of professional
excellence.
G The Optometry School/Department must be assured of the use of
buildings and equipment which are qualitatively and quantitatively
adequate to provide an environment conducive to high productivity of
students and staff.
e The Optometry School/Department must have adequate and
appropriate resources to provide clinical instruction. These must
include adequate numbers and diversity of patients, as well as
sufficient facilities for clinical training in hospitals, clinics, primary care
418
settings, private practices and health care centres in the communities,
where the full spectrum of medical care is provided. Facilities to train
students according to a community-based approach must be available.
o Optometric equipment and supplies selected must represent the grade
and type used for good optometric practice. Proper equipment and
supplies should support the instruction and training programme in such
a manner that clinical and lifelong learning skills can be developed.
8.3.3.9 Governance and organisation
o The Head of the Optometry School/Department must be qualified by
education and experience to provide leadership in optometric education
and post-graduate education per se, in scholarly activities and
research, in care of patients, and in the general management of the
School.
o The Head of the Optometry School/Department must be assisted in
his/her leadership and management tasks by staff as may be required
for administration, undergraduate and post-graduate education and
training, student and staff affairs, research, business and planning,
marketing and public relations, and relationships with the university and
authorities in areas where clinical training takes place.
(9 Staff and students must be involved in decisions concerning
admissions, promotions, curriculum design teaching and training
administration and organisation, in addition to other related matters by
means of committee structures.
o The Optometry School/Department must have structures in place to
manage organisational processes.
419
o The Optometry School/Department must have constructive
relationships and interactions with the health and health-related sectors
of society and government and allied health professions.
o The Optometry School/Department must ensure development of the
organisational structures and management principles in order to cope
with the changing circumstances and needs of the Optometry
School/Department, government and society, accommodating the
interests of different groups of stakeholders.
c The Optometry School/Department must have a clear statement on the
leadership and management necessary to govern post-graduate
education and training.
8.3.3.10 Quality assurance and enhancement
o The Optometry School/Department must have a programme/process to
assure quality.
e The Optometry School/Department must have mechanisms to identify
strengths and weaknesses, and institute processes to enhance
strengths and address weaknesses.
o Quality assurance measures must include the governance and
administration of the School/Department, the academic staff, the
students, and teaching and training programmes.
e Relevant stakeholders (e.g. professional boards and associations,
community and private bodies, government agencies) must have
access to the results of programme evaluations and assessments of
education and training in the School/Department.
420
o Quality assurance by means of self-evaluation must be an ongoing
process.
o Self-study and external reviews (HPCSA accreditation review) must be
followed by developmental actions with a view to improving the
education and training of post-graduate students on an ongoing basis.
Plans for the future enhancement of the activities of the School must be
devised and made available.
8.3.4 Recommendations with regard to contlnulng professional
development (ePD)
In this section recommendations with regard to continuing
professional development (CPO) will be made.
8.3.4.~ Recommendations concerning the CPD content and
design of programmes
o Publications used for CPO purposes must be interesting, relevant and
have a user-friendly self-assessment structure.
o A practitioner feedback system, evaluating all aspects of the CPO
activity, must be part of all activity engaged in.
o All CPO activities should have a clear goal in mind and this goal should
be relevant, articulate with other CPO activities and be communicated
clearly to practitioners. It must also provide an indication of benefits vs.
costs.
e CPO should constantly measure the needs of the practitioners and the
public in order to remain relevant and current.
e Congresses should, as far as possible, integrate with other categories
of CPO in order to respect and maximise the "golden thread" of
knowledge and skills acquisition within a paradigm of lifelong learning.
421
e CPO should provide the option that it is formal enough to be translated
into "currency" or "loyalty points", which may be recognised towards
higher qualifications.
o Besides its continuing education role, CPO should also play a re-
skilling role and thus focus on clinical training in this context.
o CPO should be mandatory and maintain professional competence.
Q CPO should be an independent third phase of education, geared to the
renewal, maintenance, enhancement and facilitation of knowledge and
skills.
o A primary purpose of CPO must be for recertification and
reaccreditation in order to keep professional registration.
o CPO should be aimed at behavioural change where needed as well as
improved clinical performance and patient outcomes.
e CPO content must transfer the most recent, practically-orientated
knowledge, skills and attitudes.
o The most effective, time-effective instruction methods, which are
educationally suitable for adult learners, must be applied in CPO.
o Training in CPO must be provided by teams with different professional
backgrounds.
ti) Educational input in the planning, preparation and presentation of CPO
is imperative.
o CPO should recognise that adults need more practical training to
absorb new concepts.
o CPO design should recognise that the relevance of a programme is
determined by the factors, namely the extent to which there is a match
or a mismatch between the content of the programme; the aims and
objectives of CPO in the area under consideration; and the deficiencies
in the learner's knowledge or competence.
e When planning appropriate CPO programmes, three problem areas
should receive attention, namely the identification of learning needs;
the prioritisation of those needs; and matching prioritised needs to
learning opportunities and activities.
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o Relevance of GPO programmes can be accentuated by presenting the
subject-matter in a context with which the learner can identify.
o In individualisation of GPO programmes, variations in individuals needs
must be considered.
o Factors which will enhance individualisation in GPO are for example:
Smaller groups.
Page lay-out designs.
Feedback and self-assessment.
A choice between a problem-based, a problem-oriented or an
information-oriented approach.
Short individual modules vs. a series of modules.
Multidisciplinary programmes.
o Self-assessment should, for example, be used as:
a diagnostic test;
a prerequisite for access;
an indicator that learners have mastered the material.
o Providers of GPO should remember that GPO may be:
informal, ongoing habitual activities directed at the maintenance of
competence;
semi-structured learning experiences which have their basis in
immediate patient concerns;
formal, intentional, planned activities.
o GPO programmes must be interesting in order to attract the participant
and to hold the attention via:
Presentation.
Visuals and colour.
Active involvement.
Admitting speculation.
e Ultimately GPO programmes must be systematic in that they must be
planned programmes of post-graduate education which are designed
to advance significantly the optometric graduates' preparation as
providers of patient care services.
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8.3.4.2 Recommendations concerning the logistics of CPD
o Besides clear communication and a relevant and clinical focus, CPD
logistics should respect the time and distance out of practice in every
activity offered.
o CPD opportunities must be available in the right place, at the right time
and at the right pace.
8.3.4.3 Recommendations concerning the marketing of CPD
o Dissemination of information regarding CPD activities is vital and must
be clear, relevant and communicated via different media and on
several occasions for any particular activity.
e All the benefits of CPD, including financial where applicable, should be
explained and marketed with a particular activity.
o During the marketing and delivery of CPD, the principle of matching the
provider's capabilities with the expectations of the practitioner, should
always be adhered to.
8.3.5 Recommendations with regard to clinical competence
For any post-graduate programme to be successful, it needs the sound
underpinning of an adequate undergraduate programme. For that reason
the professional/career outcomes for both under- and post-graduate South
African qualifications will be outlined. This is done in order to highlight the
structured approach within a vertical orientation and the articulation of the
career path.
It is also important to keep all competencies in a single framework so that
educators may adjust the outcomes of the under- and post-graduate exits
as the needs of the public, the profession and education itself change.
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The recommendations will focus on clinical competencies that will form the
basis for the most appropriate standard of care that the South African
public deserve. Recommended outcomes specific to the post-graduate
programme will be reflected in italics and in cosour and are provided in
addition to the undergraduate generic competencies which would be a
prerequisite to entry into the post-graduate programmes.
These recommendations are based on the literature cited, as well as on
the findings of this study. As a guideline for clinical competencies, the
two-tier-based "Optometric therapeutic competency standards 2000"
(Kiely, Chakman & Horton 2000:300-314), was used and adapted for the
South African scenario.
These recommendations on clinical competency are extensively detailed,
as it is important for the profession at this stage since a process of
Standards Generating has been embarked on by the regulatory body.
These recommendations may therefore serve as a basis for the SGB for
Optometry and Opticianry. However, outcomes for opticianry will not be
specifically indicated.
As this study also focused on the public need, the detail in the
recommendations regarding competency will help to ensure that the care
that the public receive is optimised.
It should be noted that clinical competencies could be further enhanced
during a compulsory community service year.
Professional competencies will be divided into six sections, namely:
e A: Clinical responsibilities.
e B: Patient history.
4) C: Patient examination.
9 D: Diagnosis.
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o E: Patient management.
o F: Recording of clinical data.
Within each section outcomes, performance criteria and indicators will be
recommended as a guide and by no means as a complete list.
SECTION A: CUNICAl RESPONSIBIUTIES
The recommendations are based 0111 the fact that the optometrist
shall demonstrate the followill1g outcomes. He/she must be albie to:
Outcome A-1: ED1slUlrethat optometric knowledqe, slkWs and
equipment remain current.
Performance criteria
1.1 Optometric knowledge and clinical skills can be maintained and
developed.
Indicators
Up to date in all categories of the CPD requirements of the Professional
Board.
1.2 Developments in clinical theory, optometric techniques and
technology can be evaluated for clinical practice.
Indicators
Prove that all options within the CPD regulations have been explored at an
appropriate level.
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1.3 New and existing procedures and techniques are applied and
adapted to improve patient care.
Indicators
Show variety within accredited CPO activities that were taken part in with
particular reference to self-assessment as well as peer appraisals.
1.4 Clinical experiences and discussions with colleagues are used to
improve patient care.
Indicators
Study groups, interactive seminars and workshops.
Outcome A-2: Practise without the need for supervision.
Performance criteria
2.1 Professional independence in optometric decision-making and
conduct is maintained.
Indicators
Patient records; perverse incentives or outside influences do not
compromise patient care.
2.2 Possible consequences of actions and advice are considered and
responsibility for one's own actions is accepted.
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Indicators
Errors acknowledged; patient complaints addressed in a responsible and
co-operative manner; professional indemnity insurance.
Informing professional indemnity insurer of cases which are
potentially litigious.
2.3 Advice is sought from other optometrists, health and other
professionals when a further opinion is required.
Indicators
Reports, referrals, record-keeping, possessing a list of suitable
professionals.
Shows understanding of the role of the post-graduate speciality field,
and collaborates with other specialists and pharmacists when
necessary.
Outcome A-3: Act in accordance with the ethical rules of the HPCSA
and the profession.
Performance criteria
3.1 Optometric services provided are necessary for the patient or are
initiated by the patient.
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Indicators
Clinically necessary follow-up visits are recommended and provided;
recommendations for additional visits can be clinically justified; record-
keeping indicates advice to the patient.
3.2 Patient interests are held ahead of self-interest.
Indicators
Only necessary visits, optical and other appliances are recommended to
the patient.
Only necessary medications, procedures and other treatments in the
post-graduate speciality field are recommended and/or administered
to the patient.
3.3 Advantage (in a physical, emotional or other way) is not taken of the
relationship with the patient.
Indicators
The dignity and rights of the patient are respected.
Outcome A-4: Provide advice and information to patients and others.
Performance criteria
4.1 Information is clearly communicated to patients, those who care for
the patient, staff, colleagues and other professionals.
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Indicators
Itemised accounts, referral letters, reports, written and oral instructions
and information: interpreters, opportunity for the patient to ask questions;
patient records; information to allow patients to give informed consent
regarding their management; sensitivity shown to different cultures.
4.2 Liaison with other professionals is maintained.
Indicators
When necessary local practitioners in appropriate allied and other fields
are known and contacted to arrange for referral. Referral letters, reports,
replies.
4.3 Significant or unusual clinical presentations can be recognised
and findings communicated to other practitioners involved in
the patient's care.
Indicators
Findings which have wider ramifications than solely to the patient,
e.g. to the community are investigated and reported, e.g. side effects
of drugs (Adverse Drug Reactions to the Medicines Control Council);
patient consent where appropriate. Notifiable diseases are reported.
Outcome A-5: Utilise resources from optometry and other
organisations to enhance patient care.
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Performance criteria
5.1 The various functions of, and resources available from, optometric
and other organisations are understood and utilised.
Indicators
Registration boards, professional associations, educational and research
institutions in optometry, other health authorities, schools for the blind,
other bodies such as associations and societies for the blind and
societies which are specifically dealing with the recognised skills
attained via post-graduate programmes.
Outcome A-6: Understands the principles of the planning,
establishment, development and maintenance of an optometric
practice.
Performance criteria
6.1 Awareness of the roles of other practice staff is demonstrated.
Indicators
The optometrist does not request or allow staff to perform duties outside
their competence.
Training of practice staff to recognise patients requiring immediate
attention.
6.2 Maintenance of equipment in a safe, accurate, working state is
ensured.
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Indicators
Calibration, cleaning, new globes, regular maintenance, repair.
6.3 Personal and general hygiene is maintained in the practice.
Indicators
Cleanliness of premises and disinfection of equipment; gloves and masks
as necessary; sterility of pharmaceuticals and other solutions (refrigeration
of pharmaceuticals as recommended by the manufacturer); hand washing.
Infection control measures required in post-graduate speciality
practice.
6.4 Patient appointments are scheduled according to the time required
for procedures.
Indicators
Appointment schedules; follow-up appointments.
6.5 Safe access by patients and staff is considered in the layout of the
practice.
Indicators
Access for children, the elderly, and disabled.
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Outcome A-7: Understand the legal obligations involved in
optometric practice.
Performance criteria
7.1 Optometric fee structures are understood.
Indicators
Medical/health insurance, fee schedules, benefits, retail price list.
7.2 Familiarity with relevant Acts and regulations can be demonstrated.
Indicators
Health Policy; Medical Aid Act, Health Professions Act, Poisons Act and
Regulations. Business legal requirements.
Pharmaceutical Schedules, Therapeutic Guidelines, MIMS Annual.
Familiarity with relevant therapeutic publications. Medicines Control
Regulations. Speciality category requirements and regulations.
7.3 Statutory and common law obligations relevant to practice are
understood.
Indicators
Registration, duty of care, informed consent, negligence, safe practice
environment, occupational health and responsibilities.
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Outcome A-8: Provide for the care of patients with special needs.
Performance criteria
8.1 Patients who cannot afford private care are or have no medical aid
cover due to high costs are advised of the services to which they
are entitled and/or subsidised eye care programmes and these
services are made available.
Indicators
Referral system to state clinic or hospitals where services are available, In-
practice subsidised services.
8.2 The ability to provide domiciliary optometric care is demonstrated.
Indicators
Portable equipment; refers patient to an optometrist who can provide
domiciliary care.
Outcome A-9: Ensure emergency optometric care is available.
Performance criteria
9.1 Emergency facilities are organised for times when the optometrist is
unavailable.
Indicators
After-hours telephone number, answering machine; optometrist or
alternative can be contacted at all times.
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9.2 Emergency ocular treatment and CPR can be provided.
Indicators
The optometrist can provide emergency first-aid or organise for the patient
to receive it.
Outcome A-10: Promote issues of eye and vision care to the
community.
Performance criteria
10.1 Information on matters of visual health and welfare (including the
need for regular eye examinations), and product and treatment
developments can be provided.
Indicators
Practitioner newsletters, other professional groups; written information,
verbal.
10.2 Advice is provided on eye protection in the home and in recreational
pursuits.
Indicators
South African Industrial Safety Standards, safety lenses, radiation
protection, sunglasses, tints, occupational lens designs, lighting,
ergonomic design.
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Outcome A-11: Understand factors affecting the community's need
for optometric services.
Performance criteria
11.1 The demography and epidemiology of the community and the
patient population are understood.
Indicators
General knowledge of epidemiology of ocular and visual disorders,
demographics of patient population.
SECTION B: PATIENT HISTORY
The recommendations are based on the fact that the optometrist
shall demonstrate the following outcomes. He/she must be able to:
Outcome B-1: Communicate with the patient.
Performance criteria
1.1 Modes and methods of communication - which take into account
the physical, emotional, intellectual and cultural background of the
patient - are employed.
Indicators
Interpreter, sign language, questionnaires, written means; use of
appropriate language, vocabulary and terminology; questions rephrased to
enhance understanding; understanding is verified.
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1.2 A structured, efficient, rational and comfortable exchange of
information between the optometrist and the patient takes place.
Indicators
Greets patient, introduction and identification, listens to patient, tact,
rapport.
Outcome B-2: Make general observations of patient.
Performance criteria
2.1 Physical and behavioural characteristics of the patient are noted
and taken into account.
Indicators
Appearance, gait and general movements, mobility, balance, posture,
behaviour, speech, verbal responses.
General comfort and well-being with specific reference to the post-
graduate skills category and scope.
Outcome B-3: Obtain the case history.
Performance criteria
3.1 The reasons for the patient's visit are elicited in a structured way.
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Indicators
Actively listens to patient, notes body language, anxieties, clarifies
understanding and ambiguities, notes and understands referral,
determines patient expectations.
3.2 Information required for diagnosis and management is elicited from
the patient and/or others.
Indicators
Presenting symptoms and patient's chief complaint; other signs/symptoms;
personal and family history; behavioural patterns; visual needs
(occupational, recreational, educational, and other requirements);
medications (current and past); previous assessments and treatment by
other professionals; previous illness with ocular, visual or developmental
significance; surgical intervention with visual/ocular relevance; trauma,
accident and injury of ocular/visual significance; follow-up questions;
ongoing history throughout examination.
Identification of risk factors for certain eye conditions; duration,
severity and progression of symptoms; time of onset of condition;
type and time of injury; precipitating factors; previous instance(s) of
similar events and their management; ocular and systemic
medications (name, dosage, frequency of use, vehicle of
administration); non-prescription interventions; systemic conditions
(allergies, pregnancy, glaucoma, hypertension, diabetes, etc.);
patient contact with infectious agents or exposure to agents which
could cause an allergic reaction (e.g. make-up, pollens, workplace,
etc.). Assess likely compliance with treatment; past medical and
surgical conditions; family ocular and systemic history (including
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diabetes, glaucoma, hypertension etc.); adverse responses to the
classes of drugs which are to be used in the eye.
Outcome 8-4: Obtain and interprets patient information from other
professionals.
Performance criteria
4.1 Pertinent information from previous assessments by other
professionals is sought and interpreted (with the patient's
permission).
Indicators
Reading previous histories, contacting other professionals for information,
patient consent.
SECTION C: PATIENT EXAMINATION
The recommendations are based on the fact that the optometrist
shall demonstrate the following outcomes. He/she must be able to:
Outcome C-1: Formulate an examination plan.
Performance criteria
1.1 An examination plan based on the patient's history is designed to
obtain the information necessary for diagnosis and management.
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Indicators
Knowledge of which tests are suitable for the particular occasion and
patient, e.g. age of patient, developmental status of patient, attention of
patient. Optometrist can justify the inclusion or exclusion of any test.
1.2 Tests and procedures appropriate to the patient's condition and
abilities are selected.
Indicators
Consideration of age, intellectual ability.
Consideration of physical ability in all relevant situations falling into
the post-graduate category.
Outcome C-2: Implement examination plan.
Performance criteria
2.1 Tests and procedures which will efficiently provide the information
required for diagnosis are performed.
Indicators
Proficiency with equipment and techniques, explanations to the patient,
accurate results are obtained, informed consent.
2.2 The examination plan and procedures are progressively modified
on the basis of findings.
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Indicators
Further tests, referral for indicated assessment, alternate test procedures
are used to maximise confidence in findings.
Outcome C-3: Assess the ocular adnexae and the eye.
Performance criteria
3.1 The structure and health of the ocular adnexae and their ability to
function are assessed.
Indicators
Assessment of skin lesions, conjunctiva, lids, lashes, puncta, meibomian
glands. Screening for disease; macro-observation, slit lamp
biomicroscopy, loupe, interpupillary distance, lid eversion, photography,
diagnostic pharmaceuticals, tear dynamics.
Lacrimal glands, punctal dilation, lacrimal lavage, cannula and
syringe, forceps, use of lid retractor, disposable gloves, sterile
cotton swabs, alcohol preparations, sharps collector, sterile saline.
3.2 The structure and health of the anterior segment and its ability to
function are assessed.
Indicators
Assessment of cornea, conjunctiva, anterior chamber, anterior chamber
angle, sclera, iris, pupil. Screening for disease; vital stains, slit lamp
biomicroscopy; keratometry; keratoscopy; gonioscopy; tonometry;
photography, diagnostic pharmaceuticals, pharmacological evaluation of
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pupil abnormalities, corneal aesthesiometry, pupil reactions, tear break-up
time, exophthalmometry.
Ultrasound, pachymetry, corneal topography, anterior chamber
imaging, tear film, tear break-up time, aqueous humour, episclera,
ciliary body, anterior sclera.
3.3 The structure and health of the ocular media and their ability to
function are assessed.
Indicators
Assessment of the lens and vitreous. Screening for disease; direct and
indirect ophthalmoscopy, retinoscopy, photography, diagnostic
pharmaceuticals, slit lamp.
Ultrasound, 2D and 3D imaging.
3.4 The structure and health of the posterior segment and its ability to
function are assessed.
Indicators
Assessment of the retina, choroid, vitreous, blood vessels, macula and
fovea. Screening for disease; direct and indirect ophthalmoscopy,
retinoscopy, photography, diagnostic pharmaceuticals, slit lamp; visual
acuity tests, colour vision tests, visual field assessment, photostress test,
pupil reactions.
Auxiliary lenses for fundus viewing, optic nerve head and retinal
assessment via coherence tomography, angiography.
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3.5 The nature of the disease state is determined.
Indicators
Inflammatory, infective, immunologic, metaplastic, neoplastic,
dystrophic, degenerative, congenital, neurological, iatrogenic,
irritative and traumatic changes (wounds, abrasions, alkali burns,
thermal, cryogenic lesions). Corneal oedema and endothelial repair,
laser-induced trauma, keratoplasty, corneal neovascularisation,
corneal changes in metabolic diseases (diabetes, Vitamin A
deficiency, hypercholesterolaemia). Glaucoma (including laser-,
a-chymotrypsin- and corticosteroid-induced). Cataract, uveitis,
vitreous and retinal infections (bacterial endophthalmitis, viral
retinitis), proliferative vitreoretin opathy, retinal detachment, retinal
vascular disease (neovascularisation, retinal ischaemia, diabetic
retinopathy), retinal degenerations and dystrophies.
3.6 Microbiological tests are selected and ordered.
Indicators
Indications for microbiological investigations, cost-effectiveness,
selection of laboratory, associated paperwork with necessary details,
diagnostic needs, lack of response to initial management, collection
technique and storage (cultures, smears and scrapings), timely
collection or delivery of samples, refrigeration or freezing, sterility of
instrumentation and storage items, disposable gloves.
Outcome C-4: Assess central and peripheral sensory visual function
and the integrity of the visual pathways.
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Performance criteria
4.1 Vision and visual acuity are measured.
Indicators
Contrast sensitivity function, neutral density filter test, photo-stress test,
glare testing, optokinetic nystagmus, pinhole, line and single letter tests
and preferential looking tests, logMAR charts, letter/number charts, etc.,
monocular/binocular measurements, corrected/uncorrected measure-
ments.
4.2 Visual fields are measured.
Indicators
Amsler grid, confrontation, frequency doubling technique, kinetic and static
screening and threshold, tests for hysterical amblyopia and malingering,
etc. Monocular/binocular measurements.
Advanced threshold tests and evaluation in the ongoing
management of glaucoma.
4.3 Colour vision is assessed.
Indicators
Colour vision and discrimination tests (pseudo-isochromatic tests, hue
ordering tests), etc. Monocular measurements, flicker, colour matching.
Discrimination between acquired and congenital defects.
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4.4 Pupil function is assessed.
Indicators
Pupil reactions, symmetry, response rate, pupil cycle times, swinging
flashlight tests, pharmacological testing.
Outcome C-5: Assess refractive status.
Performance criteria
5.1 The spherical, astigmatic and presbyopic corrections are measured.
Indicators
Logical progression of objective and subjective tests, standardised acuity
charts, retinoscopy, crossed-cylinder technique, fogging, binocular
balance, near vision cards, refractometer, cycloplegia, records findings
and aided and unaided visual acuity, sphere, cylinder, axis, addition.
Outcome C-6: Assess oculomotor and binocular function.
Performance criteria
6.1 Eye alignment and the state of fixation are assessed.
Indicators
Deviation (direction, magnitude, laterality; manifest, latent; comitancy),
associated and dissociated heterophoria, nystagmus, fixation (central,
eccentric, steadiness), prism.
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6.2 The quality and range of the patient's eye movements are
determined.
Indicators
Pursuits, saccades, excursions, nine positions of gaze, limitations of gaze,
adaptive head posture, reading saccades, versions, vergences, near point
of convergence.
6.3 The status of sensory fusion is determined.
Indicators
Fusion, suppression, diplopia, stereopsis, simultaneous perception,
amblyopia, correspondence (normal, anomalous).
6.4 The adaptability of the vergence system is determined.
Indicators
Phorias, fusional vergence ranges, vergence facility, fixation disparity
(curve analysis), Sheard's criterion, Percival's criterion, associated phoria,
near point of convergence.
6.5 Placement and adaptability of accommodation are assessed.
Indicators
Accommodative lag, lead (spasm), accuracy, relative accommodation,
accommodation facility, monocular and binocular amplitudes of
accommodation.
Outcome C-7: Assess visual information processing.
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Performance criteria
7.1 Visual perceptual abilities are assessed.
Indicators
History of learning problems, awareness of developmental milestones,
visual processing, attention, visual spatial skills (laterality, directionality),
visual analysis skills, visual motor integration, reading eye movements,
assessment of handwriting, screening of reading age, screening of
language abilities.
7.2 Visual-motor integration is assessed.
Indicators
History of learning problems, awareness of developmental milestones,
visual processing, attention, visual spatial skills (laterality, directionality),
visual analysis skills, visual motor integration, reading eye movements,
assessment of handwriting, screening of reading age, screening of
language abilities.
Outcome C-8: Assess the significance of signs and symptoms found
incidental to the ocular examination in relation to the patient's eye
and/or general health.
Performance criteria
8.1 Pertinent non-ocular signs and symptoms found incidentally during
the ocular examination are identified and considered.
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Indicators
General welfare of the patient; medical, acquired neurological disorders;
pharmacological, social, emotional factors; assault/abuse; disorders of
communication and articulation; short-term memory; history of spatial
confusion; reduced cognition; referral.
8.2 Ensures that significant non-ocular signs and symptoms are
investigated.
Indicators
Sphygmomanometry, carotid auscultation, blood sugar levels, referral for
the investigation of thyroid function, blood tests, histological
investigations and imaging procedures related to the findings and
suspicion of focal or systemic disease.
SECTION 0: DIAGNOSIS
The recommendations are based on the fact that the optometrist
shall demonstrate the following outcomes. He/she must be able to:
Outcome 0-1: Interpret and analyse findings to establish a diagnosis
or diagnoses.
Performance criteria
1.1 Accuracy and validity of test results and information from the case
history and the other sources are critically appraised.
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Indicators
Records, verification of results/information.
Significance of laboratory results (gram positive and negative
bacteria, drug sensitivities), alterations to prescribed therapeutics.
1.2 Test results and other information are analysed, interpreted and
integrated to establish the diagnosis or diagnoses.
Indicators
Information from sensory, refractive, binocular and perceptual tests,
information from other sources, ocular and general health, congenital,
developmental, hereditary and active and resolved pathological changes
are differentiated, information prioritised; establishment of a differential
diagnosis; indications for further tests; ordering of further tests.
SECTION E: PATIENT MANAGEMENT
The recommendations are based on the fact that the optometrist
shall demonstrate the following outcomes. He/she must be able to:
Outcome E-1: Design a management plan for each and implement the
plan agreed to with the patient.
Performance criteria
1.1 The diagnosis is presented and explained to the patient.
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Indicators
Language understood by the patient, invites and answers questions.
1.2 Consideration is given to the relative importance or urgency of the
precesenting problems and examination findings.
Indicators
Urgency of referral or review.
Prognosis of disease, time-course of disease (natural history of the
condition, likely outcomes if the condition is treated or left untreated
including unwanted side effects), effects of disease and treatment of
the patient (vision, driving, etc.), training of practice staff to
recognise patients requiring immediate attention, first aid measures
until medical treatment can be obtained if full management is beyond
the abilities of the optometrist, consideration of possible sequelae to
the eye and systemically, prophylactic medication.
1.3 Management options to address the patient's needs are explained.
Indicators
Optometrist is aware of the different management options; patients and
parents/guardians where appropriate are provided with sufficient
information about their options for management to allow them to make an
informed decision, e.g. costs, merits, time frame, risks, benefits, etc.
Aims and objectives of management in the specific field.
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1.4 A course of management is chosen with the patient, following
counselling and explanation of the likely course of the condition,
case management and prognosis.
Indicators
Patients (and parents/guardians where appropriate) are assisted to make
a decision regarding the management option to be used; advice regarding
the need for ongoing care; review, referral or discharge; reassurance;
advice on driving or operation of machinery; repercussions of
management options; optical correction: spectacles, contact lenses, low
vision aids, vision therapy, pharmacological therapy, task modification,
environmental adaptations, etc.; sequence of procedures, treatment
duration, criteria for discharge, awareness of validity and reliability of
treatment options, referral, co-management, eye protection, modification of
visual tasks, lifestyle requirements.
Glare sensitivity, ocular irritation, ability to carry on with
employment: avoidance of allergens, advice on modifying, risk
factors.
1.5 The informed consent of the patient is obtained for the initiation and
continuation of treatment.
Indicators
Explanation of presenting complaints, alternatives discussed, additional
findings, diagnosis, management options, expected duration, course,
costs, outcomes and limitations of treatment, possible complications and
risks, patient queries answered, ambiguities and misinterpretations
clarified, record advice given, written consent, verbal consent.
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1.6 Patients requiring ongoing care and review are recalled as their
clinical condition indicates and management is modified as
indicated.
Indicators
Review visits, modification of the management plan depending on the
results obtained, recall notices.
Outcome E-2: Prescribe spectacles.
Performance criteria
2.1 The suitability of spectacles as a form of correction for the patient:
the patient is assessed.
Indicators
Optical, recreational, occupational requirements.
2.2 The patient's refraction, visual requirements and other findings are
applied to determine the spectacle correction.
Indicators
Working distances, magnification requirements, prism, dispensing
requirements and limitations (vertex distances), anisometropia,
aniseikonia, vergence prescription, accommodation status, safety
spectacles, special lenses and treatments, sports requirements, incidental
optical effects, lens design, materials, tints, etc., spherical component,
cylindrical component, axis, prism, lens form and specifications; coatings,
additions, care regime, use, interpupillary distance, Fresnel lenses,
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hardening, prescription written, date, optometrist's signature, patient's
name, expiry date, vocational needs.
Outcome E-3: Prescribe contact lenses.
Performance criteria
3.1 The suitability of contact lenses as a form of correction for the
patient is assessed.
Indicators
Lifestyle, vocational needs, risk factors, vision, comfort and duration of
wear, contra-indications, ocular integrity, physiology and environment, slit
lamp, keratometer, vital staining. Referral of complicated cases to
optometrists with recognised post-graduate speciality skills.
3.2 The patient's refraction, visual requirements and other findings are
applied to determine the contact lens prescribed.
Indicators
Working distances, anisometropia, aniseikonia, vergence accommodation
status, referral of special lenses and treatments, sports requirements,
incidental optical prescription effects, lens design, materials, tints, etc., trial
lens fitting, current basic fitting techniques, equipment, keratometer,
f1uorescein, slit lamp, care, maintenance and disposal regimen.
Prescription written, date, optometrist's signature, patient's name, expiry
date.
Skills and knowledge of advanced procedures in keratoconus,
irregular corneas and reverse geometry.
453
3.3 Therapeutic and cosmetic contact lenses are recommended
and prescribed
Indicators
Aniridia; cosmetic and trauma management; occlusion; recurrent
erosion syndrome; basement membrane degeneration.
3.4 Contact lenses are correctly ordered and on receipt, parameters are
verified before the lenses are supplied to the patient.
Indicators
Material, power, base curves, diameter are checked against the
prescription or order; radiuscope, vertometer, lens type, standards.
(Parameters on packs of to the patient multiple disposable lenses are
checked against the prescription/order.)
3.5 Contact lenses are checked on the eye for physical fitting and visual
performance.
Indicators
Visual acuity, lens fit, overcorrection, centration, movement, fluorescein, lid
interactions.
3.6 The patient is instructed in matters relating to ocular health and
vision in contact lens wear, contact lens care and maintenance.
454
Indicators
Wearing time, aftercare visits, replacement schedules, insertion and
removal techniques, care and maintenance regimen, indications for lens
care and maintenance, removal, indications for seeking urgent care.
3.7 Contact lens performance, ocular health and patient adherence to
wearing and maintenance regime monitored.
Indicators
Contact lens-related conditions recognised and managed, aftercare visits,
recall/review, history.
Outcome E-4: Prescribe low vision devices.
Performance criteria
4.1 A range of low vision devices is demonstrated.
Indicators
Working distances, magnification requirements, physical ability of the
patient to manage different devices, pathology associated with low vision,
incidental optical effects, low vision aid design, special materials, tints,
lighting requirements.
4.2 Low vision devices suited to the patient's visual requirements and
functional needs are prescribed.
I
\
455
Indicators
Selection and prescription of most appropriate low vision aid (to take into
account the ability of the patient to manipulate the device and to meet the
cost), loan, trial period.
4.3 The patient is instructed in the use of the low vision device.
Indicators
Lighting, working distance.
4.4 The success of the low vision device is evaluated and monitored
and additional or alternative devices are prescribed.
Indicators
Review visits, reassessment of the vision and the efficacy of the device for
the needs of the patient. Advanced alternatives in speciality field.
4.5 The patient is informed of and, if necessary, referred to other
rehabilitative or specialised services.
Indicators
Low vision clinics, other practitioners, co-management.
Outcome E-5: Prescribe pharmacological treatment regimes.
456
Performance criteria
5.1 Selects appropriate pharmacological agents for the treatment of the
patient's condition.
Indicators
Allergies, required drug actions, drug interactions, side effects. Legal
requirements, e.g. Medicines Control Council Regulations, the Health
Professions Act.
"Tnerepeutic Guidelines": Agents within the scope of post-graduate
qualifications.
5.1.a Microbiological factors are considered in the choice of
therapeutic agent(s).
Indicators
Infections (viral, bacterial, fungal, chlamydia, other), non-infective
inflammations (allergies, other), protozoal parasites, prophylaxis,
drug sensitivities.
5.1.b Pharmacological factors are considered in the choice of
pharmaceutical agent(s).
Indicators
Ocular autonomic pharmacology (classification of the autonomic
nervous system: parasympathetic and sympathetic;
neurotransmission: adrenergic, cholinergic, etc.); mode of action of
different drug types (mydriatics, cycloplegics, miotics, anaesthetics,
457
anti-glaucoma medications, angle closure medications, anti-viral
agents, anti-bacterial agents, anti-inflammatory agents, combination
drugs, antihistamines, hypertonic agents, vasoconstrictors, ocular
lubricants).
5.1.c Systemic factors are considered in the choice of therapeutic
agentes).
Indicators
Interactions with systemic medications and other substances used
by the patient; toxic and sensitivity reactions; contraindications such
as pregnancy, paediatric use, restriction of certain drugs in sport,
side effects to consider for driving and use of machinery; allergies;
development of resistance by pathogenic organisms; effects of
systemic medications on the eye.
5.1.d Ocular factors are considered in the choice of therapeutic
agentes).
Indicators
Ocular side effects [corneal pathologies (toxicity) from topical
delivery, allergies]; interactions with ocular medications and other
substances used by the patient; significance of any effects on the
contralateral eye; ocular pharmacokinetics/pharmacodynamics of
cornea and anterior chamber (time intervals: transportation,
elimination phase, absorption, distribution phase, other factors);
ocular absorption of administered dose (precorneal fluid dynamics,
normal tear turnover, drainage of extra solution, induced lacrimation,
drug binding to tear proteins, conjunctival drug absorption,
458
resistance to corneal drug penetration, drug binding to melanin, drug
metabolism).
5.1.e Available delivery systems are considered in the choice of
therapeutic agent(s).
Indicators
Suitability of available delivery systems: aqueous solutions
(viscosity, pH, buffers), drug enhancement, suspensions,
particulates, chemical delivery systems, new ophthalmic delivery
system (NODS: presentation of drugs in a water-soluble drug-loaded
film), semisolids, therapeutic lenses, mucoadhesive dosage forms,
ocular inserts, corneal collagen shields, ocular penetration
enhancers, systemic delivery; peptide and protein therapeutics (oral,
nasal, buccal, pulmonary, ocular); role of systemic circulation:
systemic absorption from topical delivery, drug resistance.
5.1.f Drug substitution factors are considered in the choice of
therapeutic agent(s).
Indicators
Suitability of brand name products versus generic products (cost,
efficacy).
5.2 Understands and prescribes therapeutic drugs.
459
Indicators
Understands the written prescription, drug, dosage, frequency of use,
duration of treatment (course, package size), repeats, special instructions.
Agents within the undergraduate scope.
Can refer to appropriate pharmaceutical reference material;
maintains the appropriate standard of care in the prescription of
fluoroquinolones, topical steroid preparations and other medications
with a propensity for intra-ocular penetration; clarifies any issues
relating to the prescription with the pharmacist; uses South African
abbreviations; specifies whether alternative medications may be
substituted, concentration of medication, amount of solution, method
of administration; special advice for administration to children;
clarity of writing; date, name and address of patient, eye to be treated
with topical medication, numbers written in full and as digits, use of
metric system, signature, practitioner name and details, delivery
system (drops or other); security of prescription pads; most suitable
agent(s); need for prescription of more than one medication type;
cost; consideration of the effects of other drugs taken by the patient
on the eye, adnexa and visual system; non-drug treatments;
complications of drug use; influence of patient dexterity on vehicle
for administration; likely prognosis with different medications;
prophylactic medication.
5.3 Monitors and modifies the treatment regimen.
Indicators
Review interval, recognition of adverse signs and symptoms, authorises
repeat prescriptions, co-manages the alterations to drug, dose, etc.
Referral if appropriate.
460
Timing and frequency of review; criteria for the completion of
treatment; assessment of the progress of the disease; advice on
adverse signs and symptoms; alterations to drug, dose or type
(additional or alternative medications, other non-drug interventions);
monitors compliance.
5.4 Instructs/counsels patient on the correct use of the prescribed
drugs.
Indicators
Dose, frequency of use, timing of use, adverse reactions, method of
administration, interactions with drugs and other substances, storage and
disposal.
Type of medication; action to be taken by the patient if adverse
reactions occur; appropriate hygiene precautions for the patient to
observe when using medications; methods of administration (adults,
children, babies).
5.5 Patients are instructed about precautionary procedures and non-
therapeutic management.
Indicators
Possibility of infection of contralateral eye or infection of other people;
methods to prevent cross-infection of others and contamination of
medication; use of eye patches, sunglasses and analgesia; lid hygiene
procedures, lid scrubs, warm compresses and artificial tears;
discontinuation of contact lens wear and/or use of eye make-up during
treatment; back-up practitioner to consult in optometrist's absence; patient
461
lifestyle, occupation (e.g. contact with children), ability to observe hygiene
procedures; patient general health and dexterity.
Outcome E-6: Dispense optical prescriptions
Performance criteria
6.1 The prescription is interpreted and responsibility for dispensing is
accepted.
Indicators
Resolution of ambiguity in specification and usage, compliance with
international notation, present/previous prescriptions are considered, lens
forms, materials, apparent errors, validity of prescription.
6.2 The patient is assisted in selecting an appliance.
Indicators
Features, benefits; suitability, fashion/cosmesis, application of
contemporary lens forms, lens treatments, materials, safety factors,
spectacle frames selected considering anatomical, physiological and
proposed use factors, costs, ptosis crutches.
6.3 Lenses are ordered and fitted to spectacle frames in accordance
with accepted standards.
462
Indicators
Pupillometer, vertometer, callipers, lens measure, polariscope,
transmittance meter. Requirements, processes and limitations involved in
the fabrication of optical appliances are understood.
6.4 The appliance is verified against the prescription prior to delivery.
Indicators
Optical centres and segment heights, powers: sphere, cylinder, axis,
bifocal addition, base curves, prism, lens thickness, tints, coatings,
hardening, contact lens material, lens diameter. Compliance with South
African Standards.
6.5 The appliance is adjusted and delivered and the patient is
instructed in the proper use and maintenance of the appliance and
of any adaption effects which may be expected.
Indicators
Appliance is fitted and adjusted to optimise comfort and performance,
optical tools, specific lens cleaners and accessories, ptosis crutches,
prosthetics, hearing aid adaptations to frames, product information
literature, length to bend.
Outcome E-7: Manage patients requiring vision therapy.
Performance criteria
7.1 Treats patients diagnosed with accommodative, vergence,
strabismic and amblyopic conditions.
463
Indicators
Therapy sequence, time frame for treatment, discharge criteria,
spectacles, therapy activities, training equipment.
Advanced therapy regime, re-assess, make adaptions as required at
speciality level.
7.2 The patient is instructed in the use and maintenance of vision
training equipment.
Indicators
Ensures that the patient understands what is expected of him/her, written
instructions, loan of equipment and appliances.
7.3 Goals of the vision therapy programme and criteria for discharge
are set.
Indicators
Time frame, expected results, discharge criteria, cost.
7.4 Progress of the vision therapy programme is monitored.
Indicators
Review visits at appropriate intervals, appropriate tests at these visits,
recalls. Referral to another optometrist with speciality skills in the field.
464
Outcome E-8: Treat ocular disease and injury.
Performance criteria
8.1 Non-pharmacological treatment or intervention procedures are
performed.
Indicators
Epilation, lid scrubs, lacrimal lavage, irrigation, foreign body removal,
corneal debridement, ocular lubricants, saline.
Management of trauma to the eyes and adnexa (blunt trauma,
contusion, concussion, compression, abrasions, lacerations,
penetrating and perforating injuries, chemical and thermal burns);
instillation of drops (punctal occlusion); instruments and techniques
(speculum insertion, double eyelid eversion, expressing meibomian
glands, punctal plug insertion, pressure patching, ocular irrigation);
prophylactic antibiotic treatment, chalazion surgery.
8.2 Pharmacological and/or other regimens are instituted and
therapeutic devices are introduced to treat eye conditions.
Indicators
Knowledge of actions, interactions, contra-indications and side effects of
drugs; dosage; frequency; prophylactic management; ptosis crutches.
Subconjunctival injection.
8.3 The patient is instructed in the use, administration, storage and
disposal of pharmaceutical agents.
465
Indicators
Instructions to the patient, knowledge of shelf life of the medication and of
the appropriate disposal.
8.4 The effect of treatment is monitored and changes in management
are recommended.
Indicators
Pharmaceutical diagnostic agents, side effects, review using appropriate
tests, referral.
Outcome E-9: Fit ocular prosthetic.
9.1 Evaluate the state of the orbital cavity.
Indicators
Correctly evaluate the socket health, shape and size.
9.2 Fit and modify the appropriate prosthesis.
Indicators
Iris/scleral colour, direction of gaze, palpebral aperture size, comfort,
handling and cleaning regime, follow-up.
Outcome E-10: Refer the patient.
466
Performance criteria
10.1 The need for referral to other professionals for assessment and/or
treatment is recognised and discussed with the patient.
Indicators
Abilities and limitations of services provided by optometrists and other
health and allied health professionals, recognises when the patient
requires the services of another professional or another optometrist.
10.2 A suitable professional is recommended to the patient.
Indicators
Role and scope of services provided by other professionals - including
health, welfare and education services - are understood: general and
specialist medicines, ophthalmology subspecialities, psychology,
occupational therapy, audiology, speech pathology, community nursing,
education, dietetics, social workers, physiotherapy, chiropractic, low vision
services, rehabilitation services, experience, location.
10.3 Timely referral, with supporting documentation, is made to other
professionals.
Indicators
Telephone, written referral including all appropriate information, urgency,
timing of referral, specified tests and procedures arranged, relevant signs
and symptoms and reasons for referral, clarity.
467
Non-invasive first aid management; appropriate transport of the
patient.
10.4 Patients can be jointly managed with other health care practitioners.
Indicators
Co-management may be with another optometrist or a member of another
profession, e.g. occupational therapist, psychologist, ophthalmologist,
general medical practitioner; understanding of roles and responsibilities of
each practitioner.
Outcome E-11: Co-operate with ophthalmologist in the provision of
pre- and post-operative management of patients.
Performance criteria
11.1 Provides pre-operative assessment and advice.
Indicators
Indications and contra-indications for surgery; types of surgery that may be
the provision of pre- and post-performed patient's condition and
expectations taken into consideration; operative management of patients.
Discusses risks, benefits, complications and alternatives with
patient.
11.2 Provides post-surgical follow-up assessment and monitoring of
signs according to the surgeon's requirements and the procedure
undertaken.
468
Indicators
Normal course of recovery, degree of monitoring, intervention and
reporting, referral, recalls.
11.3 Provides emergency management for observed post-surgical
complications.
Indicators
Arranges referral, communication with other relevant professionals.
Pharmacological regimens.
11.4 Arranges appropriate referral for further post-operative treatment or
assessment of complications.
Indicators
Notes urgency of referral, suitable practitioner, etc.
Outcome E-12: Provide advice on vision in the workplace.
Performance criteria
12.1 Visual screenings for occupational or other purposes are provided.
Indicators
Ability to modify full examination to include only those tests necessary for
a visual screening.
469
12.2 Advice is provided on eye protection, visual standards and visual
ergonomics in the workplace.
Indicators
Industrial and environmental analysis, radiation protection, safety lenses,
tinted safety lenses, occupational lens designs, lighting, ergonomic design,
knowledge of lighting and vision standards, Occupational Health and
Safety Laws.
12.3 Individuals are counselled on the suitability of their vision for certain
occupations.
Indicators
Industry and other occupational requirements are known for colour vision,
visual acuity, spectacle powers, etc. Consultations with employee and
employer organisations take place.
12.4 Certification of an individual's visual suitability for designated
occupations or tasks is provided.
Indicators
Report written including all relevant information; vision standards for
different occupations. Certification is determined against written visual
standards of the industry or employer.
SECTION F: RECORDING OF CLINICAL DATA
The recommendations are based on the fact that the optometrist
shall demonstrate the following outcomes. He/she must be able to:
470
Outcome F-1: Ensure that data are organised in a legible, secure,
accessible, permanent and unambiguous manner.
Performance criteria
1.1 All relevant information pertaining to the patient is recorded in a
format which is understandable and usable by the optometrist and
his/her colleagues.
Indicators
Date, patient's name and address, examining practitioner, history,
procedures, clinical observations, diagnoses, results and management
strategies, standard terminology, photographic, video, written and manner
computer records, records of consultations and other contacts.
Medications, medication prescribed, timing of review, advice to the
patient, microbiological tests and results, modifications to
management, initialling and dating of corrections, signature, record
release forms, referral letters.
1.2 Patient records are kept in a readily retrievable format and are
physically secure.
Indicators
Correct labelling, cross-referencing, staff understand filing system [legible
and permanent (i.e. not pencil)] and, if electronic, backed up.
471
Outcome F-2: Maintain confidentiality of patient records.
Performance criteria
2.1 Understands the need to ensure that access to records is limited to
authorised personnel.
Indicators
Security of records, confidentiality, knowledge of relevant laws.
2.2 Information from patient records and/or obtained from patients is
released only with the consent of the patient.
Indicators
Maintains records in accordance with ethical rules and the law, patients'
names and addresses are not released for use in mailing lists. Anonymity
of the patient is maintained when confidential information regarding the
patient is discussed with others, unless those parties are engaged in the
management of the patient. Knowledge of relevant laws.
8.4 SUMMATIVIE PERSPECTIVE
In summary, the researcher is of the opinion that - if everything from the
literature (also compare UFS 2002a, 2002b), the empirical investigation
and the recommendations are taken into consideration - it would be
possible to propose the following framework as a starting point for post-
graduate education and training programmes.
The framework as proposed in Figure 8.4 serves as a point of departure to
develop a structured clinical post-graduate Master's Optometry
472
Programme. It enhances the most important processes, but it has to be
borne in mind that it does not completely take into consideration all
possible aspects. The framework can in short be illustrated as follows:
473
FIGURE 8.4: A PROPOSED FRAMEWORK WHICH CAN SERVE AS A
POINT OF DEPARTURE FOR THE DEVELOPMENT OF POST-
GRADUATE EDUCATION AND TRAINING PROGRAMMES IN
OPTOMETRY
GENERAL MANAGEMENT AND LEADERSHIP TO FIT POST -GRADUATE EDUCATION AND TRAINING
~ QUALITY ASSURANCE
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474
A. PROGRAMME MANAGEMENT
In order to ensure effective programme management, aspects like, for
example, the following will have to be in place:
o The programme must be lodged in the most appropriate programme
site.
o The programme must be researched/scrutinised and accepted by all
the relevant decision-making structures (at faculty and institutional
level).
e The programme must be accepted by all the applicable national bodies
(e.g. the DoH, the DoE, higher education, SAQA) and be registered on
the NQF.
f) The programme must be planned, developed and implemented within
the guidelines of Professional Bodies and must meet with all the further
requirements of these bodies.
e The programme must have a suitable programme director with the
necessary knowledge, skills and authority in order to manage the
programme effectively.
e The required processes and mechanisms, namely planning, design
and development, delivery and implementation, as well as monitoring
and evaluation, must be in place and must also be managed
effectively.
B. PROGRAMME PLANNING
e Situation and needs analysis
Taking into account all relevant internal and external factors which
play a role.
Determining whether a need exists to establish the programme by
determining the needs of society, the profession and role-players.
475
Decision-making with regard to the most appropriate programme
site and the assurance that the Faculty/School/Department
accepted ownership of and responsibility for the programme.
e Process management and co-ordination
The programme director must have the proven ability and the
required authority to effectively manage and co-ordinate the
process, while the responsibilities must be clearly outlined.
Processes must be in place with a view to democratic decision-
making; efficient communication channels; procedures for effective
co-operation; delivery procedures; effective working relationships
among the programme director and the heads of departments and
the module leaders/staff.
e Resource planning
Adequate and suitable human resources
Availability of lecturers and support staff.
Staff with adequate and relevant qualifications, expertise and
experience.
Securing suitable experts from across campus and also from
outside institutions and the private sector in a cost-effective
manner.
Adequate and suitable financial resources
Availability of and utilising financial resources optimaliy to market
and develop the programme.
Continuously obtaining new financial resources.
Affordability of programme for students.
Financial provision for the support structure of the programme.
Financial provision for buying in external expertise and
remuneration for work after hours.
476
Adequate and suitable physical resources
Suitable venues for contact learning and clinical teaching.
Suitable physical resources to develop learning material, apparatus,
teaching media, computer equipment and library resources.
Effective use of physical resources by students and lecturers.
oMarketing
Effective and professional marketing and advertising processes.
Relevant inputs of all role-players with regard to the process.
Responding structures to follow up enquiries.
C. PROGRAMME DESIGN AND DEVlElOPMIENT
e Relevance
Relevance of the programme with regard to the following:
Vision and mission of the institution.
Regional, national, career, human resources, professional, learners'
and international societal needs.
Lifelong learning.
Appropriate admission requirements which optimise learners'
chances of success.
The recognition of prior learning (RPL).
e Approval and registration
Familiarisation of staff with the format for submitting programmes.
Compliance with level descriptors which apply to the relevant NQF
level.
Compliance with the generic requirements which were stated for
programmes.
Competence profiling (see Appendix D) for structured clinical
Master's programme.
Approval by the relevant institutional decision-making structures.
477
Approval by the appropriate national and professional bodies.
o Coherence and content
Clear coherence among all the components of the programme.
Content should make adequate provision for the development of
academic skills.
Integration of disciplines/themes (modular format).
Programme components contribute to programme outcomes.
Cl Service delivery
The operationalisation of service delivery.
Input into financial and supply controls.
Managerial input and quality assurance.
D. PROGRAMME DELIVERY AND IMPLEMENTATION
f) leaming material
The learning material:
contributes to the successful achievement of programme outcomes;
is selected in terms of predetermined guidelines;
accommodates acceptable principles of instructional design;
promotes self-activity and open learning;
is approved/in line with professional guidelines.
e learning facilitation
Teaching/learning methods are suitable in relation to the learners
and for the mode of delivery of the programme.
Teaching/learning methods reflect the recent tendencies in the
discipline.
Teaching/learning methods are flexible and adaptable.
478
Teaching/learning methods are flexible and adaptable.
Post-graduate supervision takes place effectively.
c Learner support
Appropriate academic support and supervision of post-graduate
students.
Support mechanisms and procedures are in place and used
effectively.
Structures exist for dealing with student complaints.
e Learning assessment
Appropriate integrative assessment methods for every level of the
programme.
Assessment is based on good principles (unbiased, valid, reliable
and justifiable).
Clearly defined assessment criteria exist.
Lecturers are trained in recent assessment methods to use them
correctly.
Formative as well as summative assessment is used.
E. PROGRAMME MONITORING AND EVALUATiON
o Monitoring
The process of monitoring the implementation process is a continuous one
and is recorded on a regular basis.
e Evaluation
The evaluation and revision of the programme take place on a
continuous basis.
479
Efficient and a variety of mechanisms for the regular review of all
the components of programme management.
Inputs. from the profession/industry/national bodies with regard to
various aspects of the programme are handled responsibly.
Mechanisms are used to collect evidence showing that learners
have achieved the level of competence required.
Assessment/review and needs analyses of support structures for
learners to provide for changing professional needs.
Record-keeping in programme context for student data and
comparative research studies.
e Grading
Grading of programme effectiveness and efficiency with regard to
proposed outcomes, the required level of competence, consumer
expectations, cost-effectiveness, RPL, admission requirements,
success rates, learner satisfaction, etc.
o Revision
Making the proposed changes, supervising the whole process of
monitoring, evaluation, grading and revision.
COMMENTS
Programme management and the four processes as discussed must go
hand in hand with the necessary staff development actions. Quality
assurance (internal and external processes) and the accreditation of
programmes and institutions must be taken into account at all times.
General management and leadership to fit post-graduate education and
training as one of the issues in the optometry profession must receive
attention as soon as possible.
480
Some of the aspects which were dealt with in the framework for the
development of a structured Master's programme are also applicable for
the development of a Ph.D. Programme in Optometry. Although a
competence profile for a Ph.D. qualification (Appendix E) is included, it is
recommended that a specific framework for a Ph.D. programme be
developed in due course and that special attention will be devoted to post-
graduate supervision in such a framework.
8.5 CONCLUSION
The recommendations made in this chapter are based on the fact that
post-graduate education is essential and the reasons for this were clearly
outlined (see 8.1.1). At least six ways in which post-graduate training will
contribute to addressing existing needs were delineated (see 8.1.2), while
this kind of training in optometry and its role in post-apartheid South Africa
were also explicated in 8.1.3. Subsequently the essential non-negotiable
premises of post-graduate optometry education were defined (cf. 8.2)
before the actual recommendations were made in 8.3. The first aspect of
the recommendations to be dealt with, was the points of departure for the
recommendations in the study to be effectively implemented (see Figure
8.1; 8.3.1). This was followed by an overview of the different role-players
who need to be recognised and involved (see Figure 8.2; 8.3.2) and,
subsequently, by recommendations with regard to the different aspects of
post-graduate education and training (see Figure 8.3; 8.3.4). Hereafter
recommendations concerning CPD and the different aspects thereof were
made (cf. 8.3.4).
Finally, recommendations regarding clinical competence based on public
needs were made in 8.3.5. Professional competencies were divided into
six sections, each of which was dealt with thoroughly and in detail under
the headings "Outcomes"; "Performance criteria"; and "Indicators". The six
sections are the following:
481
o A: Clinical responsibilities.
o B: Patient history.
e C: Patient examination.
o D: Diagnosis.
o E: Patient management.
• F: Recording of clinical data.
This chapter will be followed by a summary of the conclusions and the
limitations of the study in Chapter 9.
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CHAPTIER 9
SUMMARY or CONClUS~ONS AND UM~TAT~ONS or THE
STUDY
9.1 INTRODUCTION
In this chapter the main conclusions and the limitations of the study will be
highlighted.
In addition, recommendations will be made with regard to further studies
which may be undertaken.
9.2 CONCLUSION
With reference to the above-mentioned aspects, the researcher wishes to
accentuate the following:
e The researcher is of the opinion that the overall goal and objectives of
the study were addressed and realised and that meaningful
recommendations were made.
o The recommendations made in this study are in line with the
recommendations in the documents which concern Vision 2020 - The
Right to Sight (IAPB s.a.c,d), as well as the appropriate sections of the
Education White Paper 3 (RSA DoE 1997c) and the White Paper for
Health (RSA DoH 1997). Similarly the recommendations in this study
are in synergy with the principles and guidelines in the documents
regarding the Global Vision Care Campaign (Di Stefano 2001) and The
National Prevention of Blindness Programme (RSA DoH 2000).
483
Q Recommendations on clinical competencies are in line with
international norms, in particular those in the two-tier Australian
Optometric Therapeutic Competency Standards 2000, as they conform
to a laddered approach.
o The researcher concludes that in South Africa, based on current
undergraduate programmes, there is a need for a post-graduate
programme aimed at providing education and training to learners in
order to become competent to render a professional specialist service
in optometry which will enhance the discipline through research.
o It follows from the recommendations that the articulation between the
under- and post-graduate programmes will result in an overview of the
undergraduate programme in order to train more appropriate at this
level and for the public sector in particular.
o From the recommendations, it is clear that the role and functions of the
Professional Board (cf. 4.5.1; 4.6.3) are pivotal to the success of
education at both under- and post-graduate level.
o This study makes a contribution to the way in which optometry
education should evolve; the expansion of the role of the optometrist;
and the profession's transformation into a fully-fledged health
profession.
e From this study it is clear that the transformation of the South African
education and health care systems is a reality and the changing health
scene is well established. Indirectly this situation calls for a new focus
on Public Health within the optometry teaching programmes.
o Indirectly the study also highlights the fact that current relevant clinical
post-graduate programmes lack co-ordination between providers. This
484
calls for a national strategy sponsored by the SGB of the Professional
Board.
o A further conclusion is that the current optometry educational model
fails to address the immediate public need. This study also provides at
least some of the guidelines in the design of a new model.
C!) What is furthermore clear, is that ePD (Optometry) is in its infancy in
South Africa and its success depends on whether it can influence the
delivery of services positively. However, it is of paramount importance
that, for ePD to be effective, it will need to articulate with formal
qualifications.
• It is evident from this extensive report that the research study in
question will make an extremely relevant contribution to optometry
education and training. Few references written in the South African
context are available. This study could therefore lay the foundation
and serve as a reference for a scientific point of departure, thereby
introducing a new era of development in a clinical relevant context in
the optometry profession. The educational foundation, as supported
by the literature and the empirical research, is extensive. In addition, it
will be valuable and could serve as background and a point of
departure to further develop the proposed framework in a didactic
responsible manner.
9.3 LIMITATIONS OF THE STUDY
The researcher recognises the following limitations of the study:
li) The opinion on the public need was limited, as the researcher sought
this opinion from the respondents who were optometrists. However, it
485
was done in this manner as there had been no preceding study in the
field and the costs of a study based on the broader public opinion
would have been prohibitive.
o Literature and statistical sources of the South African situation were
limited in that epidemiological data are incomplete and fragmented.
Conclusive proof of this statement is that, in the full report of the South
Africa Demographic and Health Survey 1998, there is information
about various categories, e.g. oral health and care, but there in
absolutely no information on eye care or ocular diseases (RSA DoH
1998; personal communication with Prof. L. Bates). In addition, formal
optometry clinical training stagnated during the apartheid years.
9.4 RECOMMENDATION FOR FURTHER STUDIES
For the recommendations in this study to be successfully implemented, it
is obvious that a model and a detailed curriculum plan for post-graduate
optometric education, which may form the basis of a further study, will be
required.
9.5 CONCLUSIVE REMARKS
Besides the recommendation for further study in 9.4, the researcher is of
the opinion that the profession as a whole needs a leadership and
management model that would ensure cohesion between all the facets of
the eye care field. These facets must include, but not be limited to, the
following elements:
Providers of education.
The quality assurer.
Professional associations.
The State.
486
Clinical training networks.
Service delivery structures.
Programme development at all levels.
CPD articulation with all education and training structures.
Neighbouring countries.
Such a model will provide direction and momentum to education- and
needs-driven eye care services in South Africa and will open the way for
the profession to develop to its full potential as a major player in the eye
care team.
It is therefore the explicit wish of the researcher to pursue such a model as
part of a future study.
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PERSONAL COMMUNICATION
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Von Poser, H. 2003. 22 May.
WRITTEN COMMUNICATION
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SUMMARY
Key terms: Needs and opportunities; post-graduate optometry education
and training; National Prevention of Blindness Programme; Vision 2020 -
The Right to Sight; White Papers for Education and Training and for
Health; career ladder of the optometrist; continuing professional
development; public needs and public health; Professional Board;
education and health care systems; clinical competencies.
This research study was undertaken to determine the needs and
opportunities for post-graduate education and training programmes in
optometry in post-apartheid South Africa. The rationale for this study can
be found in the stimuli which contributed to the commencement of the
study, namely the Vision 2020 - The Right to Sight Campaign of the World
Health Organisation that resulted in the resolution of the World Council of
Optometry, entitled the Global Vision Care Campaign. That the above-
mentioned are fully endorsed by the South African government, is
substantiated by policy documents such as the White Paper for the
Transformation of the Health System (RSA DoH 1997) and the National
Prevention of Blindness Programme (RSA DoH 2000). These aspects
resulted in, inter alia, the identification of issues like preventable blindness;
the importance of public health; public needs; the lack of human resource
development; demographic representation; and the lack of clear clinical
competency guidelines.
The problem statement pertains to the career ladder for optometry, already
accepted in South Africa. It opened the door for magister programmes,
allowing practitioners to develop clinical and speciality skills within the
scope and parameters set forth and regulated by the Professional Board
for Optometry and Dispensing Opticians. Despite this career ladder, there.
is a need for a programme aimed at providing education and training to
learners in order to become competent to render a professional specialist
509
service in optometry and to contribute to the enhancement of the discipline
through research. Such a programme must afford professional
optometrists the opportunity to further their education and training in terms
of the optometry career ladder, in addition to gaining certain therapeutic
privileges and speciality skills.
The research took the form of a descriptive and an exploratory survey,
comprising a literature review and an empirical investigation. The
literature study covered two aspects, namely in the first place factors
. influencing the design of optometry education and training programmes.
Features like the changing health scene; the history of the development of
the optometry profession; the transformation of the health care system in
South Africa and the eye care needs of the South African population; as
well as the transformation of education and training in South Africa were
dealt with. The second aspect covered by the literature review was a
selective review of optometry training, which dealt with optometric
education and training in South Africa; its history and the current state of
affairs; as well as legislation in South Africa. Subsequently optometric
training in the rest of Africa and the developed world was discussed in
broad terms. The empirical study entailed a questionnaire survey carried
out among South African optometry practitioners. A quantitative design
was employed, but - because the questionnaire also contained some
open-ended questions - the study had a qualitative dimension as well.
The overall goal and objectives were to make a contribution to eye care
and the prevention of blindness, as well as to make a meaningful
contribution to education and training in optometry. The aim was to
determine the needs of optometrists with regard to optometric education
and training and the opportunities existing in South Africa, measured
against the background of the needs of society (from the optometrists'
perspective). The objectives were in the first place to enhance
competence beyond graduate level, thereby better serving the eye care
510
needs of the population of South Africa in particular and, in an indirect
way, of neighbouring countries. In the second place the objective was to
make recommendations concerning the delivery of relevant and applicable
post-graduate studies at Optometry Schools/Departments. All of these
aspects were achieved by conducting the above-mentioned literature
study and by using the findings from the questionnaire.
The research design consisted of a needs analysis in the form of the
questionnaire survey used as the method to determine the needs of
optometrists in respect of post-graduate studies, as well as to obtain their
views regarding existing opportunities in this regard. The questionnaire
consisted of six categories, each containing five different types of items
(cf. 5.4.1; Appendix C).
Four rounds of questionnaires were sent out over a period of 16 weeks
and the response rate was 70.2% (cf. 5.5). After the returned
questionnaires had been analysed by the Department of Biostatistics at
the University of the Free State, it became possible for the researcher to
draw conclusions; discuss the findings; make recommendations; and
identify the limitations of the study. Each of the six categories was
followed by a summative conclusion as well as by the main findings of the
content of that specific category. The main findings as well as those
obtained via the literature study, enabled the researcher to make
recommendations on post-graduate optometric education in South Africa.
Different factors, which are listed under the following headings and
subheadings, influenced these recommendations:
e Points of departure: These include accessibility; affordability; personal
development; professional development; addressing public need;
addressing higher education and health policies; addressing research;
addressing management skills; and addressing HPCSA Regulations.
511
o Role-players: The role-players include, infer alia, students; providers;
the Professional Board; individual optometrists and associations;
industry; the public; the State; professional stakeholders; SAQA; and
the CHE.
o Post-graduate optometric education and training itself was divided into
three aspects, namely:
Recommendations concerning the programme.
Recommendations with regard to CPO.
Recommendations on clinical competence based on public
needs.
The recommendations on clinical competencies were extensively detailed,
since they may serve as a basis for the SGB of Optometry and Opticianry.
As this study also focused on the public need, the detail in the
recommendations regarding competency will help to ensure that the care
which the public receive, is optimised. In order not to confuse the
professional competencies with the categories of the questionnaire, they
were divided into six sections, namely Sections A to F. Each of these
sections was divided under the headings "Outcomes"; "Performance
criteria"; and "Indicators". Hereafter a framework as a starting point for
post-graduate education and training programmes was proposed.
In summation, the researcher is of the opinion that the overall goal and
objectives of the study were addressed and realised and that meaningful
recommendations were made. The latter are in line with legislation and
with the policy documents referred to earlier. In addition, recommendations
on clinical competencies are in line with international norms.
Conclusions are, infer alia, as follows:
G Based on current undergraduate programmes, there is a need for a
post-graduate programme aimed at providing education and training to
learners.
512
o The articulation between the under- and post-graduate programmes
will result in an overview of the undergraduate programme.
o The role and functions of the Professional Board are pivotal to the
success of education at both under-and post-graduate level.
o As the current optometry educational model fails to address the
immediate public need, this study provides at least some of the
guidelines in the design of a new model.
o It is clear that CPO (Optometry) is in its infancy in South Africa and its
success depends on whether it can influence the delivery of services
positively. It is of the utmost importance, however, that - for CPO to be
effective - it will need to articulate with formal qualifications.
The researcher realises the limitations of the study, namely in the first
place that the opinion on the public need was limited, as it was
optometrists who were the respondents to this category of the
questionnaire. In the second place, literature and statistical sources of the
South African situation were limited in that epidemiological data are
incomplete and fragmented. In addition, clinical training in optometry had
stagnated during the apartheid years.
It is recommended that this study be followed by the compilation of a
model for post-graduate education and the development of a detailed
curriculum plan, as that is essential in order for these recommendations to
be successfully implemented.
The researcher is of the opinion that the profession as a whole needs a
leadership and management model that would ensure cohesion between
all the facets of the eye care field. These facets must include, but not be
limited to, elements like the providers of education; the quality assurer;
professional associations; the State; clinical training networks; service
delivery structures; programme development at all levels; as well as CPO
articulation with all education and training structures and neighbouring
513
countries. Such a model will provide direction and momentum to
education- and needs-driven eye care services in South Africa and will
open the way for the profession to develop to its full potential.
OPSOMMING
Sleutelterme: Behoeftes en geleenthede; nagraadse optometrie-onderrig
en -opleiding; Nasionale Voorkoming van Blindheid-program (National
Prevention of Blindness Programme); Vision 2020 - The Right to Sight;
Witskrifte vir Onderwys en Opleiding en vir Gesondheid; loopbaanleer vir
die optometris; voortgesette professionele ontwikkeling; openbare
behoeftes en openbare gesondheid; Professionele Raad; onderwys en
gesondheidsorgstelsels; kliniese vaardighede.
Hierdie navorsingstudie is onderneem om die behoeftes en geleenthede
vir nagraadse onderrig- en opleidingsprogramme in optometrie in Suid-
Afrika gedurende die periode na apartheid te bepaal. Die grondrede vir
hierdie studie is geleë in die aansporing wat bygedra het tot die aanvang
van die studie, naamlik die Vision 2020 - The Right to Sight-veldtog van
die Wêreldgesondheidsorganisasie, wat die resolusie van die Wêreldraad
van Optometrie met die titel die Global Vision Care Campaign tot gevolg
gehad het. Dat bogenoemde ten volle deur die Suid-Afrikaanse regering
ondersteun word, word bewys deur beleidsdokumente soos die Witskrif vir
die Transformasie van die Gesondheidstelsel (RSA DoH 1997) en die
Nasionale Voorkoming van Blindheidprogram (RSA DoH 2000). Hierdie
aspekte het onder andere die identifikasie van vraagstukke soos
voorkombare blindheid; die belangrikheid van openbare gesondheid;
openbare behoeftes; die gebrek aan menslike hulpbronontwikkeling;
demografiese verteenwoordiging; en die gebrek aan duidelike kliniese
vaardigheidsriglyne tot gevolg gehad.
Die probleemstelling het betrekking op die loopbaanleer vir optometrie wat
alreeds in Suid-Afrika aanvaar is. Dit het die deure geopen vir
magisterprogramme en praktisyns die geleentheid gebied om kliniese en
spesialisvaardighede te ontwikkel binne die omvang en parameters wat
deur die Professionele Raad vir Optometrie en Resepterende
515
Oogkundiges (Professional Board for Optometry and Dispensing
Opticians) daargestel en gereguleer word. Ten spyte van hierdie
loopbaanleer bestaan daar In behoefte aan In program wat daarop gemik
is om onderrig en opleiding aan leerders te voorsien met die oog daarop
om In professionele spesialisdiens in optometrie te lewer en tot die
verbetering van die dissipline deur middel van navorsing by te dra. So In
program moet professionele optometriste die geleentheid bied om hul
onderrig en opleiding in terme van die loopbaanleer te bevorder, asook om
sekere terapeutiese voorregte en spesialiteitsvaardighede te verkry.
Die navorsing het die vorm van In beskrywende en In verkennende
ondersoek aangeneem wat uit In literatuuroorsig en In empiriese
ondersoek bestaan het. Die literatuuroorsig het twee aspekte gedek,
naamlik in die eerste plek faktore wat tot die ontwerp van optometrie-
onderrig en opleidingsprogramme bydra. Aspekte soos die veranderende
gesondheidsomgewing; die geskiedenis van die ontwikkeling van die
optometrieprofessie; die transformasie van die gesondheidsorgsisteem in
Suid-Afrika en die oogsorgbehoeftes van die Suid-Afrikaanse bevolking;
asook die transformasie van onderrig en opleiding in Suid-Afrika is
hanteer. Die tweede aspek van die literatuuroorsig was In selektiewe
oorsig van optometrie-onderrig, wat optometrie-onderrig en
-opleiding in Suid-Afrika hanteer het; die geskiedenis daarvan en die
huidige stand van sake; asook wetgewing in Suid-Afrika. Vervolgens is
optometrie-onderrig en -opleiding in die res van Afrika en die ontwikkelde
wêreld in breë terme bespreek. Die empiriese studie het In vraelys
ingesluit wat deur Suid-Afrikaanse optometriepraktisyns ingevul is.
In Kwantitatiewe ontwerp is gevolg, maar - omdat die vraelys ook In aantal
oop vrae bevat het - het die studie tog ook In kwalitatiewe dimensie
gehad.
Die oorhoofse doel en oogmerke was om In bydrae tot oogsorg en die
voorkoming van blindheid te lewer, asook om In betekenisvolle bydrae tot
516
onderrig en opleiding in optometrie te lewer. Die hoofdoel was om die
behoeftes van optometriste met betrekking tot optometrie-onderrig en
-opleiding - asook die geleenthede wat in Suid-Afrika bestaan - te bepaal,
gemeet teen die agtergrond van die behoeftes van die gemeenskap
(vanuit die perspektief van die optometriste). Die onderlinge oogmerke
was in die eerste plek om bekwaamheid bo die vlak van graduering te
verhoog en om sodoende die oogsorgbehoeftes van die Suid-Afrikaanse
bevolking in die besonder en, indirek, ook dié van die aangrensende lande
te dien. In die tweede plek was die oogmerk om aanbevelings te maak
rakende die onderrig van relevante en toepaslike nagraadse studies in
Optometrieskole/-clepartemente. AI hierdie aspekte is bereik deur middel
van bogenoemde literatuurstudie en deur die bevindinge van die vraelys te
gebruik.
Die navorsingsontwerp het bestaan uit 'n behoeftebepaling in die vorm van
die vraelysondersoek wat gebruik is as die metode om die behoeftes van
die optometriste ten opsigte van nagraadse studies te bepaal, asook om
hul standpunte aangaande bestaande geleenthede in hierdie verband te
verneem. Die vraelys het uit ses kategorieë bestaan, waarvan elk vyf
verskillende soorte items bevat het (vgl. 5.4.1; Aanhangsel C).
Vier rondtes vraelyste is oor 'n periode van 16 weke uitgestuur en die
responskoers was 70.2% (vgl. 5.5). Nadat die vraelyste wat terug ontvang
is deur die Departement van Biostatistiek aan die Universiteit van die
Vrystaat ontleed is, het dit vir die navorser moontlik geword om
gevolgtrekkings te maak; om die bevindinge te ontleed; om aanbevelings
te maak; en om sodoende die beperkinge van die studie te identifiseer.
Elk van die ses kategorieë is deur 'n samevattende opsomming gevolg,
asook deur die hoofbevindinge van die inhoud van daardie spesifieke
kategorie. Die hoofbevindinge, asook daardie wat deur middel van die
literatuurstudie bekom is, het die navorser in staat gestelom aanbevelings
te maak rakende nagraadse optometrie-onderrig in Suid-Afrika. Verskeie
517
faktore, wat onder die volgende hoofde en subhoofde gelys word, het
hierdie aanbevelings beïnvloed:
o Vertrekpunte: Hierdie sluit in toeganklikheid; bekostigbaarheid;
persoonlike ontwikkeling; die aanspreek van openbare behoeftes; die
aanspreek van hoëronderwys- en gesondheidsbeleide; die aanspreek
van navorsing; die aanspreek van bestuursvaardighede; en die
aanspreek van HPCSA-regulasies.
I\) Rolspelers: Die rolspelers sluit onder andere in studente;
voorsieners; die Professionele Raad; individuele optometriste en
assosiasies; industrie; die publiek; die Staat; professionele
belanghebbendes; die Suid-Afrikaanse Kwalifikasie-owerheid (SAKO)
(SAQA); en die Raad op Hoër Onderwys (RHO) (CHE).
e Nagraadse onderrig en opleiding is in drie aspekte verdeel, naamlik:
Aanbevelings rakende die program.
Aanbevelings met betrekking tot voortdurende loopbaan-
ontwikkeling.
Aanbevelings rakende kliniese bevoegdheid gebaseer op
openbare behoeftes.
Die aanbevelings rakende kliniese vaardighede is tot in die fynste
besonderhede uiteengesit, aangesien dit as In basis vir die Standaarde-
genererende Liggaam (SGL) van Optometrie en Optici (Opticianry) mag
dien. Aangesien hierdie studie ook op openbare behoeftes gefokus het,
.sal die detail in die aanbevelings betreffende bekwaamheid help om te
verseker dat die sorg wat die publiek ontvang, verhoog word. Om te
verhoed dat die professiOnelevaardighede nie met die kategorieë van die
vraelys verwar word nie, is hulle in ses seksies verdeel, naamlik Seksies A
tot F. Elk van hierdie seksies is in die afdelings "Uitkomste",
"Prestasiekriteria" en "Indikatore/Aanwysers" verdeel. Hierna is In
raamwerk as 'n vertrekpunt vir nagraadse onderrig- en
opleidingsprogramme voorgestel.
518
Opsommenderwys is die navorser van mening dat die oorhoofse doel en
onderlinge oogmerke van die studie aangespreek en verwesenlik is en dat
betekenisvolle aanbevelings gemaak is. Laasgenoemde stem ooreen met
wetgewing en met die beleidsdokumente waarna vroeër verwys is. Verder
stem aanbevelings rakende kliniese bevoegdhede met internasionale
norme ooreen.
Gevolgtrekkinge sluit onder andere die volgende in:
o Gebaseer op huidige voorgraadse programme, bestaan daar 'n
behoefte aan nagraadse programme wat gemik is op die voorsiening
van opleiding en onderrig aan leerders.
o Die artikulasie tussen die voor- en nagraadse programme sal In oorsig
van die voorgraadse programme tot gevolg hê.
o Die rolle en funksies van die Professionele Raad is deurslaggewend vir
die sukses van onderrig beide op voor- en nagraadse vlak.
o Aangesien die huidige optometrie-onderrigmodel nie daarin slaag om
in die onmiddellike behoeftes van die publiek te voorsien nie, voorsien
hierdie studie in ten minste sommige van die riglyne wat nodig is vir die
ontwerp van 'n nuwe model.
e Dit is duidelik dat VLO (Optometrie) in sy kinderskoene in Suid-Afrika is
en die sukses daarvan hang daarvan af of dit die lewering van dienste
positief kan beïnvloed. Dit is egter van deurslaggewende belang dat,
vir VLO om effektief te wees, dit met formele kwalifikasies sal moet
artikuleer.
Die navorser besef die beperkinge van die studie, naamlik in die eerste
plek dat die opinie van die openbare behoefte beperk was, aangesien dit
optometriste was wat die respondente in hierdie kategorie van die vraelys
was. In die tweede plek was literatuur en statistiese bronne vir die Suid-
Afrikaanse situasie beperk in soverre epidemiologiese gegewens
519
onvolledig en gefragmenteerd was. Verder het kliniese opleiding In
optometrie gestagneer gedurende die apartheidsperiode.
Dit word aanbeveel dat hierdie studie gevolg word deur en model vir
nagraadse studie en die ontwikkeling van engedetailleerde kurrikulumplan,
aangesien dit noodsaaklik is met die oog op die suksesvolle
implementering van hierdie aanbevelings.
Die navorser is van mening dat die professie as geheel enleierskaps- en
bestuursmodel benodig wat ensamehang en verband tussen al die fasette
van die oogsorgveld sal verseker. Hierdie fasette moet insluit - maar nie
beperk wees nie - tot elemente soos die voorsieners van onderrig; die
kwaliteitsversekeraar; professionele verenigings; die Staat; kliniese
opleidingsnetwerke; en VLO-artikulasie met alle onderrig- en
opleidingstrukture, asook met aangrensende lande. So en model sal
rigting en momentum aan onderrig- en behoeftegedrewe oogsorgdienste
in Suid-Afrika gee en sal die weg baan vir die professie om tot sy volle
potensiaal te ontwikkel.
APPENDIX A
Division of Educational Development
Faculty of Health Sciences
University of the Free State
PO Box 339 -
BLOEMFONTEIN
9300
SOUTH AFRICA
3 December 2001
Dear Sir/Madam
Questionnaire to be filled 0111 by practising optometrists with a view to
determining the needs and opportunities for post-graduate education
and training programmes for the optometry profession onpost-apartheld
South Africa
I would hereby like to kindly request you to devote some of your valuable time
to fill in the accompanying questionnaire (see Appendix C).
The opportunity for the profession of optometry to play a broader role in the
field of eye care under the new dispensation in South Africa is obvious. Any
growth in professional scope and recognition of specialised skills can only be
based on educational advancement which addresses both the needs of the
public and the profession. This questionnaire forms part of a Master's thesis
which will propose future post-graduate development in the profession and it
will undoubtedly impact on undergraduate programmes as well. Your co-
operation is therefore vital in order to determine educational direction and
development based on scientific fact. Please note that it is of cardinal
importance to obtain a high response rate to ensure the optimum reliability of
the results of this survey.
When filling in the questionnaire, please follow these instructions:
o Definitions to key concepts are provided in Appendix B. Please study
them before you attempt to fill in the questionnaire.
o Should you find the space for comment on the questionnaire inadequate,
please write your comments on the reverse side of that specific page.
o After you have completed the questionnaire, you can either return it in the
self-addressed envelope included herewith, or you can e-mail it to
gndkln@med.uovs.ac.za not later than 3 January 2002.
Responses will be treated with the utmost degree of discretion and
confidentiality. Your name or the name of your practice will not be disclosed
anywhere or in any way.
Your kind co-operation in filling in the questionnaire promptly and in as
thorough a manner as possible will be sincerely appreciated.
Kind regards
APPEND~X IS
LIST OF DEFINITIONS OF KEY CONCEPTS
1. DEFINITIONS
In order to fill in the questionnaire correctly and to the best of one's ability,
it is necessary that certain concepts which are referred to, have to be
defined and explained. This will subsequently be done.
1.1 Target population
The term "target population" has repeatedly been referred to. It is
therefore essential to understand what it entails. According to Halldorson
(1999:s.p.), it is the "[p]opulation to which we hope to generalize the
findings of a research study. In most research, the entire target population
is not accessible to the researcher".
For the purposes of this research, the target population is the practising
optometrists in South Africa.
1.2 Goai of the study
The broad definition of the term "goal" is as follows: "A goal is a direction-
setter. It is an ideal future end, condition or state related to the public
health, safety or general welfare toward which planning and planning
implementation measures are directed. A goal is a general expression of
community values and, therefore, abstract in nature" (El Dorado County
Planning Department 2002:s.p.). According to The Evaluation Center of
the Western Michigan University (2002:s.p.), it is "[a] statement of intent or
an end that a person or a group strives to attain".
For the purposes of this study, the goal is determining the needs and
opportunities for post-graduate education and training programmes for the
optometry profession in post-apartheid South Africa.
1.3 Stumbling-blocks
According to The Reader's Digest Oxford Wordfinder (Tulloch 1993: 1548),
a stumbling-block is "an obstacle or circumstance causing difficulty or
hesitation", while the Reader's Digest Wordpower Dictionary (Browne
2002:974) defines it as "an obstacle to progress".
1.4 Activities
"Activity" can be defined in various ways. Browne (2002: 18) defines it as
"the exertion of energy; vigorous action" or as "a particular occupation or
pursuit". Synonyms for this word are, interestingly enough, provided as
"pursuit", "occupation", "vocation", "work", "employment", etc. The
American Heritage Dictionary of the English Language (2000:s.p.) agrees
with the above definition and adds that it also means "An educational
process or procedure intended to stimulate learning through actual
experience". The Merriam-Webster Dictionary (s.a.:s.p.) provides the
following definition: "a process actually or potentially involving mental
function; specifically: an educational procedure designed to stimulate
learning by firsthand experience". The Committee on Family Issues, Inc.
(COFI 2000:s.p.) defines "activities" in its FRN Glossary as "Specific action
steps that are planned to accomplish an objective".
1.5 Opportunities
According to The Reader's Digest Oxford Wordfinder (Tulloch 1993: 1065)
"opportunity" means "a good chance; a favourable occasion" or "a chance
or opening offered by circumstances". The American Heritage Dictionary
of the English Language (2000:s.p.) concurs with this definition by saying
that it is "A favorable or advantageous circumstance or combination of
circumstances"; "a favorable or suitable occasion or time" or "A chance for
progress or advancement".
1.6 Needs
The Reader's Digest Oxford Wordfinder (Tulloch 1993: 1016) defines
"need" as follows: "stand in want of'; "require"; "be under the necessity or
obligation"; "a want or requirement"; "circumstances requiring some course
of action"; "necessity"; "destitution"; or "poverty". The American Heritage
Dictionary of the English Language (2000:s.p.) provides virtually the same
definition by saying that it is "A condition or situation in which something is
required or wanted" and that it is "Something required or wanted; a
requisite". Another interesting definition is that provided by Nordby
(1997:s.p.): "A word often used in such phrases as 'behavioral needs' and
'educational needs' which can only be understood when the goals are
known. A statement of needs makes sense only with an explicit or implied
'in order to"'. A definition which may be of particular value as far as this
study is concerned, is the following: "The concept that people with health
problems have health care needs. Can be defined as the ability to benefit
from health care. A specific indicator of disease may show unmet needs
which require intervention. 'Needs' always reflect prevailing value
judgements as well as the existing ability to control a particular public
health problem. Sometimes differentiated from healthcare supply and
demand for services" (Wall 1999:s.p.).
1.7 Needs assessment
In order to make a needs analysis, a needs assessment must first be
made. Some references use the two terms "needs assessment" and
"needs analysis" interchangeably, e.g. - according to the Instructional
Technology Global Resource Network (s.a.:s.p.) - it is "a systematic study
that incorporates data and opinions from varied sources in order to create,
install and evaluate educational and informational products and services.
The effort commences as a result of a 'hand-off' from performance
analysis. Also known as training needs assessment, need analysis, front
end analysis, task and subject matter analysis ... ". Other definitions
provided by the same Network read as follows: "process of gathering data
to determine if a problem exists, instructional or non-instructional" and
"identify the gaps between current results and desired/required results,
and place the needs (gaps in results) in priority order on the basis of 'What
it costs to meet the need' versus 'What it costs to ignore the need'''.
According to COFI (2000:s.p.), it is "A systematic process to assess
community needs and develop priorities. Information gathering strategies
include a review of existing data, and if more information is needed, use of
surveys, interviews, focus groups, and town meetings".
1.8 Needsanalysis
An especially apt description is that of the Electronic Resource Center
(ERC s.a.:s.p.), namely that it is "An analysis that studies the needs of a
specific group (employees, clients, managers), presents the results in a
written statement detailing those needs (such as training needs, needs for
health services, etc.) and identifies the actions required to fuifiII these
needs, for the purpose of program development and implementation".
According to the Instructional Technology Global Resource Network
(s.a.:s.p.), it is a "process performed after a need/problem has been
determined to exist, where the need is analyzed and the causes of the
need are identified, e.g. motivators, lack of skills or knowledge, lack of
equipment, etc.". Another definition provided by Instructional Technology
(2000:s.p.) reads as follows: "The primary stage of a training project where
the definition of the criteria for success takes place by analysing the
competence level of the target audience and the gap between this and the
proficiency needed".
BIBLIOGRAPHY
Browne, J. (Ed.). 2002. Reader's Digest Wordpower Dictionary. London
New York Sydney Montreal Auckland Cape Town: The Reader's Digest
Association Limited.
COFI (Committee on Family Issues, Inc.). 2000. FRN Glossary: Planning
and Evaluation terms for FRNs
<http://www.pleasantscounty.netlCOFI/glossarv.htm>. Retrieved on 5
February 2003.
El Dorado County Planning Department. 2002. General Plan (Glossary)
<http://www.co.el-dorado.ca.us/planning/genplan/glossarv.htm> .
Retrieved on 11 February 2003.
ERC (Electronic Resource Center). s.a. The Family Planning Manager's
Handbook <http://erc.msh.org/fpmhenglish/gloss/gloss6.html>. Retrieved
on 4 February 2003.
Halldorson, M.K. 1999. Glossary
<http://www.uwinnipeg.ca/-mhalldor/2102%20CD%20SupplementIglossar
y/glosst.htm>. Retrieved on 11 February 2003.
Instructional Technology. 2000. Multimedia Glossary
<http://www.uog.edu/coe/ED451/glossary.htm>. Retrieved on 4 February
2003.
Instructional Technology Global Resource Network. s.a. IT Glossary
<http://www.ittheory.com/glossary.htm>. Retrieved on 5 February 2003.
Merriam-Webster Dictionary. s.a. Available online: <http://www.m-
w.com/cgi-bin/dictionary>. Retrieved on 4 February 2003.
Nordby, S.M. 1997. A Glossary of Gifted Education
<http://members.aol.com/svennord/ed/GiftedGlossary.htm> . Retrieved on
4 February 2003.
The American Heritage Dictionary of the English Language, Fourth
Edition. 2000. Boston, Massachusetts: Houghton Mifflin Company.
The Evaluation Center, Western Michigan University. 2002. Teacher
Evaluation Kit: Glossary <http://www.wmich.edu/evalctr/ess/glossarv/glos-
e-I.htm>. Retrieved on 11 February 2003.
Tulloch, S. 1993. The Reader's Digest Oxford Wordfinder. Oxford:
Clarendon Press.
Wall, M. 1999. The Annual Report of the Director of Public Health
(Glossary)
<http://www.staffshealth.co.uklHADocs/Reports/Public%20HeaIth/glossary
.htm>. Retrieved on 4 February 2003.
APPENDIXC
NEEDS ANALYSIS
PRACTISING OPTOMETRISTS
IDE11lERMIINIINGTIHIENEEDS AND OPPOIRTUINIITIES fOR POST-
GRADUATIE EDUCATiON AND TRAiNING PROGRAMMIES fORTHIE
OPTOMETRY PROfESSION IN POST-APARTHEID SOUTH AfRICA
INSTRUCTIONS: Please devote some time to complete the following
questlonnaire all1l1pdl1ay a IPéllrt on the futare development of YOlUlr
profession.
When answering the closed! questlons, please indicate your response
!by means of an "X" in the applicable box, Responses to open
questions should Ibetyped/written in the space provided. Should you
wish to do this electronically, please replace the applicable box witlhlan
"X", and type in your responses to open questions in the spaces
provided. A questionnaire in Afrikaans is available from tlhle
researcher, should you require it.
QUESTIONNAIRE
1.2 Full address:
Postal address:
Code:
E-mail:
Province:
1.3 Racial group:
DAsian
o Black
o Coloured
o White
1.4 Gender:
o Male
o Female
2
1.5 Age:
o 20-30
o 31-40
o 41- 50
o 51-60
Formal Year obtained Name of
qualification institution
1.7 Type of practice:
o Private solo
o Private group
o State
DOther
1.8 If "Other", explain your answer.
1.9 Is your practice located in a:
a) 0 residential area?
o commercial area?
b) 0 rural area?
o city area?
1.10 If possible, would you wish to obtain a further
(higher) qualification in optometry?
DYes
o No
3
1.11 If "Yes", state the reason.
1.12 If "No", state the reason.
In your opinion, are you keeping abreast of
developments in the field of optometry
practice?
DYes
o No
2.2 If "Yes", in what manner?
2.3 Are there sufficient opportunities to keep you
informed?
OYes
o No
2.4 State the reason for your answer.
2.5 Do you experience any stumbling-blocks with
regard to your continuing professional
development (CPD)?
DYes
o No
2.6 If "Yes", please elaborate.
4
2.7 What motivating factor(s) should there be for
2.8 Do current CPD activities on offer meet your bI:\~;!~~~~~ll~[t~illl~~~~l~~llneeds?
OYes
o No
2.9 State the main reason for your answer.
2.10 How do you intend to acquire points for
professional development in order to maintain
your licence to practice?
2.11 Which of the following CPD activities would
you prefer to participate in?
o Informal activities to acquire points (e.g.
study groups, reading professional
journals).
o Formal activities that do not necessarily
lead to a formal qualification (e.g. seminars,
congresses).
o Formal activities that lead to a formal
qualification.
o All of the above.
2.12 Motivate your answer.
2.13 Would you like to specialise in a in
optometry?
OYes
o No
5
2.14 If "Yes", should formal post-graduate
qualifications form the basis of such
specialisation?
OYes
o No
2.15 Motivate your answer.
2.16 Should formal qualifications represent
expanded scope privileges which recognise
a broader skills base?
OYes
o No
2.17 Motivate your answer.
Have you investigated post-graduate
possibilities in the field of optometry in South
Africa?
DYes
o No
3.2 If the opportunity arises, would you embark on
post-graduate/post-diploma studies?
OYes
o No - (If "No", go to question 6.11)
3.3 If "Yes", state the reason for not pursuing
present.
3.4 Why would you like to pursue formal post-
graduate studies? Explain.
3.5 Should a formal post-graduate programme
meet your needs, would you like to:
o receive information?
o enrol for the programme?
6
3.6 In which area in the field of optometry would
you prefer to acquire a post-graduate
qualification? Explain.
3.7 Do you experience any inadequacies/short-falls
in your professional practice that you would like
to address? Explain.
Would you prefer:
o full-time studies?
o part-time studies?
4.2 Would you prefer:
o a modular lectured course (course work)?
o a research study?
o a combination of the two?
4.3 Would it be possible for you to do part of the
course work by means of online technology
such as the Intemet?
OYes
o No
4.4 Would it be possible for you to attend
lectures/modules on campus for a short period
of time?
OYes
o No
7
4.5 How often would you be able to attend lecturesl
modules (say a module will be a maximum of .
four days)?
o 1 x year
o 2 x year
o 3 x year
o 4x year
o 2-4 weeks continuous by year
4.6 Where would you prefer to do the practical
(clinical) sessions of the course?
4.7 Explain your answer in 4.6.
4.8 What qualification would you like to obtain?
o Certificate for short courses
o Post-graduate Diploma
o Advanced Diploma
o Master's degree
o Ph.D.
4.9 Other - Please explain.
4.10 Are you aware of any post-graduate
opportunities in South Africa?
OYes
o No
4.11 If "Yes", do these fulfil your needs?
OYes
o No
4.12 Motivate your answer in 4.11.
8
4.13 Are you aware of post-graduate programmes
available in another country?
OYes
o No
4.14 If "Yes", these fulfil your needs?
OYes
o No
4.15 Motivate your answer in 4.14.
4.16 Would you prefer that the programme which
you enrol for in South Africa, have
international recognition?
OYes
o No
you would like to follow be? (Tick all those
applicable.)
o Diagnostic agent privileges
0 Contact lenses
0 Business management skills
0 Public health
0 Therapeutic agent privileges
0 Binocular vision
0 Industrial/environmental optometry
0 Sports vision
0 Surgical co-management
0 Low vision
0 Other
9
5.2 If "Other", elaborate.
5.4 Should the programme consist mainly of:
o self-study?
o contact sessions?
o lectured sessions?
5.5 Should the programme consist of:
o practical/clinical work?
o theory?
o research?
o a combination?
5.6 Should the programme include elective
modules for enrichment in related fields?
OYes
o No
·5.7 Should the programme be aimed at broadening
your scope of practice?
OYes
o No
5.8 Motivate your answer.
a) accessibility;
b) affordability;
c) equity.
10
6.2 Give your cetaaeo opinion on the public's
current needs regarding eye care with specific
reference to the management of ocular disease
in the following: 1!lillll;lli~lllii[tl;!iilii!i!iii!Rill
a) diabetes;
b) retinopathy;
c) glaucoma;
d) cataract;
e) impaired (Iow) vision.
6.3 What role do you think can the optometrist play
in the improvement of the standard of eye
care?
6.4 What role do you think can post-graduate
education play in the improvement in eye care
delivery and standards?
6.5 Do you see yourself as part of the community
you serve?
OYes
o No
Motivate your answer.
6.6 What role should the State play in the provision
of eye care?
6.7 How many optometrists do you think the State
should employ for the whole country?
Il
6.8 Motivate your answer.
6.9 Do you believe that the profession should
develop a Private/Public Sector Partnership to
assist the State in addressing the eye care
needs of South Africa?
DYes
o No
6.10 Motivate your answer.
6.11 Compulsory community service for optometry
graduates is earmarked to be possibly
implemented in 2007. Is that a good idea?
DYes
o No
6.12 Explain your answer.
6.13 Should community service be implemented
earlier?
DYes
o No
6.14 Is a National Health Insurance an option for
South Africa?
OYes
o No
6.15 Motivate your answer.
12
6.16 In your opinion, will post-graduate education
and training have a positive impact on
addressing the needs of the public?
DYes
o No
6.17 State the main reason for your answer.
Thank you for your co-operation.
C/o Stef Kriel
Division of Educational Development
Faculty of Health Sciences
University of the Free State
PO Box 339
BLOEMFONTEIN
9300
SOUTH AFRICA
COMPETENCE PROFILE OF QUALIFICATION: M. OPTOMETRY
Title of qualification: Magister in Optometry/Master in Optometry (M. OPTOMETRY) Field of Learning: 09; Health Sciences and Social Services
Type of qualification: Structured Masters NQF Level: 7
Exit after six modules (120 credits): Post-graduate Diploma in Optometry Credits: 300
- ---------.--. -----.--.--- ... -t' ._. ..._.". _I ~_~"""""'"_II' "1...... IIIIVUUVII
Purpose of the Exit level outcomes Specific exit level Assessment criteria Forms of integrated
quahtication and (capabilities) outcomes (products) assessment
com_j)_etence ,labilitiesl
The purpose of the Learners who qualify The learner will be Proof of competency will be Assessment of skills and
qualification is: (A) will be capable of able to demonstrate: provided by demonstration of the knowledge applied will be as
• To provide optometrists working as a achievements of the stated follows:
who have the necessary [specialist] health outcomes. Efficiency and o· Assessment in the
knowledge, skills, care professional in effectiveness in the achievement of programme will be
professional thinking, the field of the set outcomes and general based on an integrated
behaviour and attitudes optometry. performance in the field of and continuing
to pursue a career as The learner will be optometry will be evaluated in evaluation approach.
optometrist with capable of: terms of standards set by the Evaluations will be
advanced clinical •professional board. formative in nature to »
competencies 1. Demonstrating a 1.1 A sound knowledge 1.1.1 Proof of competency will be ensure that the process "'C
The learner will be sound knowledge and and understanding of given by means of seminars, as well as the end ""0
competent in: understanding of the philosophy of health assignments, as well as oral and mproduct is regarded as
• fulfilling a professional ocular disease and care and the basic :zwritten examinations. important.
role as [an expert in a research in this field. CJprinciples underlying the • Continuous informal
specialised field of field of optometry and assessment will ensure ><
study in optometry]/[a eye care. that the evaluation CJ
specialist optometrist] process is utilised as a
Professional roles will be: 1.2 Knowledge of and 1.2.1 Proof of competence will be learning opportunity.
• [Specialist]![ Expert skills in the treatment given by means of log books, • A module credit system
optometrist] in a and management of assignments, as well as oral and will be followed and,
specific clinical field ocular disease. written examinations. where applicable, the
• Manager and leader in 1.3 Knowledge of and 1.3.1 Proof of competence will be end evaluation
a specific clinical field skills in a specific field in given by means of log books, (summative evaluation)
• Educator and trainer ocular optometry assignments, and written and practical will comprise a written
• Developer (electives). examinations. and oral examination,
Qualification: as well as an evaluation
• Exit with a Post- 1.4 A basic knowledge 1.4.1 Proof of competence will be of practical and clinical
graduate Diploma in and understanding of given by means of compiling a work.
Optometry skills in research research portfolio (e.g. assignments, 0 Skills will be evaluated
Professional registration: methodology. literature reviews, seminars, reports, in real settings.
• Must be approved if etc.).
applicable (e.g.
optometrist with
professional privileges
in specific field)
Purpose of the Exit level Specific exit level outcomes Assessment criteria Forms of integrated
qualification outcomes (abilities) assessment
and (capabilities) (products)
competence
2. Demonstrating 2.1 Specialist knowledge and 2.1.1Proof of competency will be Assessment of skills and
the skills required understanding of and skills in planning, given by means of: Compiling a knowledge applied will be as
in a specialist designing and executing preventive, clinical skills portfolio with follows:
optometry identification (diagnostic), assessment ~supporting documentation (e.g. log • Assessment in the
practice. and therapeutic programmes for persons books, assignment, on-site programme will be based
with a vision disorder, or at risk to evaluations, OSCEs, clinical on an integrated and
develop such a disorder, within the examinations. continuing evaluation
context of their daily functioning. .approach,
2.2 The ability, knowledge and 2.2.1 Proof of competency will be • Evaluations will be
understanding, skills and attitudes to given by means of professional formative in nature to
function within the ethical context of stature, attitude, appearance and ensure that the process
health care professions and according to self-control, on-site evaluations, as well as the end
the guidelines of the Health Professions contribution on professional level. product are regarded as
Council of South Africa and the important.
Professional Board. • Continuous informal
assessment will ensure
2.3 Skills in patient interviewing and 2.3.1 Proof of competency will be that the evaluation
counselling. given by means of structured oral process are utilised as
examinations, OSCEs . learning opportunities.
• A module credit system
will be followed and
2.4 The ability to be effective managers 2.4.1 Proof of competency will be where applicable the end
in the health care context; to render a given by means of on-site evaluation (summative
service as a member of the health team; evaluations, community evaluation) will comprise I
to communicate well; be critical thinkers; involvement and service, liaison a written and oral
and professional practitioners in the with health care professionals, examination, as well as
application of relevant social and seminars and discussion groups. an evaluation of practical
behavioural sciences. and clinical work.
• Skills will be evaluated in
real settings.
COMPETENCE PROFILE OF QUALlFICATION:Ph.D. (Optometry)
Title at qualification: Ph.D. (Optometry)
Type at qualification: Doctorate Field at Learning: 09; Health Sciences and Social ServicesNQF Level: 8
- . - - ---- .. -- .. -- .. - .. -'..., .................. , '"ll """f.J..\oIlllw,'y I lVI. 'IC,,",'I lVP\.ullltarYJ UI equIvalent Credits: ;jOU
Purpose of the qualification and Exit level outcomes Specific exit level outcomes
competence Assessment criteria(capabilities) (abilities) Forms at Integrated(products) assessment
The purpose of the qualification is: The learner will be On this advanced level the
• The learner should provide Assessment at skills andTo provide optometrists who have capable of: learner will: evidence of a specialised knowledge applied to the
the necessary knowledge, skills, and a high level of
professional thinking, behaviour field of study will be• Providing • As an expert in the competencies, knowledge
and altitudes with a chance to composed of:expertise in the protession identify, define and attitude through:
pursue a career as optometrist profession in the and provide solutions to 0
with advanced research skills A proposal and theadvancement and complex problems, and
and decision - making • A research report successful defending offurther advise authoritatively on
competency to make a providing expertise in the the proposed researchdevelopment of such matters of all degrees
contribution to science field of study. At least two before a panel.knowledge in the of predictability pertaining to external examiners, apart
specialised field of the specialised field of study.
The learner will be competent in: from the supervisor(s) will
0 A thesis submitted after at
study.
• determine the acceptance
»
Advanced study and research least two years after• Possess in-depth and or not of the thesis . "0
methodology procedures in the • registration andInitiating research comprehensive knowledge "0
specific field ot study and the preparation in consultationand applying in a complex and specialised • mThe draughting of a with the supervisor(s). andapplication of results. The learner advanced area and/or across zframework for a in which the learner
will distinguish him-/herself as an research specialised or applied areas opublication complying with delivered proof of
expert in the specialised field of methodology. and demonstrates the standard of an advanced and applicable ><
study and will show competency intellectual independence in accredited journal in the research. m
in initiating and co-ordinating the application of scientific field of study.
continued research activities. methods and procedures
and autonomous
Professional roles will be: synthesising of information
• Educator and trainer that expand or redefine
• Manager and leader in research existing knowledge.
• Policy-maker
• Consultant
• Education Manager
• Administrator.
Qualification:
• Ph.D. (Optometry)
Professional registration:
Must be approved if applicable (e.g.
specialist scientist in the field of
optometry)
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