Investigating the need and structure for a comprehensive eye care competency framework

Stage 1: desk review

A desk search was conducted to review existing competency frameworks, models, scopes of practice being currently used within health, specifically eye care practice. Other competency frameworks that the WHO had recently developed were also investigated, some of which were not specific to eye care.

The following three questions were being explored through the first stage to make a baseline assessment of the existing approach to competency frameworks within eye care globally:

1. Geographically, where are the current competency frameworks in eye care being used and are there any competency frameworks that are global or international? This will help determine their utilisation and reach.

2. How specific are the current competency frameworks for each occupational-group in eye care? This will help determine how inclusive they are.

3. What is the structure and key terminology used in the current competency frameworks relevant to eye care? This will help determine how comprehensive they are, and be used to guide the new framework structure, including the domains and key components.

The three strategies used to identify competency-related materials (in English language) included:

• Electronic database searches (PubMed) and grey literature databases (Global Index Medicus – WHO) and web search engines, for the following fixed terms “eye care/ ocular/ ophthal*/ optometr*” AND “competenc*” AND/OR “framework/ model” OR “clinical” AND/OR “scope”. For each term, the search was carried out for the first 10 pages of results, over the period between 1 December 2020 and 15 December 2020.

• Open call for competency-related documents was raised to eye care associations, training institutions and development partners globally including WHO and the International Agency for the Prevention of Blindness (IAPB) representatives in each region; chair and members of IAPB’s Human Resources in Eye Health group; Contacts at International Ophthalmology Council and World Council of Optometry (WCO).

• Competency frameworks developed by WHO were identified and selected as they covered other health sectors while remaining relevant to eye care due to their transferable terminology and content.

The documents relevant to eye care that were found were reviewed and analysed using the qualitative statistical software tool, Mendeley. Data were extracted and entered in a pivot table created in Microsoft Excel that included what WHO region and country they were from; what occupational group they covered and if the documentation covered a particular occupational group or covered multiple occupational groups within their eye care workforce. Occupational groups were categorised into ophthalmology, optometry and allied ophthalmic personnel (AOP), based on the three key categories identified in the WHO Core Competencies for the Eye Health Workforce (WHO AFROCF).12

A desk analysis reviewed the identified competency frameworks for their structure and key terminology. Depending on their format, a header domain and subdomains were identified and run through a word frequency query to identify the occurrence of each label.

Selected competency frameworks developed by WHO were further examined for their terminology. Key terms were extracted, and the structural arrangement and competencies were analysed for their applicability to eye care. The various structural arrangements of the existing frameworks that were analysed were used to develop a proposed structure for an ECCF.

Stage 2: stakeholder consultation

A Technical Working Group (TWG) was established and composed of 13 individuals from diverse occupational groups in eye care and represented the 6 WHO regions. The TWG was engaged to review the findings from stage 1 and inform the development of a comprehensive ECCF. The proposed ECCF structure was presented to the TWG, during a virtual meeting where input and feedback were gathered. The TWG was given a further fourteen days to submit feedback through emails and comments directly on draft ECCF proposed structure.

Patients or the public were not involved in the design, or conduct, or reporting, or dissemination plans of our research.

Geographical distribution of the competency frameworks relevant to eye care

Figure 1 presents the geographical distribution of the identified competency frameworks, according to WHO regional locations (Africa Region, European Region, Eastern Mediterranean Region, South-East Asian Region and Western Pacific Region) with the addition of Global region, which covers all regions. A majority of the competency frameworks were from the USA, Canada, UK and Australia. The Rehabilitation Competency Framework (RCF) and Global Competency and Outcomes Framework for Universal Health Coverage (GCOFUHC) were grouped in the Global region. No competency frameworks were found from countries in South-East Asian Region.

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Occupational group-specificness of the competency frameworks in eye care

There were only two frameworks that covered all occupational groups within the eye care workforce. These were from the Africa Region,12 and Western Pacific Region.13 The latter was disease specific, focusing on cataract clinical care. Several frameworks included more than one occupational group. In several instances, optometry and AOP were covered together (figure 2). Note: AOPs include opticians, orthoptists, ophthalmic nurses and ophthalmic technicians. The large proportion of the AOP frameworks can be predominately attributed to the recently published framework series from the European region.

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Competency frameworks from outside the eye care sector, such as the RCF and GCFUHC, were excluded from this analysis.

Domains and subdomain labels of the competency frameworks relevant to eye care

Examining the frequency of the domain labels used showed the three most frequent domain labels to be manager, patient and professional (table 1). The result of manager being the most frequent domain was expected, as the frameworks described competencies for occupational groups predominantly found in secondary and tertiary healthcare settings.

Examining the frequency of the subdomain labels used showed that the three most frequent subdomain labels to be level, component and element (table 2).

Based on our review, there are no existing global comprehensive workforce competency frameworks for eye care as part of the health system. The only existing overarching eye care competency framework is for the Africa Region (AFROCF), which does not include all competencies found in eye care globally and is occupational group specific. Most current ECCF used are for specific occupational groups only. In UK specifically, 11 competency frameworks were found. Of note, is the Common Clinical Competency Framework for non-medical ophthalmic healthcare professionals in secondary care covering four clinical areas.14 The Royal College of Ophthalmologists created the framework in 2019, and their extensive emphasis on non-medical competences is novel for the eye care sector. In addition to the AFROCF, review of existing WHO competency frameworks found two relevant frameworks, the RCF15 and GCOFUHC,16 both of which demonstrate a competency framework appropriately structured for global application.

Following the review of the 52 competency frameworks, competency standards and models related to eye care (including 11 from the UK) 3 types of gaps of gaps were found: (1) narrow in focus on specific occupational groups; (2) limitations in the competencies expected from an eye care worker and (3) limitations in regional focus, such that they could not easily be applied in a global context.

Proposed framework structural arrangements to capture competencies in the eye care workforce

The TWG affirmed the gaps found through the desk review, which informed and guided the creation of the six domains for an eye care worker, and other key components as part of the proposed structure for a more comprehensive ECCF. The TWG collectively agreed on the following final ECCF structure:

• Six top domains (table 3).

• Competencies and activities to be described within each domain that are linked to knowledge and skills, and are specific to eye care.

• Four levels of proficiencies as subdomains across each competency under each top domain.

The need for a comprehensive competency framework in eye care

There is a need for a comprehensive framework that encapsulates the competencies found across the diverse eye care workforce. Current competency frameworks tend to segregate the overall view of the eye care workforce. Although they serve a purpose of allowing for a deep dive into the tasks required from each occupational group, they hinder demonstration of how different occupational groups can interact with each other making it difficult for groups to easily collaborate and coordinate to deliver comprehensive eye care in a team setting. Thus, the gaps in the current tools and methods pose a challenge for effective workforce planning and development, particularly when looking at the overarching eye care workforce within a country.

A comprehensive competency framework can be a useful tool to assist planners in identifying gaps between the services required and the overarching workforce development, specifically in areas of education curricula and competencies by regulatory bodies and policy makers. A comprehensive framework also provides a valuable advocacy tool for those carrying out health workforce development and planning to consider the diverse range of competencies and activities required to provide the eye care services needed for their population. This includes the consideration of non-medical-related competencies and activities, which often get overlooked, yet still expected from eye care workers. Aspects from existing frameworks that include non-medical-related competencies and activities, such as the Common Clinical Competency Framework from UK,14 should be used to in the content development of the ECCF.

Recommendations on the structural arrangement

The structural arrangement of the ECCF will influence the utilisation of the framework by education institutions, regulation authorities, policy makers, employers and other non-government agencies. Based on the findings of the existing frameworks being too narrow for the need, the structural arrangement for the ECCF should be broader and not segregated by occupational groups, particularly for national or regional workforce planning and development purposes. Using a comprehensive competency model that is overarching of the workforce, supports a team approach and allows role optimisation in order to make more efficient use of the available human resources for health. Often eye care workers that should be practising at a secondary or tertiary level, for example, ophthalmologists, end up conducting refractions, vision screening activities and practising at a primary level, thus resulting in an inefficient and ineffective use of resources.17 A comprehensive ECCF would be particularly beneficial to address this and develop the workforce in settings where resources at the primary care level are often limited, unregulated and overlooked during workforce planning and development.1

For eye care services and related frameworks to be comprehensive, it must possess four attributes—availability, competency, productivity and responsiveness.18 The ECCF should allow for these attributes to come through its design by using the following approach:

• Encapsulate the roles of the diverse eye care workforce and encourage role optimisation,19

• Be adaptable to accommodate various contexts, particularly low-middle-income countries, where tools for workforce planning and development are limited,

• Reflect different areas of practice and levels of expertise,

• Be used to develop competency-based education programmes, whereby it can be used to build a curriculum.

There is much to be learnt from the development of competency frameworks that go beyond eye care. First, according to Mills et al’s scoping review of 623 competency frameworks in the health field, competency frameworks should be reconceptualised using the key words of competency, behaviours, activities and tasks.20 This recommendation was used in addition to the results of desk review, to guide the development of the ECCF structure. Second, a systematic review of literature related to competency framework development methodology in health showed that is it essential that framework developers engage a variety of relevant stakeholders such as external health professions and the community, to match education to health service demands. Thus, it is critical that a wide range of stakeholders are not only consulted as part of the TWG, but also in the continued development of the ECCF.21

Limitations of the study

Almost all the frameworks found through the desk analysis, were found through the internet search. As such, this may have limited the frameworks to countries that operate predominantly in the English language. On many occasions, this represented middle-high-income countries, thus, there is a gap in understanding of what models and frameworks are being used in the low-income countries.