Journal of the New Zealand Medical Association, 13-March-2009, Vol 122 No 1291
Education of eye health professionals to meet the needs of the Pacific
Rènée du Toit, Garry Brian, Anna Palagyi, Carmel Williams, Jacqueline Ramke
Worldwide, an estimated 314 million people have impaired vision, of whom 45 million are blind.1,2 Vision impairment is an important public health problem, with significant impact on quality of life3–5 and substantial economic consequences.6 More than 90% of visual impairment occurs in developing countries,7 predominantly from conditions8 that can be prevented or treated using established and cost-effective means.2,9
Globally, the major causes of blindness and low vision are cataract (39% and 25%, respectively) and refractive error (18% and 49%, respectively).7 In Timor-Leste, in people over 40 years of age, cataract accounted for 72.9% of blindness, and uncorrected refractive error for 81.3% of low vision.10 In Papua New Guinea, in the over-50 age group, cataract caused 71.9% of functional blindness. Uncorrected refractive error was responsible for 44.9% of low vision.11,12 However, as non-infectious chronic diseases increase in low- and middle-income countries,13 vision-threatening diabetic retinopathy is assuming greater importance.14
The International Agency for the Prevention of Blindness and The World Health Organization’s (WHO) Vision 2020: The Right to Sight initiative was established to eliminate avoidable blindness by the year 2020.15 It is unrealistic to expect the current global eye care workforce to achieve this goal; workforce capacity, both in size and effectiveness, must be increased.16,17
The 16 low-resource countries of the Pacific have a total population in excess of 9 million people, who are predominantly rural dwellers (85%), either in rugged mountainous Papua New Guinea, or on thousands of islands in Melanesia and Polynesia spread across nearly a million square kilometres of ocean. Although a private ophthalmic workforce offers some services, most eye care is provided in the public sector by an indigenous Pacific workforce of fewer than 15 eye doctors and 65 eye nurses.
A whole-of-health approach is needed to effectively tackle this workforce shortage, including strategies such as: increase the output of undergraduate medical and nursing schools so that the balance of eye to other health care providers can be suitably maintained; swell the number and output of postgraduate eye care courses; encourage workforce retention, in part by reducing attrition to Australia and New Zealand; and increase the capacity of the public health sector to employ and deploy personnel.18 Further, strategies for workforce support are needed to improve effectiveness of current and future eye care personnel, including by capital works and equipment acquisition, recurrent funding for service provision, and development of management and monitoring and evaluation systems to underpin functioning and capable services.
It is, however, the quality and content of the preparatory education for eye care professionals, and their commitment to professionalism and life-long learning, that is fundamental to improvement in workforce effectiveness. Therefore, using current best practice approaches in education, the aim should be to produce a sufficient number of competent eye health personnel who are capable of effectively and acceptably providing eye care to meet local needs within community and hospital settings.
Various agencies have defined competencies for health care providers to enable them to provide appropriate, high quality care. The Accreditation Council for Graduate Medical Education (ACGME) have proposed a core set of competencies to be included in medical education to improve the quality of patient care and to facilitate working effectively within health care systems. These relate to medical knowledge systems-based practice, patient care, interpersonal and communication skills, practice-based learning and improvement, and professionalism.19
These encompass competencies developed by The Institute of Medicine in 200320: being able to work in interdisciplinary teams, utilise informatics, provide patient-centred care, apply quality improvement, and employ evidence-based practice. The AGCME competencies are considered relevant to health care providers around the world, and have been recommended for inclusion in curricula for ophthalmologist training.21
Another set of competencies for the management and treatment of chronic disease have been provided by WHO.8,13 These relate to a public health perspective; partnering/working as a member of a health care team; patient-centred care; use of communication, technology, and information; and quality improvement.
The broad scope of the competencies for medical education and disease management suggests that Pacific eye health providers, if only taught clinical skills based on a curative approach to individual patients, would be unlikely to successfully meet the challenge of delivering optimal eye care and making a significant impact on reducing visual impairment. This eye health workforce needs a broader base of competencies.
Therefore, in addition to clinical eye care competencies relevant to the workplace environment and available equipment, the WHO and ACGME competencies have been adapted and embedded in curricula for the training of Pacific eye health professionals and linked to course outcomes, content and assessment (Table 1).
Table 1. Core competencies* required of Pacific Eye Institute (Suva, Fiji) graduates
Graduates must be able to:
* Adapted from Accreditation Council for Graduate Medical Education19, and World Health Organization8
The Pacific Eye Institute, an initiative of The Fred Hollows Foundation New Zealand, delivers these curricula in Suva, Fiji. Programs include a Postgraduate Diploma in Eye Care for nurses and Diploma in Ophthalmology offered for doctors. Both are conferred by The Fiji School of Medicine. Masters qualifications are presently undergoing development.
Public health perspective / systems-based practice—Students are introduced to a public health perspective and the importance of providing eye care integrated in the broader health systems, especially those of primary health care. To enable graduates to provide accessible and sustainable eye care services at the community, district and national level, they learn to develop and coordinate curative, rehabilitative, promotive, and preventative services.16,18 They also develop skills with which to advocate for these.
Partnering / working in teams—Students learn to work as part of a team, consisting of an ophthalmologist, “eye doctor” trained to perform cataract surgery and manage uncomplicated eye conditions, and eye care nurses providing comprehensive eye care, diagnosing and treating common anterior eye conditions and referring of more serious and posterior eye abnormalities.23
This model of care, based on mid-level personnel providing the bulk of care, has proven to be effective in the Pacific Islands: nurses and nurse practitioners provide health care across remote and sparsely populated areas.24 Partnerships with other health care personnel, social agencies and the community are initiated by inviting guest lecturers from other disciplines, and organizing visits to the community.16,18
Patient-centred care / interpersonal and communication skills—Students explore differences in perspectives of eye care. This encourages them to provide care that is responsive to and respectful of the needs and preferences of the patient. Creating and sustaining ethical relationships with patients and providing care that meets patient expectations, supports effective self-management and adherence to management plans, and healthy behaviours to achieve good outcomes. These factors are all emphasised throughout the courses. So too is the development of effective communication skills.
Information and communication technology—Many eye nurses in remote areas are expected to provide eye care with limited opportunities for referral or to discuss cases. Given current restrictions in information technology in the Pacific, the courses emphasise radio and mobile phones for information exchange, and paper-based systems to organise and monitor patients and their information.
Quality improvement /practice-based learning and professionalism—Pacific eye care providers habitually work with little direct support or supervision, or opportunity for peer and supervisor appraisal. Therefore, it is especially important that they have the awareness and skills to monitor and evaluate their work and its outcomes. To this end, students use reflective journals and learn how patient outcome, expectation and satisfaction feedback can be used to continually improve the eye care they provide. The courses model the continuous improvement process in that formative assessments are used to identify areas of learning that need attention, and evaluations of the classroom and practical sessions are used to improve the learning environment and its outcomes.
Provide evidence-based eye care—Students learn to integrate research findings, best practice guidelines, and patient needs and values25 into their clinical activities. They practise using this information when under close supervision they diagnose and manage eye conditions, correct refractive errors, perform surgery and/or provide assistance in the operating theatre.
The Pacific Eye Institute offers courses in circumstances and with equipment similar to that in the individual’s home country. It attempts to apply current best practice in medical education delivery to its courses to facilitate student learning.26–28 However, implementing innovative education strategies is not a simple process. Identified barriers include financial constraints and lack of qualified staff,29 political instability, cultural factors, and a lack of motivation to adapt to health environment.27
The Pacific Eye Institute supports faculty to develop skills conducive to student-centred, case-based, experiential self-directed learning. As more eye care personnel graduate and gain work-experience, the intention is to increase the number of local faculty at the Institute.
Those interested in joining will be able to complete an effective teaching and learning module as part of their masters qualification. To ensure ongoing improvement, curriculum, course, lecturer, supervisor, and learning environment evaluation are regularly undertaken by students, peers and the education director.
Curricula to facilitate outcome-based education and an integrated approach—Education at The Pacific Eye Institute is competency and outcomes based. Curricula are presented in a "know-how" (students learn what they need to know to provide eye care) rather than "know-all" approach.18,28,30
Learning outcomes, evidence-based management, and clinical guidelines have been developed to reflect the competencies and context19 required by the Pacific workforce. Ongoing evaluation will ensure these remain current.
Curriculum delivery is designed to be interactive, creating opportunities for students to apply concepts and develop skills and appropriate attitudes.19 Biomedical and social sciences are presented in the context of Pacific communities—to facilitate acquisition, retention, consolidation, and application of knowledge.
Teaching and assessment are context-rich, with at least 50% of a programme’s course-time practical or applied. This encourages a departure from rote learning of “pure theory”.
To ensure students learn to work as part of a team, nurses and doctors share didactic and practical sessions during the operating theatre and refraction courses.
Assessment: competency- and performance-based—The Pacific Eye Institute uses continuous assessment to give feedback to students, so that each can identify learning gaps/areas in need of improvement. A battery of assessments31 is used. For example: supervisor and patient assessment of patient-centred care, including professional demeanour and communication skills; supervisor assessment of clinical skills by grading student suggested diagnosis and management; self-assessment of performance by students.
Students keep logbooks to record clinical skill attainment. Reflective journals are used to encourage students to think critically about the eye care needs of individuals and their communities. This is not only from a treatment, service or infrastructure viewpoint, but with consideration of the whole person, and the barriers each faces to accessing care. These journals also document the application of learning. Portfolios assist in identifying where further learning is required, and hopefully promote a commitment to life-long learning and professional development.32
Learning technologies—The Pacific Eye Institute Resource Centre has computers with Internet access. Students are required to become familiar with these technologies as they develop an evidence-based approach to their learning and work. This prevents the lecturer being the sole source of information, and reliance on textbooks, which soon become outdated.
The Pacific Eye Institute envisages that increasing reliance on e-learning will facilitate learner-centred education. Students will be better able to learn at their own pace and in response to identified learning needs. Also to this end, the possible use of video-based instruction and assessment33 will be examined.
However, until more reliable internet connection and increased bandwidth become available in the Pacific, paper-based systems and radio or phone communication will be the norm for patient care and continuing education. Their use is discussed and modelled during Pacific Eye Institute courses.
Using the best education practices available, The Pacific Eye Institute aims to produce graduates who have the necessary competencies to deliver good quality, effective, comprehensive eye care services to meet their communities’ needs. As these eye care professionals move into the workforce, the Institute and its partners provide equipment and help establish a productive and supportive working environment.
The success of The Pacific Eye Institute’s education and workplace integration activities will be determined in time, through continued evaluation with improvements where required, and ongoing development to meet changing needs.34,35 Although small, this is a definite step toward ensuring education of eye health professionals meets the needs of the Pacific.
Competing interests: None known.
Note: This article forms part of the NZMJ's contribution to the International Joint Special Issue on scaling up training and education of health workers, a collaboration between over 20 health-related journals to publish on a common critically important theme, led by the journal Human Resources for Health (www.human-resources-health.com) and the WHO department of Human Resources for Health. For more information, please see the website.
Author information: Rènée du Toit, Education Director; Garry Brian, Medical Director; Anna Palagyi, Pacific Manager; Carmel Williams, Executive Director; Jacqueline Ramke, International Programs Manager; The Fred Hollows Foundation New Zealand, Auckland
Correspondence: Rènée du Toit, The Fred Hollows Foundation New Zealand, Private Bag 99909, Auckland 1149, New Zealand. Email: firstname.lastname@example.org
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