During the pandemic, trainee optometry and dispensing optician students have had fewer opportunities to take part in practical sessions as part of their undergraduate training. The pre-registration year is, therefore, an essential time for graduate trainees to consolidate the skills required to practice as independent professionals upon qualification.
Some trainees are naturally inclined to take an active approach to learning while others benefit from more guidance. What can healthcare professionals do to support trainees so that they reach their full potential? What is the difference between merely observing an optometrist in a specialist clinic and active observation with pre-determined learning objectives, observation prompts and case discussions? What do trainees appreciate most when they are developing their skills? What skills do trainees want to acquire?
This article will address these questions in the context of graduate trainees observing the author in hospital-based and private specialist low vision clinics. The principles so developed can then, I believe, be applied to other clinical settings as well. As this article uses the example of a low vision clinic, the low vision competencies for graduate trainee optometrists from the College of Optometrists are listed in table 1.
Table 1: Low vision competencies for trainee optometrists from the College of Optometrists
How do we learn best?
It has been recognised that students learn best when they are held accountable for their learning.1 Passive observation is, therefore, not enough if the aim is to help the student to reach their full potential. Accountability can be achieved by setting achievable and meaningful learning objectives for training session2, 3 and these learning goals can be referred back to at the end of the session. During the session, students can enhance their learning by documenting any observed cases.4
It has also been shown that both written documentation5 and subsequent case discussions6, 7 aid in developing clinical practice. This approach ties in with the recommendations from the General Optical Council,8 which promotes reflective practice once optometrists are qualified. It encourages learners to think about their experiences rather than simply ‘collecting experiences’.5
Teaching Tailored to Needs
Every student is unique in terms of their prior knowledge, their interest in specific subjects, their learning style and their self-perceived confidence and competence. Understanding the student’s level of competence and confidence and assessing their understanding throughout teaching sessions, something known as ‘situational leadership’, has proved to be effective in other health care settings9, 10 and this approach was taken for the graduate trainee optometrists and dispensing opticians in the low vision clinics discussed in this article.
At the start of each teaching/training session, the trainee was asked to rate their own level of knowledge about a series of competencies, including the following:
- The impact of visual function on quality of life (QoL), functioning and emotional well-being
- Knowledge about different low vision aids
- Visual hallucinations
- Compensation strategies
- Sight loss charities
- Sight impairment registration
This quick assessment of self-perceived knowledge allowed the tutor to identify gaps in knowledge and support the trainees in setting their learning objectives. During the session, the trainees were given a list of observation prompts to guide their note taking and case descriptions. They were encouraged to ask questions when appropriate during the session and, at the end of the session, all cases were discussed and any topics that were not covered during the session were addressed.
After the session, the trainees were asked to rate their level of knowledge on the same items as before the session and any remaining gaps in knowledge were either addressed or recommended for further study. Table 2 summarises the session structure for the low vision clinic. This structure is not specific to this specialism and can be applied in many different settings.
Table 2: Session structure for pre-registration optometrists
The next few sections describe the feedback from the trainees who participated in the low vision sessions when this teaching approach was first introduced.
What Do Trainee Optometrists Want to Learn?
One interesting observation is the great variety of learning objectives between trainees. This supports the idea that trainees benefit from individualised sessions. While some trainees are eager to learn more about very specific skills or topics, others are keen to achieve a better overall understanding of low vision, others the low vision assessment in particular.
Trainees are keen to learn how to tailor the routine assessment for low vision patients, to gain a better understanding of the impact of visual impairment on everyday life, and to understand more about visual hallucinations. Some want to know more about prescribing low vision aids, such as magnifiers and filters, while others are particularly interested in understanding the process and criteria for vision impairment certification and registration. A discussion about learning goals before the session helped to give the session a structure.
What Are Trainees’ Strengths and Weaknesses?
The trainees’ self-perceived knowledge varied with some students feeling more confident and competent than others. Many trainees commented on the benefit of rating their knowledge prior to the session as they would otherwise not have considered certain topics as learning goals. As a tutor, it was very easy to identify which topics needed extra attention during the session. Figure 1 shows the self-perceived knowledge of trainees when they were asked to rate their knowledge on these topics on a scale of 1 to 10 before and after the session.
Figure 1: Self-perceived knowledge of trainees before and after the LV session. Trainees were asked to rate their knowledge on these topics on a scale of 1 to 10 with 1 being no knowledge and 10 being excellent knowledge
Case Descriptions and Case Discussions
Trainees used observation prompts to write their cases (see table 3) and this resulted in some very detailed case descriptions. This proved to be particularly helpful when the cases were discussed at the end of the session. Low vision clinics tend to be hugely variable, depending on the patient’s various eye conditions, stage of life, personality and needs and, therefore, each trainee’s learning experience is unique. However, most low vision assessments follow a similar structure, typically comprising the following:
- History taking
- Assessment of needs
- Goal setting
- Visual function assessment
- Assessment for magnifiers and digital low vision aids
- Recommendations in terms of coping strategies and sight
- substitution
- Signposting to charities, rehabilitation services and other
- professionals
Therefore, all trainees should have the opportunity to address the majority of their learning goals through active observation and case discussions. Any remaining items were discussed at the end of the clinic.
Table 3: Observation prompts for trainees observing low vision clinics
Feedback From Trainees
Feedback from trainees was very positive. They felt that all their learning objectives had been met, they were clear about the aim of the session, and engaged and related well with the tutor. Their understanding about the impact of low vision on quality of life had improved and they felt better equipped to assess a patient with low vision in their own practice as a result of the session. However, most students realised they would need more practice in order to feel confident enough to assess patients with vision impairment optimally.
All trainees learned about the range of available low vision aids, what they are used for and how to prescribe them. Those who attended the hospital eye service were introduced to the Patient Support Service, also known as the Eye Clinic Liaison Officer (ECLO) service. This is a service usually led by a local eye care charity, such as RNIB or Visibility Scotland, and provides support for patients with a visual impairment both within and outside the hospital eye service, forming a bridge between clinical care and social care and rehabilitation.
Trainees improved their knowledge of available support services and referral pathways for people with sight impairment. All commented on the usefulness of the observation prompts, and some felt that note-taking was easier after thinking about their learning goals. Defining the competencies up front helped them identify gaps in their knowledge, and they felt that these topics were addressed during the session. It helped them to know what sort of things to ask about. Despite the fact that trainees did not have a chance to prescribe low vision aids themselves, all students felt they learned a lot about prescribing and onward referrals.
Take-Home Message
Shadowing can be a passive form of learning, but one that can be transformed into active engagement when trainees formulate specific learning objectives, which are subsequently evaluated.
Learning goals can include becoming familiar with procedures, equipment and resources in the clinic. They can also be more specific, such as actively observing how relevant information is elicited during history taking, how decisions are made to carry out specific tests, what the impact is of visual impairment or how the practitioner decides about the recommendation of low vision aids, referrals and other management.
Observation can be further enhanced when cases are discussed before, during and after patient encounters. In the author’s experience, learning is a two-way process whereby the trainee and the tutor learn new things and, often, patients enjoy being part of the learning process too.11
While this article has presented this teaching approach in the context of a low vision clinic, it can work well in any setting.
Preparing For Tuition Sessions
Trainees appreciate it when tutors are fully prepared. The eye care professional is very well placed to maximise the learning experience as they are specialists in their subject area. Here, we looked at ways to support trainees observing an optometrist in a low vision clinic. In other clinics, tutors might list some competencies and observation prompts that are applicable to their own particular specialism, such as contact lens practice or ocular disease. Trainees can also prepare for the sessions that they shadow by thinking of learning goals and observation prompts prior to the session.
Continual Professional Development
Optometrists and dispensing opticians have a unique opportunity to learn from qualified optometrists, dispensing opticians, ophthalmologists and other clinical and non-clinical staff during their pre-registration year. However, learning is a life-long exercise. Eye care professionals have many opportunities to learn through CPD articles, podcasts, webinars, conferences, peer discussions and post-graduate courses, but fewer opportunities for receiving one-to-one tuition in specialist subjects.
Community optometrists are often isolated, but ensuring the opportunity to discuss cases with peers on a regular basis leads to better knowledge development and measurable changes in practice compared to distance-learning.6 To facilitate this, peer review case-based discussions have been introduced as a compulsory part of CPD for optometrists and dispensing opticians in the UK. Small group teaching promotes independence in learning and a deeper understanding of content,6 compared to large group lecturing or online learning. Mansouri and Lokyera have demonstrated that small group size and interactive teaching methods for physicians improved knowledge, practical skills and patient outcome.12
A recent survey by the author revealed that primary care optometrists have a keen interest in learning more about low vision-related topics. In response to this, the author has provided workshops with case discussions for optical practices, which have been very well received. The more we learn, the more we know and the more we know, the better we understand what we have yet to learn.
- Cirta Tooth is a specialist low vision optometrist with a special interest in paediatric and neurological sight impairment. She works in the Hospital Eye Service and for Cameron Optometry. She also enjoys research and writing and offers online and face-to-face workshops and teaching sessions for health care professionals. For more information, contact cirtalevelt@hotmail.com.
References
- Mokadam NA, Dardas TF, Hermsen JL et al. 2017. Flipping the classroom: case-based learning, accountability. Assessment, and feedback leads to a favorable change in culture. Journal of Thoracic and Cardiovascular Surgery 153(4), pp.987+
- Archer JC. 2009. State of the science in health professional education: effective feedback. Medical Education 44, pp.101-108
- McKimm J and Swanwick T. 2009. Setting learning objectives. British Journal of Hospital Medicine 70(7), pp.406-409
- Bavani SM, Almasi K and Mohammadpour Y. 2018. Effect of logbook-based training as a modern educating method on clinical competence of the nursing students. Journal of Re-search in Medical and Dental Science 6(2), pp.24-28
- Chambers S, Brosnan C and Hassell A. 2011. Introducing medical students to reflective practice. Education for Primary Care 22, pp.100-105
- Bullock A, Barnes E, Ryan B et al. 2014. Case-based discussion supporting learning and practice in optometry. Ophthalmic and Physiological Optics 34(5), pp.614-621
- Norcini J and Burch V. 2007. Workplace-based assessment as an educational tool: AMEE Guide No 31. Medical Teacher 29, pp.855-871
- GOC (General Optical Council). 2021. Regulators unite to support reflective practitioners across healthcare. https://optical.org/en/news/news-and-press-release... [Accessed on 19 March 2022]
- Bedford C and Gehlert KM. 2013. Situational supervision: Applying situational leadership to clinical supervision. The Clinical Supervisor 32, pp.56-69
- Walls E. 2019. The Value of Situational Leadership. Journal of the Community Practitioners’ & Health Visitors’ Association 92 (2), pp.31- 33
- Bentley SA, Trevaskis JE, Woods CA et al. 2018. Impact of supervised student optometry consultations on the patient experience. Clinical and Experimental Optometry 101(2), pp.288-296
- Mansouri M and Lockyera J. 2007. Meta-analysis of continuing medical education effec-tiveness. Journal of Continuing Education in the Health Professions 27(1), pp.6-15