The Development of Entry Level Low Vision Rehabilitation Competencies

Home , Habilitation

Background n 2004, the American Opto- metric Association approved a The Development of definition of vision rehabilita- I tion as: Entry Level Low “The process of treatment and education that helps individuals who are visually Vision Rehabilitation disabled attain maximum function, a sense of well-being, a personally satisfying Competencies in level of independence, and optimum qual- ity of life. Function is maximized by eval- Optometric Education uation, diagnosis, and treatment including, but not limited to, the prescription of optical, non-optical, electronic and/or Rebecca L. Kammer, OD other assistive treatment options. The rehabilitation process includes the develop- Richard J Jamara, OD ment of an individual rehabilitation plan specifying clinical therapy and/or training Elli Kollbaum, OD in compensatory approaches.”1 Tracy Matchinski, OD This definition is part of a comprehensive and complex rehabilitative medi- Roanne Flom, OD cine model that involves the creation of an individual rehabilitation plan for each patient based on a medical evaluation provided by the doctor and a plan of treatment provided by therapists.2 Although some training in these procedures is provided in the schools and col- Abstract leges of optometry, current curriculum hours and the training of the instruc- The purpose of this study was to determine entry level vision rehabilitation tors limit the extent to which graduates competencies for graduating optometrists and to examine the level of agreement can realistically be prepared to practice about those opinions using consensus methodology. A mixed methods consensus at this level. approach to define competencies in entry level low vision rehabilitation was used. A low vision curriculum model was The study extended 6 months, incorporating online surveys and a 2-day meeting. proposed in 1982 by the Association Twenty entry level low vision competencies were approved by the Association of of Schools and Colleges of Optometry Schools and Colleges of Optometry in 2009. A 2-level approach to the education (ASCO)3 with recommendations for a and practice of low vision may be a solution to the call for trained doctors who significant increase in the number of can meet the growing need in the current low vision landscape. faculty and hours of instruction. This plan proposed that optometry students Key Words: Low vision rehabilitation, optometric education, competencies, be exposed to 30 hours of didactic lec- consensus methods, entry level low vision. ture, 20 hours of laboratory time, and 120 hours of direct patient clinical experience in the area of rehabilitative optometry. In 2008, a non-published survey of low Dr Kammer is an Associate Professor and Chief of Low Vision Rehabilitation at vision educators at an ASCO low vision the Southern California College of Optometry. special interest group meeting revealed Dr Jamara is a Professor of Optometry at the New England College of Optometry that all 19 of the schools and colleges of and a Diplomate of the American Academy of Optometry Low Vision Section. optometry in the United States, Cana- Dr Kollbaum is an Associate Clinical Professor and Chief of the Vision da, and Puerto Rico provided a curricu- Rehabilitation Service at Indiana University School of Optometry. lum in rehabilitative optometry.4 How- Dr Matchinski is the Low Vision Class Coordinator and Chief of the Low Vision ever, the number of lecture (median 28 Rehabilitation Service at the Illinois College of Optometry. hours), laboratory (median 8 hours), Dr Flom is a Professor of Clinical Optometry and Chief of the Vision and patient contact hours (median 49 Rehabilitation Service at The Ohio State University College of Optometry. She is a Diplomate of the American Academy of Optometry Low Vision Section.

Optometric Education 98 Volume 35, Number 3 / Summer 2010 hours) varied considerably from school blindness occur each year.6 With the ring for complex care. to school. The content of the curricula aging population, the number of peo- In 2008, the Low Vision Intervention at the schools was also varied and was ple with visual impairment is expected 6 Treatment (LOVIT) trial recommend- often driven by the training of the indi- to double over the next 25 years. It is ed early intervention while patients are vidual instructors, national board exam- also estimated that another two million waiting for more complex treatment.10 ination content, and general accredita- Americans have best corrected visual This suggests a high priority should be tion criteria.4 There were outliers in this acuity in the better eye that is worse 6 placed on preparing optometry gradu- survey in that five schools only offered than 20/40 but better than 20/70. ates to provide early intervention in low vision clinical exposure as an option These patients are classified with mild rehabilitating low vision patients. The to their students. visual impairments that negatively im- definition of entry level or primary low With the growing demand for expand- pact their daily functioning, but they vision care and the features of a suitable ed training consistent with the cur- may not qualify for rehabilitation under education to provide care at that level rent, more comprehensive low vision the CMS guidelines for visual acuity. In should be established, and serious effort rehabilitation model, there is concern a small pilot study of the potential of should be exerted to ensure the adequate that the curricula in the schools and low vision clinical trial sites, six optom- preparation of graduates. Optometric etric low vision clinics recorded patient colleges may not have the resources to 7 educators need to explore the feasibility produce the required highly skilled and characteristics over a 30-day period. of teaching entry level low vision reha- knowledgeable low vision providers. This study showed that approximately bilitation for all graduating optometrists Postgraduate educational opportuni- 78% of all patients (n=163) who were (i.e., primary vision rehabilitation care), ties for optometrists seeking greater ex- considered “low vision” by the doctors which necessitates the defining of entry pertise include 14 low vision residency met the ICD-9 classification for moder- level competencies. programs. It is unlikely, however, that ate visual impairment or better based on visual acuity of better than 20/200, and The Low Vision Educators Special- In this number of residencies can support terest Group (SIG) was formed in 2006 the necessary number of doctors who more specifically, 36% had acuity better than 20/70. These findings suggest through the Association of Schools and would be trained in the rehabilitation Colleges of Optometry (ASCO) and medicine model to meet the growing a need to revise the current model to include a multi-tiered approach to low consists of representatives from every demand of patients with vision impair- school and college of optometry in the ment. A dichotomy exists between the vision rehabilitation. All patients with visual impairment could be triaged and United States, Canada, and Puerto Rico. skills and experience required to imple- The direction and goals of the SIG were ment a highly complex model of vision managed within the profession of optometry, using a well-defined, two-level determined through group discussions rehabilitation and the current and var- and polls during initial meetings held at ied low vision optometric curriculum. approach to vision rehabilitation based on a patient’s level of visual impair- the meeting site of the American Acad- A coordinated effort among the vision emy of Optometry. A common theme rehabilitation educators to reach con- ment. Clearly defined referral criteria and education of comprehensive vision surfaced: The low vision curricula at the sensus about the specific elements of schools and colleges had not evolved vision rehabilitation curricula for entry rehabilitation services would be critical when more complex care is needed. to consistently address the educational level or comprehensive level care would competencies required for our gradu- seem warranted. The concept of levels of low vision re- ates. There was concern that the depth The definition of visual impairment -es habilitation was introduced in general and breadth of the classroom, labora- tablished by the Centers for Medicare ophthalmology in the United States tory, and clinical experiences were not and Medicaid (CMS), requires a diag- through the efforts of the Vision Reha- adequately tailored to the needs of grad- nosis of best corrected visual acuity of bilitation Committee of the American uating optometrists. As a result, the SIG Academy of Ophthalmology through less than 20/60 or certain visual field 8 undertook an effort to define and devel- defects for coding and billing of vi- the SmartSight initiative. The first op specific entry level competencies for sion rehabilitation. There are, however, level in the initiative called on oph- graduating optometry students, with the many patients who experience visual thalmologists to refer at 20/40 level of idea that such a document would have impairment and functional difficulties, vision, provide a simplified model of the potential to serve as a foundation for yet have better than 20/60 visual acu- care in the second level, and provide faculty in creating or maintaining the a complex rehabilitation model in the ity. This is important because the pri- 8 vision rehabilitation educational curri- mary goal of low vision rehabilitation is third level. The International Council cula in the schools and colleges of op- to restore functional ability in patients of Ophthalmology also supports three tometry. In particular, the group consid- with permanent vision loss.5 By apply- levels of training (competencies) or cur- ered it unrealistic to provide graduates ing measured prevalence rates of visual riculum for low vision rehabilitation with the highest levels of competency in including basic, standard, and advanced impairment and blindness in the Unit- 9 this complex field given the limitations ed States to 2000 census data, it is es- level goals. The goal of a two-tiered ap- of the standard 4-year optometric cur- timated that approximately 1.5 million proach for optometry would be to have riculum and the number of patient en- Americans over the age of 45 have less 100% of optometrists providing entry counters that can be made available to than 20/60 visual acuity, and 240,000 level low vision care (levels one and two interns. The low vision educators instead new cases of visual impairment and in SmartSight) in-office and then refer- decided to develop a solid set of entry

Optometric Education 99 Volume 35, Number 3 / Summer 2010 level competencies, with the idea that information on the topic in question residency program was included. An they might later address more advanced and a period of idea generation. The in-person meeting included 14 experts levels of competency that might require ideas are organized by the investigators at 13 schools and colleges and one VA postgraduate residency training. and formatted into a rating scale ques- externship site. Three other participants tionnaire where a group of experts are in the 2-day meeting, who did not act Purpose asked to rate and may also be asked to as Delphi experts but participated in 12 The purpose of this study was tode- comment on each idea anonymously. group discussions, included the ASCO termine entry level vision rehabilita- The investigators analyze the results of board representative and two vision tion competencies for graduating op- the ratings, inform each expert of the rehabilitation faculty from the repre- tometrists and to examine the level of collective responses, and administer sented colleges. at least two more rounds of question- agreement about those opinions using Procedures consensus methodology. The specific naires until a list of ideas is formulated questions addressed in this study in- or consensus is achieved. Initial items (competencies) were draft- clude: One of the criticisms of the Delphi ed by steering committee members 1) What are the most important com- method is that it forces consensus by not through a compilation of background allowing experts to participate in open preparation, literature review, and cur- petencies in the education of vision 11 rehabilitation for the optometric discussion. In this study, a modifica- riculum review of the five schools rep- graduate as determined by a steer- tion of the process that borrows from resented by the committee members. ing committee of educators? the nominal group technique (NGT) The Delphi method was employed was utilized to allow for a deeper explo- 2) What are the opinions of the vision through the use of an online survey site ration of areas of disagreement or for through round 2. Each item or tentative rehabilitation faculty at all schools clarification of comments. and colleges of optometry regard- competency utilized Likert ratings with ing those competencies? The NGT also utilizes a panel- ofex “0” representing “not important at all” perts, but it is completed in person with and “10” representing “very important 3) How do expert opinions change a facilitator guiding the process. The for minimum competency.” Anonymous between rounds and influence the experts silently generate ideas about comments were also solicited for each final level of agreement (consensus) the topic of inquiry, the ideas are listed item and a final item requested ideas regarding those competencies? for all to view and are discussed by the for additional themes. Between each 4) What are the opinions of the fac- group. Then each expert selects and round, the steering committee revised ulty (experts) with regard to the ef- ranks the top ideas in order of priority. items based on rating scores and com- fectiveness of the methods used to Group discussion is held after rankings ments gathered from the survey system. gain consensus? are reviewed by the facilitator, and a The mean for each item represented the second round of ranking is completed. level of priority of the item for inclusion Methods The process may continue until a final as a competency (group opinion), and 12 A mixed methods approach was used endpoint is achieved. the standard deviation represented the level of agreement. for the study, consisting of consensus Participants methodology of quantitative estimates Rounds 3 and 4 were conducted at a through qualitative approaches.11 Such The ASCO Low Vision SIG steering stand-alone meeting in July 2008 to a hybrid process can be complicated in committee members were the investiga- which all low vision educators (experts) design and data analysis, but the steer- tors in this study and also participated were invited. A modified NGT was ing committee chose this method with as experts in each round of the Delphi employed through the use of a group the intention of developing trust and process. In later rounds, the primary facilitator (the first author), small dedication while exploring the opin- educators of vision rehabilitation cur- work groups, and large group discus- ions of optometric faculty at the ASCO riculum at each of the schools served as sion. The Delphi online survey system institutions. the Delphi experts. Twenty-two experts was used to gather opinions after the Consensus methodology were invited to participate in round 2 group discussions. One key deviation This study primarily utilizes the Delphi online. At the time of the study, there from the typical NGT process was that method but incorporates some aspects were 16 schools and colleges of optome- items were not ranked in priority but of the nominal group technique in a try in the United States and three mem- were individually rated by importance hybrid methodology with qualitative ber or affiliate schools in Puerto Rico (scale of 1 to 10). Small working groups and quantitative design characteristics. and Canada. All low vision educators each revised four competencies and re- (appointed by respective deans as the ported revisions to the whole group The Delphi method is designed to gain contact person) were e-mailed the link for discussions and final revisions. The opinions from members of a group and to the initial Delphi survey. Remind- group then rated items anonymously work toward a consensus without the ers were sent weekly for several weeks online. Round 4 included a review of influence or time delay of extended dis- to the educators who did not respond. means and standard deviations for each cussions and personality interplay.11,12 In addition to the ASCO college repre- item and collectively; final revisions in- It is an iterative process that usually sentatives, one representative of an af- cluded language consistency and uni- starts with presentation of background filiated Veteran’s Affairs (VA) low vision formity of competency structure. For a

Optometric Education 100 Volume 35, Number 3 / Summer 2010 summary of methods for each round, ment. The document was distributed Results see Figure 1. by e-mail to all members of the Low Vi- Round 1 During the week following round 4 sion Rehabilitation Educators SIG for (in-person meeting), the experts com- final comments and approval. The final competencies were then submitted to The mean was a measure of central pleted a brief online survey about the tendency and, therefore, represented overall effectiveness of the process, the the executive committee of ASCO for official acceptance. the level of agreement of the experts competencies were reviewed by a few item by item. No criteria were of the educators for minor editing for predetermined for level of agreement; consistent terminology and were then however, after evaluating the results of sent to the American Optometric As- the initial survey, the group considered sociation (AOA) Vision Rehabilitation a score of 8 or above to indicate Section Chair for comments. Minor strong agreement that the item should comments and suggestions were gath- remain as a competency. The standard ered and integrated into the final docu- deviations were also reviewed and

Figure 1: Summary of methods by round

Round 1 Steering Committee Initial Draft Online Delphi 16 Competencies

Round 2 Round 3 Round 4 20 Educator 14 Educators 14 Educators Experts In-person NGT In-person group Online Delphi revisions + Online Delphi 20 Competencies 20 Competencies 18 Competencies

Optometric Education 101 Volume 35, Number 3 / Summer 2010 represented the spread or the amount of disagreement of the experts. The initial draft of 16 competencies from Table 1 the steering committee is shown in Round 1 steering committee competency development. Table 1. Four items were noted for extremely low scoring (<8, SD>1) and three items for extremely high scoring Competency Mean St (9 or greater, <1.0 SD). All items were Dev reviewed with comments to better 1. Understand and be sensitive to the psychological and emotional 8 0.63 understand any necessary deletions, aspects of visual impairment and be able to describe challenges commonly encountered by individuals with visual impairments. revisions, or preservation. 2. Be sensitive to psychological and emotional aspects of visual impair- 8 0.89 The steering committee reviewed the ment and be able to describe challenges commonly encountered by poorly rated items to determine if some individuals with visual impairments. key points were salvageable rather than 3. Be able to describe functional implications of various visual system 8.2 0.75 eliminate the entire concept. For exam- pathologies and diseases. ple, if an item was not entry level, the 4. Be able to describe significant co-morbidities that impact low vision 7.8 1.17 issue was discussed by conference call rehabilitation to determine if there was a clear divi- 5. Be able to perform appropriate visual acuity testing at both distance 9.8 0.4 sion of the topic into two levels, and and near for visually impaired patients. then an item was drafted to capture the 6. Be able to describe low vision assessment techniques (e.g., ETDRS, 9.2 0.75 entry level idea. Items were more spe- Bailey-Lovie, Feinbloom charts) cifically defined, and redundancy was 7. Be able to examine the visually impaired patient: history, ocular in- 8 1.79 spection, refraction, visual acuity, reading assessment, fields, contrast eliminated (e.g., items 1 and 2 from sensitivity, and other vision functions. Table 1 developed into different items 8. Be aware of various visual field tests and their purposes and be able 8.2 0.4 in 1 and 2 of Table 2), and more were to select appropriate visual field testing based on patient profile. added to the list (20 total competen- 9. Be able to assess eccentric viewing postures and skills, patient moti- 6.4 1.36 cies). New items included use of elec- vation, scanning ability (for patients with restricted fields). tronic magnification and knowledge of 10. Be able to prescribe simple but appropriate rehabilitative therapies 9.4 0.8 how to refer and sign a plan of care for and optical devices to help the patient meet their goals. (e.g., magnifi- occupational therapists. cation, illumination). 11. Be able to describe various low vision aids and the optics of low vi- 7.4 1.36 Round 2 sion devices. A revised list of 20 competencies was 12. Demonstrate low vision devices and educate low vision patients on 9 1.26 sent to 22 experts. Twenty experts the uses and limitations of these devices for patients with low com- (including the five steering commit- plexity vision loss (i.e. low powered hand and stand magnifiers, high reading addition lenses, low powered telescopes). tee members) responded to the online 13. Be able to describe visual field enhancing techniques for hemianopic 6.6 1.62 survey with 18 schools and colleges field loss. represented. Six items were noted for 14. Develop an understanding of the interdisciplinary approach to low 8.2 1.33 extremely low scoring (<8, SD>1), and vision rehabilitation, including the role of the O&M instructor, social three items for extremely high scoring worker, psychologist, educator, rehabilitation counselor, audiologist, occupational therapist, and ophthalmologist. 15. Be able to evaluate visual acuity and visual field for determination 9 1.26 of level of visual impairment for determination of legal blindness or disability. 16. Understand the local licensing regulations and be able to assess a 8.4 1.5 patient for vision requirements for those regulations and complete appropriate driving documentation when necessary.

Optometric Education 102 Volume 35, Number 3 / Summer 2010 (9 or greater, <1.0 SD). A scatterplot of the 20 items (Figure 2) shows the overall distribution of the opinions and Figure 2: the extent of the agreement through the Round 2 Scatterplot of 20 items representing means and standard deviations, respec- level of priority (means) and level of agreement tively. (standard deviations)

Round 3 (In-Person) Following small group and corporate Round 2 (20 experts) revision processes according to a modi- 2.5 fied NGT, 14 experts (including the five steering committee members) responded to the online survey, with 13 schools 2 and colleges and one VA externship site represented. A scatterplot of the 18

items (Figure 3) demonstrates a stabili- 1.5 zation of group opinion as seen by the clustering toward the right of the figure with high means (close to 10) and low St Dev standard deviations. Seventeen items 1 had means above nine, and 16 items had standard deviations less than one. This indicated strong agreement and 0.5 priority for the inclusion of the majority of the items. 0 Round 4 (In-Person) 6 6.5 7 7.5 8 8.5 9 9.5 10 Rating scale (0-10) Online anonymous ratings of items were presented to the full group on the last day of the in-person meeting. Through full group participation, most items were revised with minor changes, while several were subject to Figure 3: Round 3 Scatterplot of 18 items representing level of priority (means) and level of agreement (standard deviations)

Round 3 (14 experts)

2.5

1.5 St Dev

0.5

0 6 6.5 7 7.5 8 8.5 9 9.5 10 Rating Response (0-10)

Optometric Education 103 Volume 35, Number 3 / Summer 2010 major group revision. Examples of major changes included items 1, 2, and 11 Table 2 in Table 2. Item 11 addressed the con- Round 4 Final competencies cept of predicting magnification and understanding the optical principles 1. Be able to apply epidemiologic aspects of visual impairment, appropriate terminology and classifications of visual impairment in order to communicate with patients, the public of low vision devices. Two new items and other health care providers. were added at the end of the consen- 2. In addition to performing a standard case history, be able to ask basic questions about sus process regarding considerations for symptoms, functional difficulties, and rehabilitation goals to anticipate the level of care examining pediatric and special popu- that patients with visual impairment may require. lations (final item 15) and about iden- 3. Be able to recognize functional implications, hereditary factors and prognoses of com- tifying agencies that can offer support mon causes of visual impairment and explain them in language understandable to and information to patients with visual patients, families and other care providers. impairment (item 19). 4. Be able to recognize psychological factors (e.g. depression, grief, motivation) that may affect adjustment to vision loss and the potential for rehabilitation. Final Follow-up 5. Be able to recognize pertinent social factors (e.g. social support system, education level, vo- A few comments suggesting wording cation, physical environment) and how they may influence the rehabilitation plan and process. consistency were collected by e-mail 6. Be able to recognize significant physical and neurological co-morbidities (e.g. Parkinson within 2 weeks after the meeting. The disease, stroke, dementia) that influence low vision rehabilitation and modify evaluation list of final competencies was intro- strategies and rehabilitation. duced to the AOA executive commit- 7. Be able to perform visual acuity testing at both distance and near on patients with visual tee, and no major changes were recom- impairment using appropriate charts with proper documentation (e.g. working distance, mended. The final list was submitted eccentric viewing, illumination). to the appropriate ASCO committee 8. Be able to perform trial lens refraction and modify refractive techniques for the patient and ultimately to the board for approv- with visual impairment (e.g. bracketing, hand held Jackson cross cylinder). al. Official approval occurred in June 9. Be able to recognize common symptoms of contrast sensitivity loss, screen for loss, 2009. recommend basic modifications (e.g. filter, lens, lighting and environmental options) and refer for comprehensive low vision rehabilitation when indicated. A final brief online survey was issued 10. Be able to detect scotomas of the central visual field, understand their impact on visual to all the experts prior to leaving the acuity and visual function, and educate patients about their implications for activities of in-person meeting. The first question daily living. was: “How would you rate the effec- 11. Understand basic optical principles of low vision rehabilitation devices and be able to tiveness of this meeting overall?” The predict magnification levels needed to achieve patient goals. scale for rating extended from 0 (not 12. Be able to prescribe basic optical and non-optical low vision rehabilitation devices, provide effective) to 10 (extremely effective). training in their use, and refer for comprehensive low vision rehabilitation when indicated. All 14 experts responded. The mean 13. Be able to recognize availability of and indications for use of adaptive technology (e.g. video was 9.5, and the standard deviation was magnification, software) and refer for comprehensive low vision rehabilitation when indicated. 0.5, indicating a positive assessment of 14. Be cognizant of rehabilitation strategies for visual field deficits (e.g. sighted guide the meeting. One expert commented, technique, orientation and mobility, visual field enhancement devices and equipment, scanning training) and refer for comprehensive low vision rehabilitation when indicated. “I felt that this meeting was highly effective and that we accomplished the 15. Develop an understanding of the special considerations for examining children, the elderly, and the multiply handicapped and educate about referral options and potential stated objectives that had been set for for rehabilitation. the meeting. I am encouraged that we 16. Understand relevant vision standards for driving, provide necessary assessment and have laid the groundwork for the de- documentation, and refer for comprehensive low vision rehabilitation, driver evaluation/ velopment of appropriate and effective training, and medical evaluation when indicated. standards for low vision education in all 17. Be aware of the criteria for legal blindness determination and be able to educate pa- academic institutions and the momen- tients on the basic social and legal ramifications of legal blindness certification. tum is definitely there to ensure that we 18. Understand that the needs of patients with visual impairment may require professional will accomplish our objectives.” collaboration and be able to coordinate care with available rehabilitative, educational and social service resources. Another item asked: “How do you feel 19. Identify governmental, private and consumer organizations that offer support and about the organization and structure of information to individuals with visual impairment (e.g. NEI, Veterans Administration, the meeting?” The scale extended from state rehabilitation agencies, foundations for the blind, consumer advocacy groups and 0 (did not meet expectations) to 10 (ex- support groups). ceeded expectations). Again, the mean 20. Be familiar with third party reimbursement for low vision rehabilitation services and was 9.5, and the standard deviation materials. 0.5. Most experts thought the meeting was efficient and well-organized. One statement expressed the collective thought: “Very well organized overall. …Liked the interaction and collaboration aspects of the discussions ... no one

Optometric Education 104 Volume 35, Number 3 / Summer 2010 person “taking over”... actually finished tained some key elements, but invalu- from the first round. Between-round a major task w/many leaders in one able discussion occurred regarding comparison is shown in Figures 4 and room ... enjoyable group!” The other several concepts, such as field enhance- 5. Figure 4 demonstrates the changes items in the final survey asked open- ment, driving standards, comprehen- from round 1 through round 3, show- ended questions about the future ac- sive rehabilitation models, and depth ing the changes in group opinion for tions of the groups and about how they of teaching and terminology for optical first round items 3, 4, 5, and 12. Vi- would make changes at their schools in principles. sual acuity testing appeared to have response to the meeting. The responses Both the quantitative analysis using high consensus throughout the rounds, may be explored in a future paper. descriptive statistics and the qualitative although the specific choice of words changed significantly throughout the Discussion analysis of comments were useful for converging on consensus. Comments rounds. The competency related to co- In summary, data were collected for from the online survey process were morbidities (item 4 in round 1) started four rounds over 6 months through on- gathered between rounds and provided as a weaker scoring item and lost some line survey administration in quantita- the context for the statistical perfor- agreement in round 2, but in round 3, tive and qualitative format. In-person mance of the items. The comments the revisions were significant enough to small groups and corporate discussion could be grouped into themes of rec- maintain the concept as a final compe- also accomplished opinion-gathering ommendations for revisions: 1) State- tency (Table 2, item 4). and formation of tangible competen- ments that the competency was not Figure 5 demonstrates similar changes cies. The expert opinion changed be- entry level (i.e., should belong to com- in the other four items from round 1 tween rounds, with the final round prehensive low vision rehabilitation); 2) (13-16). The ratings for item 13, field gaining consensus for all items, with The competency was too broadly stat- enhancement, changed dramatically the majority of the mean ratings in the ed; or 3) The item was redundant from and reached final consensus that entry nine or above range and less than one another stated competency. The general level would necessitate that the gradu- on standard deviations. Overall, the ex- agreement for the importance of a cat- ate be cognizant of techniques, devices, perts were pleased with the organization egory or theme was obvious from the and when to refer (Table 2, item 14). and structure of the process and com- comments, which helped determine if Two of the items regarding issues re- mented on the efficiency of the process a competency needed to be eliminated lated to driving and legal blindness de- due to the amount of work completed vs. dramatically revised. The specific termination were debated relative to in- through the rounds of the consensus choice of wording was usually the basis ternational standards (one school from methods. for disagreement with the majority of Canada was represented), and revisions From start to finish, the development the competencies early in the process. included generic language while main- of the final draft of competencies main- Eight items were similar in content taining the core competency.

Figure 4: Figure 5: Changes in group opinion from round 1 Changes in group opinion from round through round 3 for first round items 3, 1 through round 3 for first round items 4, 5, and 12. 13-16.

Between Round Changes Between Round Changes

2.5

Disease Impact 2 2 Field Enhancement Co-morbidities 2 VA Testing Coordinate Care 1 2 Prescribe Devices Legal Blindness 2 1.5 1 2 Driving 1 1.5

2 1 2 1 1 2

Standard Deviation 1 2 1 Standard Standard Deviation 3 3 3

0.5 0.5 3 1 3 3 3 3 0 0 6 7 8 9 10 11 6 7 8 9 10 11 Mean Mean

Optometric Education 105 Volume 35, Number 3 / Summer 2010 Limitations of the expert decision- Practice Implications number is consistent with the number making process should be considered, of AOA low vision members, although Since the consensus process in 2008, because they could affect the stability this does not account for optometrists the vision rehabilitation educators have or reliability of the final consensus deci- who are not AOA members. met twice, and the outcome has been sion. Two possible processes could have the creation of objectives for each of Another limiting factor is the distribu- occurred during this study. The halo ef- the competencies. The purpose of writ- tion of low vision rehabilitation services fect is when an expert changes opinion ing the objectives was to provide mea- nationally. Owsley and colleagues re- radically throughout the rounds, seem- surable guidelines for the educators to ported a low density of service provid- ingly to conform to the group opinion. more easily integrate the competencies ers on a population basis in the south- Conversely, the expert who never budg- 10 into their curricula. Future work at edu- ern United States. es on opinion may be damaging to the cator meetings will include sharing and final result, as well. The Delphi process Current practice patterns and under- brainstorming ideas for teaching strat- does not typically include a comment standings of patients’ needs suggest that egies of each of the competencies. It phase or an open discussion phase to 1000 optometrists cannot adequately would also be helpful to create a study explain why experts vote the way they meet the demands of the estimated 1.5 that measures the level of implementa- do. Therefore, with the hybrid design million people with impaired vision, tion of the competencies accomplished of an open meeting to discuss issues, all much less the additional 2 million who by the educators over time. Another opinions were sought in a friendly en- have mild vision loss. The Low Vision large project for the educators is the de- vironment by the facilitator, and group Educators SIG aspires to have all grad- velopment of advanced competencies consensus did seem to be achieved with uating optometrists meet competencies for comprehensive low vision rehabilita- all extreme opinions explored. in entry level low vision rehabilitation tion. Studies should also be performed or primary low vision care, with the po- Expert dropout is another area of con- to test the effectiveness of primary low tential that 1000 or so new and fully cern. In this study, dropout did occur vision care on patients with early stages equipped optometrists would become due to the modified nature of holding of vision loss. available to serve the public each year. an in-person meeting rather than fol- Some optometric educators have been lowing all rounds online with the origi- To further facilitate the increased pro- concerned that too often low vision re- nal experts. While all of the experts in vision of low vision rehabilitation, habilitation has been taught as an op- the later rounds were involved in the research is needed to establish more tion to be practiced by only a few and original online voting process of round clearly the most efficacious and cost- that to practice well requires residency 2, the group discussion aspect was val- effective models of vision rehabilitation training or equivalent clinical experi- ued more than the traditional Delphi for private outpatient vision rehabilita- ence not typically available to optom- 14 anonymous methods. tion. With the development and uti- etry students. With a lack of clear di- lization of entry level competencies, Educational Policy rection in their work, some low vision graduating optometrists should be fa- rehabilitation educators may have been miliar with the concept of two levels of The comprehensive low vision rehabili- left to focus on simply offering inspi- care, especially since many of the com- tation curriculum recommendation in ration, training the most interested, or petencies contain a directive to refer for 1982 offered extensive recommenda- dispensing large quantities of unfocused comprehensive vision rehabilitation. In tions for specific instructional hours information to entire classes. this way, the competency structure it- and faculty resources. The high level of The number of students who pursue self encourages students and educators curricular commitment this would have further training or practice comprehen- to consider advanced rehabilitation. required may have led to its incomplete sive rehabilitation is estimated by the Not only are expectations set for the adoption.3 Low Vision Educators SIG as less than care of patients with early vision loss, The development of a well-defined set 10% per class year. With approximate- but expectations are created for referrals of entry level competencies in vision ly 1400 optometry graduates in the to colleagues who practice comprehen- rehabilitation care reported here may United States per year, 140 doctors in- sive rehabilitation. allow for schools and colleges to evalu- terested in vision rehabilitation would Overall, this project has utilized novel ate their programs individually and not seem sufficient to change practice techniques to allow optometric educa- to determine what curriculum adjust- patterns significantly. In a recent inves- tors to define competencies in entry ments may be warranted to best meet tigation of low vision practice patterns, level low vision rehabilitation or prima- the needs of graduating optometrists at Owsley initially identified 1228 low vi- ry low vision care that may have sub- their particular institution. Addition- sion service entities in the United States stantial implications for the education 10 ally, these entry level competencies may (any type of provider). Of the 608 en- and practice patterns of optometrists have implications at the national level tities responding to the census survey, in serving the needs of people with im- in the context of AOA policies and in 79.6% or 484 had an optometrist pro- paired vision. the consideration of specialties within viding some or all of the services. If the optometry as an outgrowth of the re- proportions hold true to the remain- Acknowledgements cent development of board certification ing entities that did not respond to the procedures for optometrists. survey, an estimated 1000 optometrists Special thanks to Low Vision Educa- are providing low vision services. This tors SIG Steering Committee members Optometric Education 106 Volume 35, Number 3 / Summer 2010 Dr. Pamela Oliver and Dr. Ana Perez, 5. Stelmack JA, Tang XC, Reda DJ, ophthalmic specialist. Klinische who assisted in conducting the consen- Rinne S, Mancil RM, Massof Monatsblätter für Augenheilkunde. sus process. Also, special thanks to Dr. RW. Outcomes of the Veterans 2006;223:S1-48. Dennis Sheridan, professor at Azusa Affairs Low Vision Intervention 10. Owsley C, McGwin G Jr, Lee PP, Pacific University, who assisted in the Trial (LOVIT). Arch Ophthalmol. Wasserman N, Searcey K. Charac- construction of the initial draft of the 2008;126:608-617. teristics of low-vision rehabilitation manuscript. 6. Massof RW. A model of the preva- services in the United States. Arch lence and incidence of low vision Ophthalmol. 2009;127:681-689. References and blindness among adults in the 11. Jones J, Hunter D. Consensus meth- 1. Gormezano SR. Promoting inde- U.S. Optom Vis Sci. 2002;79:31- ods for medical and health services pendence through low vision reha- 38. research. BMJ. 1995;311:376-380. bilitation. Optometry. 2005;76:327- 7. Kammer R , Jones L. Study of low 12. Hasson F, Keeney S, McKenna H. 331. vision recruitment potential. In: Research guidelines for the Del- 2. Massof RW, Alibhai S, Deremeik J, Optom Vis Sci; 2006:Supplement. phi survey technique. J Adv Nurs. Glasner N, Baker F, DeRose J, et 8. American Academy of Ophthal- 2000;32:1008-1015. al. Low vision rehabilitation docu- mology. SmartSight. In: Vision 13. Gallagher M, Hares T, Spencer J, mentation of patient evaluation rehabilitation for adults preferred Bradshaw C, Webb I. The Nomi- and management. J Vis Rehabil. practice pattern; 2006. nal Group Technique–a Research 1996;10(2):1-31. 9. International Task Force on Resi- Tool for General Practice. Fam 3. Association of Schools and Col- dent and Specialist Education in Pract. 1993;10:76-81. leges of Optometry. A plan for an Ophthalmology on behalf of the 14. Kammer R, Sell C, Jamara RJ, Koll- educational program in rehabilita- International Council of Oph- baum E. Survey of optometric low tive optometry. J Optom Education. thalmology (ICO). Principles and vision rehabilitation training meth- 1982;7:12-18. guidelines of a curriculum for edu- ods for the moderately visually im- 4. Association for Schools and Col- cation of the ophthalmic specialist. paired. Optometry. 2009;80:185- leges Low Vision Special Interest Chapter 15: Low Vision Rehabili- 192. Group. Low Vision Curriculum tation Principles and guidelines of Survey (unpublished data). 2008. a curriculum for education of the

Optometric Education 107 Volume 35, Number 3 / Summer 2010