*1.1. Proto-Professional*

The prefix 'proto' derived from the Greek word 'protos' meaning first, suggests that this may be applied to professionals in the early part of their career journey. Considering the application of this term to the Optometrist, it may be considered that pre-registration and newly qualified Optometrists are considered proto-professionals.

In the UK, pre-registration Optometrists are those who have completed an undergraduate Optometry qualification at the honors degree level and are working in a practice or hospital under the supervision of a qualified Optometrist during their 'Scheme for Registration', administered by The College of Optometrists. They are required to complete a period in practice, examining and dispensing a specified number of patients during this period. Following this time, which is typically a one-year period, they are required to undertake a series of assessments, or Objective Structured

Clinical Examinations (OSCEs). These OSCEs represent Stage 2 of the qualification, with Stage 1 being the completion of the degree level qualification. In addition to the Stage 1 and 2 qualifications, Optometrists are also required to achieve clinical competency in a number of areas at both these time points and in addition, have observed assessments during the course of the pre-registration period.

Pre-registration Optometrists work full-time while studying for their final professional qualifications. There are limited data describing the perceptions of pre-registration Optometrists, however, Parkins, et al. [2] suggested that newly qualified Optometrists are more likely to generate a higher number of referrals to the Hospital Eye Service than more experienced practitioners. This study revealed that two newly qualified Optometrists generated 12.5% of the total number of referrals in the audit. The study suggested that pre-registration Optometrists referred more appropriately than newly qualified Optometrists, but this is perhaps due to the fact that pre-registration Optometrists are supervised closely and any referrals will be signed o ff by the supervisor.

The General Optical Council (GOC), the regulatory body for Optometrists, published a discussion paper on 'Professional boundaries and service needs in eye health services' and recognized that there may be specific areas of training required for newly qualified Optometrists to ensure 'registrants are equipped to practice safely across the UK in accordance with professional standards' [3].

Howell-Du ffy, et al. [4] also agreed that experience influences managemen<sup>t</sup> and prescribing decisions made by Optometrists. Newly qualified Optometrists were more likely to prescribe full spectacle corrections while older and more experienced optometrists more likely to 'prescribe a partial correction'. This was three times more likely for Optometrists with a career of at least 40 years. Reasons for this included more experience with patient's intolerance to spectacle prescriptions.

Often, Optometrist's duties may be delegated to other optical sta ff including dispensing opticians and optical assistants. Dispensing opticians are a separate professional group, educated to either diploma or degree level who work with Optometrists to ensure that patients have an appropriate choice of spectacle frame and lenses. These delegated duties may include dispensing and pre-screening which involves obtaining measurements prior to the actual eye examination to inform the Optometrists' clinical managemen<sup>t</sup> decisions (e.g., measurements of intraocular pressure or visual field assessments). Post eye examination screening may also take place following recommendations for further tests by the Optometrist (e.g., measurements of retinal thickness during optical coherence tomography). These roles may be considered proto-professional in the context of the Optometry practice. Delegation of duties is often viewed as a minefield and leaves the Optometrist exposed to legal ramifications. Delegation is discussed in detail as part of the Professional Guidance from The College of Optometrists [5]. The guidance states that when you delegate duties you are still responsible for the overall managemen<sup>t</sup> of the patient and the work of the person to whom you have delegated. Recently, Optometrist Honey Rose was convicted of manslaughter after a missed diagnosis of papilledema, or optic disc swelling in an eight-year-old boy who later died [6]. Although the photographs of the child's optic discs were available at the trial there was a query regarding whether the Optometrist had actually seen these on the day the patient attended. This highlights how the delegation of roles can put both the patients and the professionals at risk of adverse outcomes. This conviction has since been overturned, however, the case has prompted Optometrists to seek additional training and advice from professional bodies regarding this medical condition.

## *1.2. No Optometrists*

Whilst strictly outside the Place Model, millions of people across the world have limited access to eye care. Globally, 36 million people are blind with over 200 million having a moderate or severe visual impairment, however, more than 75% of all vision loss is avoidable [7]. In 2012, the World Health Organisation stated that governments could add millions of dollars to the global economy by investing in eye examinations and the provision of glasses for 700 million people worldwide [7]. The study estimated that 65,000 more Optometrists, Ophthalmologists, Optical Dispensers and other eye care professionals would be required to provide these services and that a cost of approximately 25,000 million to set up and run would be returned 10 fold by providing much needed eye care services. Investing in eye care demonstrated a 22% productivity increase amongs<sup>t</sup> tea plantation workers in India during a one-month period [8]. Investing in education for eye care has vast economic and health benefits for the community.

## *1.3. The De-Professionalised*

According to the Place Model, the de-professional includes practitioners who have significant experience in their profession but have become demotivated and disengaged with their professional values and skills over time. The members of this quadrant may previously have been highly motivated and enthusiastic professionals but have been a ffected by their experiences in the workplace, which have left them cynical and uninspired by their role. The role of Optometrists has changed gradually over the previous generation with newer practitioners being more likely to work in large practices with multiple Optometrists rather than smaller community practices. In addition, the increase in the use of technology has been rapid over the previous 20 years with many practices now owing optical imaging technology, automated refractive technology and computerized patient record systems. Some practitioners may be unable or unwilling to invest in the technology which they may feel is unnecessary or prohibitively expensive which may perhaps present an image of not being up-to-date with modern practice.

Fortunately, Optometrists in the UK are required to enroll on a continual scheme of education and training which ensures that they engage with peers and Optometric educators on a regular basis. The scheme, administered by the regulatory body, the General Optical Council ensures that Optometrists must gain new or updated knowledge and skills across a broad range of di fferent clinical areas. In addition to gaining a specific number of 'CET (continuing education and training) points' over a three year period, registrants are required to gain a certain number of points per year, some of which must be 'interactive'. The interactive nature of this engagemen<sup>t</sup> ensures that practitioners have some level of engagemen<sup>t</sup> with others during the course of their work, preventing those practitioners working in more remote locations or in small practices from becoming isolated from any important developments in the field.

## *1.4. Precarious Professionals*

The Place Model describes precarious professionals as those who may have low status and have not maintained professional development beyond their initial qualification. It also may include both transients and also unprofessionals.

This status may be due to many contributing factors, such as the inability to secure a permanent position, an unsupportive or ine fficient workplace or a lack of enthusiasm for the profession. The precarious professional may also represent over-confident professionals who place their own professional judgements above guidelines and regulations. The Precarious Professional is at risk of being investigated for Fitness to Practice issues.

In the UK, the General Optical Council is the professional regulator for Optometrists, Dispensing Opticians and optical businesses [3]. One of the four key functions of the GOC is 'investigating and acting where registrants' fitness to practice, train or carry on business is impaired'. Fitness to practice complaints about GOC registrants can be received from members of the public, patients, carers, employers, the police and other GOC registrants. Fitness to practice issues may relate to one or more of the following factors:


## • A finding by another regulatory body.

The precarious professional may find themselves the subject of a Fitness to Practice investigation if they do not maintain an adequate level of knowledge and skills.
