Stakeholder Experiences of Competency-Based Optometry Education in Nigeria: A Multi-Site Qualitative Study Including Private Practice Employers

Technical Summary: Stakeholder Experiences of Competency-Based Optometry Education in Nigeria

Problem Statement
Health professions education globally is shifting from time-based curricula to competency-based education (CBE) models. However, in Nigeria, the optometry discipline remains understudied regarding this transition. While the National Universities Commission (NUC) and the Optometrists and Dispensing Opticians Registration Board of Nigeria (ODORBN) are driving reforms toward a Core Curriculum and Benchmark Minimum Academic Standards (BMAS), the perspectives of the primary stakeholders—students, lecturers, institutional leaders, and private practice employers—remain undocumented. The study addresses the gap between policy adoption and the lived reality of implementation, specifically investigating whether the current system produces clinically competent graduates and identifying the barriers to a successful transition to CBE.

Methodology
The study employed a qualitative descriptive design utilizing reflexive thematic analysis (Braun & Clarke). Data were collected from 31 purposively recruited participants across four stakeholder groups:

• 16 students (400–600 level)
• 7 lecturers
• 2 institutional leaders (Heads of Department)
• 6 private clinic owners/employers

Participants were drawn from five anonymized Nigerian universities and associated private practice settings. The primary data collection method was individual semi-structured interviews (conducted predominantly via telephone), supplemented by structured written responses from a subset of participants unable to attend oral interviews. The analysis followed six phases of reflexive thematic analysis, coding data independently within and across stakeholder groups to identify convergences and divergences. Trustworthiness was established through Lincoln and Guba's criteria (credibility, dependability, confirmability, transferability), and the study received ethical approval from the University of KwaZulu-Natal and Benue State University Teaching Hospital.

Key Contributions
The paper's primary contribution is the identification of private practice employers as an "informal corrective layer" in the competency verification process. While existing literature on CBE in Africa focuses largely on university-based implementation, this study empirically demonstrates that private clinic owners currently perform a de facto competency verification and remediation function for new graduates. This role is currently unrecognized, unstandardized, and unpaid within the formal regulatory framework.

Additionally, the study distinguishes between attitudinal readiness (stakeholder support for the CBE philosophy) and structural readiness (the availability of resources, equipment, and staffing), clarifying that the latter is the primary bottleneck in the Nigerian context.

Results
Five distinct themes emerged from the data:

1. Competence as Intended but Inconsistently Verified: Stakeholders agreed that while the system aims to produce competent optometrists, passing examinations does not reliably predict independent clinical performance. There is a noted disconnect between theoretical exam success and the ability to perform basic clinical tasks.
2. Theoretical Strength vs. Practical Uncertainty: Participants reported a strong theoretical grounding but significant uncertainty in practical skills. Specific procedures such as retinoscopy, ophthalmoscopy, and slit-lamp examination were cited as areas where students lacked sufficient repeated, supervised practice opportunities.
3. Resource and Manpower Constraints as Central Barriers: The primary obstacles to CBE implementation were not philosophical opposition but structural deficits. These include shortages of diagnostic equipment, high student-to-lecturer ratios, and insufficient clinical space.
4. Cautious Optimism and Conditional Readiness: Stakeholders expressed support for CBE but conditioned their readiness on specific factors. Lecturers noted a lack of training in designing rubrics and conducting workplace-based assessments (e.g., OSCEs), while students emphasized the need for earlier introduction of competency expectations.
5. Employers as an Informal Corrective Layer: Private clinic owners described a period of "informal training" during the first months of a graduate's employment. They actively verify and correct competencies that the university system failed to confirm, effectively acting as an unstandardized safety net.

Significance and Claims
The paper claims that the transition to competency-based optometry education in Nigeria is supported by stakeholders in principle but hindered by resource constraints rather than ideological resistance. The study argues that the current reliance on private clinics to "fix" competency gaps is an unsustainable, informal mechanism.

The authors propose that for CBE to be effective, the informal verification role of private practice must be formalized through structured externship partnerships. This would involve creating accredited externship sites, mapping entrustable activities to the WHO Eye Care Competency Framework, and establishing shared assessment scales. The study concludes that successful reform requires simultaneous investment in diagnostic infrastructure, faculty training in assessment design, and the institutionalization of the employer-educator partnership, rather than viewing curriculum reform as a standalone academic exercise.

Limitations
The authors acknowledge that the small sample size (particularly the n=2 for institutional leaders) limits the generalizability of findings to all Nigerian institutions. Furthermore, the mixed-mode data collection (oral interviews vs. written responses) introduced variations in depth and spontaneity, which were managed during coding but noted as a methodological constraint.