Abstract
Background
An estimated 285 million people are vision impaired, 90% live in developing countries. There is little research examining ways in which mid-level
cadres can optimally contribute to eliminating avoidable visual impairment. This research sought to explore how the capacity of Pacific Eye Nurses
(PENs) can be further developed and better supported to provide quality care.
Methods
Using a Delphi process, PENs defined and prioritized elements of quality care. In semi-structured interviews 27 PENs shared their positive
experiences, challenges, contexts, and processes of improving care. A theoretical framework of self-regulation, synthesized from professionalism,
social-cognitive theory, and quality improvement, underpinned the qualitative data analysis.
Findings
PENs perceive that they are clinically competent and capable of making a difference. PENs descriptions of self-regulation and quality care are
concordant with literature from Western countries: PENs set goals, often to meet patient needs, and undertake self-reflection. If they detect a
discrepancy they attempt to improve care by engaging with local health systems and other practitioners, rather than through professional
development. PENs also describe changes to their perspective leading to innovations in care and intrinsic rewards. These improvements appear
strongly influenced by their reflective and metacognitive processes, values, beliefs, commitment, and emotions, interacting with contextual factors.
Reported challenges to care provision include competing goals, such as guideline-directed care versus care responsive to patients perceived
expectations, and attitudes towards traditional medicine.
Discussion
This research proposes a unique practitioner-centred approach underpinned by a transformative self-regulation framework, which provides insight
into improving health care quality. This approach expands upon both the synthesized framework and upon existing concepts of self-regulation as
maintaining a certain level of care. Even small changes can transform both care, and practitioners themselves, through a deeper understanding of
their inner self and abilities. The framework places practitioners and patients at the centre of complex socio-cultural, professional, and health
systems. Practitioners add value to care by challenging their own attitudes, beliefs, and behaviour, augmenting and strengthening health systems
from within. Recommendations for ongoing capacity development; cognitive, emotional, and systems support should encourage practitioners to
use a flexible approach to enhance care and mitigate breakdowns in self-regulation.