Original Research

Confident but undertrained: South African optometrists’ reflections on communication training

Elene Kruger, Mathys J. Labuschagne, Elzana Kempen

Received: 13 Aug. 2025; Accepted: 16 Mar. 2026; Published: 13 June 2026

Copyright: © 2026. The Authors. Licensee: AOSIS.
This work is licensed under the Creative Commons Attribution 4.0 International (CC BY 4.0) license (https://creativecommons.org/licenses/by/4.0/).

Abstract

Background: Effective communication is central to optometric care; however, structured training in delivering complex or emotionally sensitive information remains limited within undergraduate optometry programmes, particularly in comparison with other healthcare disciplines.

Aim: This study explored registered optometrists’ perceptions of communication skills training and their self-reported communication competence within undergraduate optometry education in South Africa.

Setting: The study was conducted in South Africa amongst registered optometrists working across diverse clinical settings.

Methods: A cross-sectional electronic questionnaire was distributed to registered South African optometrists. The instrument included closed- and open-ended items related to communication training exposure, self-assessed communication ability and perceived challenges. Quantitative data were analysed using descriptive statistics, and qualitative responses were thematically analysed.

Results: Despite limited formal undergraduate training, most respondents rated their communication positively, with 41.2% rating themselves as good and 38.8% as excellent, while only 1.2% rated themselves as novice. Training was inconsistent: 54.9% reported seldom receiving explicit training on consultation communication, while only 15.2% reported always receiving such training. Empathy was emphasised, with 85.4% agreeing that understanding the patient’s perspective is essential. Language and cultural diversity were recognised as inherent to practice, with 42.8% rating themselves as good and 16.8% as excellent at navigating these differences.

Conclusion: The findings reveal a mismatch between optometrists’ high self-reported communication confidence and limited formal undergraduate training.

Contribution: The results underscore the need for structured, intentional education in communication skills within optometry curricula to align training with the demands of contemporary clinical practice.

Keywords: clinical training; communication skills; cultural competence; optometry education; undergraduate curriculum.

Introduction

This study addressed the identified gap in optometry-specific evidence on undergraduate communication skills training by conducting a needs analysis amongst registered optometrists in private practice in South Africa. Using a structured questionnaire, it examined which communication skills are considered important, how well undergraduate training supported their development, and how confident practitioners feel in their communication ability. Understanding how communication skills are developed beyond formal education may offer valuable insight for curriculum reform and continuing professional development.¹

In contemporary optometric practice, effective communication is fundamental to patient care; however, it remains underemphasised within undergraduate optometry training. Whilst optometrists are well prepared to diagnose and manage ocular conditions, many receive limited formal instruction in delivering complex or emotionally sensitive information or in managing patient anxiety.^2,3 Despite this, optometrists frequently report high levels of confidence in their communication abilities. This apparent mismatch between self-reported competence and limited undergraduate preparation highlights a gap within optometry education.

Effective clinical communication is grounded in key principles, including active listening, empathy, clear information exchange and cultural competence.^4,5 Communication during optometric patient interactions, including case history taking, explanation of diagnoses and management plans and patient counselling, requires more than clinical accuracy; it demands the integration of interpersonal sensitivity and professional judgement.^3,6 Evidence suggests that effective communication enhances patient satisfaction, treatment adherence and clinical outcomes.^3,6 Nevertheless, structured and assessed communication skills training remains inconsistently implemented in undergraduate optometry programmes, leaving many new graduates feeling unprepared to manage complex interpersonal dynamics and diverse patient backgrounds.^7,8,9 Whilst medical and physician assistant programmes have made significant advances in formal communication training, optometry education appears to lag.²

Within the South African context, these challenges are further underscored by the expectations of professional competency. The Health Professions Council of South Africa (HPCSA) identifies the roles of Communicator, Collaborator and Health Professional as core competencies for optometric practice, emphasising the need for adaptable, patient-centred communication that supports understanding, autonomy and culturally responsive care.¹⁰

Despite South Africa’s diverse linguistic and cultural landscape, there has been limited research specifically examining communication training that is responsive to South Africa’s linguistic, cultural and practice context within undergraduate optometry education. Understanding these training experiences from the perspective of registered optometrists offers insight into perceived preparedness for real-world clinical practice.⁸ Existing studies have largely focused on general healthcare communication or have originated from international contexts with differing healthcare systems and practice environments.^11,12,13 Key aspects, such as sociolinguistic competence, cultural sensitivity and empathy, are seldom explicitly addressed within existing curricula.^5,14

This study addressed the limited optometry-specific evidence on how undergraduate communication skills training is perceived in retrospect by practising optometrists in South Africa, by conducting a needs analysis amongst registered optometrists in private practice. Using a structured questionnaire, this study examined the perceptions of registered optometrists regarding communication skills training and their self-reported communication competence within undergraduate optometry education in South Africa. The study was guided by the following research question: How do registered optometrists perceive their undergraduate training in patient-centred clinical communication, and how confident do they feel in applying these communication skills in practice?

Research methods and design

Setting

This study was conducted within the context of optometric clinical practice in South Africa, with data collected from registered optometrists predominantly practising in private practice. Although optometrists may engage with multiple professional environments during their careers, the focus of this study was on communication experiences relevant to routine patient care in private practice. Data collection occurred between November 2023 and May 2024.

Population and sampling

Eligible participants were optometrists registered with the HPCSA who were actively engaged in clinical practice at the time of data collection. The study focused on practitioners reflecting retrospectively on their undergraduate communication training in relation to their current clinical practice. Optometrists not involved in patient-facing clinical work were excluded from the study. Formal postgraduate qualifications or Continuing Professional Development (CPD) activities were not considered exclusion criteria, as the study aimed to capture practitioners’ perceptions of undergraduate preparation rather than post-qualification training. At the time of the survey, there were 3697 registered optometrists in South Africa. Based on this population size, the recommended sample size at a 95% confidence level was n = 348. A non-probability convenience sampling approach was employed, utilising available mailing lists from professional organisations, and the survey link could also be shared amongst peers, allowing for elements of snowball sampling.

Recruitment and data collection

Recruitment was initiated through the Graduate Institute of Optometry, which distributed the survey link to approximately 1500 optometrists via their membership mailing list, in line with the approved research protocol. To optimise participation, an additional professional organisation with a similar membership profile was approached to circulate the invitation. As participation was voluntary and the link could be freely shared amongst peers, some snowball sampling may have occurred, a common phenomenon in online survey research.

Response rate

A total of 175 completed responses were received, yielding a minimum response rate of 11.7%. As the link could be freely shared amongst peers via snowball sampling, the exact denominator cannot be determined, and the true response rate may differ. Although the achieved sample size represents approximately 50.3% of the calculated target sample size for this population, the study was descriptive in nature and did not aim to achieve statistical representativeness or inferential generalisation.

Study design

This study employed a cross-sectional descriptive design, using a self-administered electronic questionnaire to collect data from optometrists registered with the HPCSA. This design was appropriate for obtaining optometrists’ retrospective perceptions of undergraduate communication training and their self-reported confidence in communication at a single point in time.¹⁵ As the aim was to describe patterns rather than to test hypotheses or causal relationships, a descriptive design was considered most suitable.

To explore optometrists’ retrospective perceptions of undergraduate communication training and their perceived preparedness for clinical practice, a questionnaire was developed, guided by Harden’s extended curriculum framework.¹⁶ Harden’s framework recognises that learning occurs across three levels: (1) the formal curriculum, (2) the informal curriculum and (3) the hidden curriculum. Accordingly, the questionnaire included items addressing explicit undergraduate teaching of communication within clinical modules, informal skill development through observation and supervised clinical exposure during undergraduate training and unspoken learning experiences such as managing cultural and emotional challenges encountered in patient care.

Questionnaire items were designed to align with the study aim by capturing the perceived importance of communication skills, perceived adequacy of undergraduate communication training and self-reported confidence in applying these skills during patient interactions in clinical practice.

Data collection

This tool aimed to help registered optometrists identify important communication skills and reflect on past and current teaching methods. Participants were explicitly instructed to reflect on communication skills training and learning opportunities encountered during their undergraduate optometry education, whilst drawing on their current clinical experience to contextualise perceived preparedness for practice. Structured responses were facilitated by presenting statements instead of direct questions, in which participants rated their level of agreement on a Likert-type scale.¹⁷ This approach was used to enhance interpretability and to identify consistent patterns in participants’ responses. Closed-ended items were structured using Likert-type response options. Depending on the focus of the question, three different formats were applied:

• ‘Never or Seldom or Often or Always’ to capture frequency of experiences and behaviours.
• ‘Strongly disagree or Disagree or Agree or Strongly agree’ to capture levels of agreement with attitudinal statements.
• ‘Novice or Average or Good or Excellent’ to capture self-rated confidence in specific communication abilities.

For clarity, these response options are explained in the footnotes of the results tables. For ease of interpretation and to highlight consistent or frequent experiences, the proportions of participants selecting the two highest response categories (‘often’ and ‘always’) were combined when reporting key results.

The questionnaire also included open-ended items, allowing participants to elaborate on their responses and provide additional comments as needed. Open-ended items were presented as prompts rather than interrogative questions to encourage reflective responses. These questionnaire items are summarised in Table 1. The open-ended responses were intended to provide illustrative context for the quantitative findings rather than to generate in-depth qualitative interpretation. As responses were collected via a self-administered survey, opportunities for probing or contextual clarification were necessarily limited.

The questionnaire consisted of three sections: participant demographics, key elements of effective communication and perceptions of communication training and its relevance to optometric practice. The first section focused on the demographic profile of participants, including age, gender, year of graduation and home language. The second section examined the foundations of effective communication, encompassing key elements such as empathy, active listening, nonverbal communication and cultural competence. The third section explores the adequacy of training and communication skills, focusing on participants’ perceptions of their undergraduate training, their confidence in communication and the relevance of these skills in optometric practice.

For this study, an online web questionnaire in English was compiled using the EvaSys Education Survey Automation Suite. Before launching the main study, a pilot study was conducted to enhance the quality, reliability and validity of the questionnaire.¹⁸ Five full-time, HPCSA-registered optometrists were purposively selected for the pilot study, as they were representative of the target population and able to provide informed feedback on the content and format. Participants were requested to comment on the wording and relevance of questions, appropriateness of response options and the overall length and flow of the questionnaire. Feedback was provided directly via email and follow-up discussions. Pilot study participants reported no difficulties in completing the questionnaire, confirming its clarity, readability, feasibility and suitability for the research. No technical difficulties were reported. As no changes were made to the questionnaire following the pilot study, and pilot participants met the same inclusion criteria as the main study sample, the data collected during the pilot phase were included in the main analysis.

The researchers extracted numerical data from the closed-ended survey responses via the EvaSys system in Excel format. Qualitative comments from the open-ended items were exported separately. A biostatistician at the University of the Free State (UFS) conducted the statistical analysis of the numerical data. Frequencies and percentages were used to calculate categorical data. No inferential statistical analyses were conducted, as the purpose of the study was descriptive rather than hypothesis-testing in nature. Analyses were performed using Statistical Analysis Software (SAS) version 9.4 (SAS Institute Inc., Cary, NC, United States [US]).

A methodical coding technique was applied to the qualitative data gathered from the open-ended answers (Table 1). Open-ended responses were analysed using a thematic analysis approach. Initial line-by-line coding was conducted by the primary researcher, followed by independent coding by a second researcher. Coding differences, primarily related to the interpretation and grouping of meaning units, were identified through comparison of code lists. These differences were resolved through iterative discussion and refinement of code definitions until agreement was reached on the final themes, thereby enhancing credibility and reducing researcher bias.^18,19 No qualitative software was used; coding was conducted manually.

Ethical considerations

Ethical approval for this study was obtained from the Health Science Research Ethics Committee (HSREC) of the UFS (reference number: UFS-HSD2022/1963/2006). The study was conducted in accordance with the principles of the Declaration of Helsinki. Participation was voluntary, and participants could withdraw without penalty. Informed consent was obtained electronically at the beginning of the questionnaire. Participants were presented with an information sheet outlining the study’s aim, purpose and procedures, and by continuing with the questionnaire, they indicated their consent. The study was designed to minimise any potential risks or discomfort to participants. No identifying information was collected to ensure anonymity, and all responses were de-identified.

Results

Demographic profile

A total of 175 optometrists completed the survey. Not all participants completed every item on the questionnaire. As a result, the total number of responses for some questions is slightly less than the overall sample size of 175. Most were females, with 119 identifying as female (70%). The ages ranged from 20 years to 60 years, with the 20 years–30 years age group being the most represented, comprising 31.43% of the sample. Age was collected in predefined ranges; therefore, measures such as mean and standard deviation could not be calculated. Many participants had graduated between 2011 and 2020, with a significant proportion (33.73%) completing their studies more recently, between 2017 and 2020. Afrikaans was the most commonly spoken home language amongst participants, reported by just over half (53.18%), followed by English at 39.88%. Four per cent indicated Pedi as their home language, 2% Sotho and 1% Tsonga. The demographic data are shown in Table 2.

Key elements of effective communication

The questionnaire explored participants’ views on the essential elements of effective communication during patient–optometrist interactions in clinical practice, including case history taking, examination procedures and patient instruction (Table 3). Participants emphasised the importance of verbal and non-verbal communication in clinical consultations. A total of 63.91% indicated that verbal and non-verbal communication almost always play a significant role in patient interactions.

Additionally, 95.93% of participants reported that the phrasing of questions significantly influences the likelihood of obtaining honest patient responses, particularly during the case history-taking process. These views were further supported by 97.1% of participants, who confirmed that patient performance during an eye examination is directly affected by the quality of the optometrist’s procedural instructions, such as those given during visual acuity testing and refraction. A total of 86.12% of participants indicated that their undergraduate training focused primarily on practical aspects of communication, notably case history taking, rather than broader communicative competencies.

Most participants (63.74%) agreed that it is important to consider a patient’s physical characteristics (e.g. posture, mobility, visual or hearing limitations) and intellectual background when conducting eye examinations. An overwhelming majority of participants (97.7%) indicated that the ability to communicate with a diverse group of patients is important in practice. Overall, 98.27% of participants indicated that linguistic and cultural diversity, rather than diversity itself, can significantly impact patient communication when not adequately accommodated. Additionally, 72.78% noted that the physical setup of the consultation room, including the positioning of instruments, can influence how comfortably they interact with patients.

When prompted about their abilities, 42.77% of participants felt they could adequately manage language and cultural differences, whilst 85.38% reported that their ability to understand the patient’s point of view was good to excellent.

Perceptions of undergraduate training

Participants reflected on the adequacy of their undergraduate training in communication (Table 4). When asked whether enough opportunities were provided during their training to practise communication skills within undergraduate clinical modules and supervised clinical practice sessions, 59.64% indicated that this was seldom or never the case. Participants were instructed to consider structured opportunities for communication practice, such as guided case history taking, patient explanation and feedback during undergraduate clinical training. In line with this, 68.21% of participants reported not receiving adequate communication training at their training institutions. More than half (54.91%) of participants indicated that communication skills were not always explicitly taught during their studies.

In terms of the critical roles that underpin professional practice,¹⁰ participants reported that undergraduate training focused primarily on developing the role of health professional, particularly communication with patients during consultations (75.58%). In contrast, less attention was perceived to be given to the collaborator role (38.02%), which includes communication with other healthcare professionals. Only 21.18% of participants felt that communication with other healthcare professionals was adequately covered in the training. Participants reported that these communication outcomes were either ‘seldom’ (40.3%) or ‘never’ (18.7%) addressed during their undergraduate studies. Training related specifically to communication during patient consultations was also perceived as lacking (56.64%).

Relevance to practice and self-perception

The relevance of communication to patient care and optometrists’ confidence in their own skills was also explored (Table 4). The results showed that 97.68% of participants believed that effective communication has a significant influence on patient responses to care and improves clinical outcomes. Similarly, 97.64% emphasised that all forms of communication are important, highlighting the content of what is said and how it is conveyed and interpreted. Correspondingly, 97% of optometrists believe that their performance during an eye test strongly influences how the patient communicates with them.

Most participants (88.3%) emphasised the importance of considering a patient’s physical and intellectual abilities when collaborating with them, as these factors influence how information is explained, instructions are adapted, and patient understanding is verified during clinical interactions. Participants also emphasised the importance of accuracy during the examination, noting that unclear or misinterpreted findings could lead to patients receiving the wrong prescription glasses (81.18%). This highlights the importance of clear, patient-centred communication in ensuring that clinical findings are effectively conveyed and accurately understood. Despite having minimal formal training, participants recognised that communication significantly influences clinical outcomes and patient understanding. This importance appears to have been internalised primarily through practical clinical experience, rather than through structured undergraduate communication education.

To further explore self-perceptions, participants were also asked to rate their own communication abilities (Table 5). It is clear from the overwhelming number of participants (91.86%) who agreed that communication skills training would have helped them better understand the patient’s perspective, and 94.15% felt that learning better communication skills during clinical training would be beneficial for effective communication in actual practice. In response to whether communication is a natural ability or a teachable skill, 80.35% of participants believed communication can be taught. When asked to rate their own communication abilities more specifically, most participants rated themselves as good to excellent in their ability to communicate effectively during consultations (80%), to manage language and cultural differences (59.6%) and to understand the patient’s point of view (85.4%).

Questionnaire items were included to explore participants’ perceptions of how communication skills training, particularly in areas such as active listening, empathy and question phrasing, supports understanding the patient’s perspective and effective information exchange during clinical encounters. The questions were designed to capture participants’ perceptions of how communication-related competencies, such as listening, empathy, clarity of explanation and question phrasing, support patient understanding and effective clinical interaction, rather than to measure specific communication behaviours.

Thematic analysis

In addition to the quantitative findings (Table 2, Table 3, Table 4, Table 5 and Table 6), responses to open-ended questions (Table 1) were analysed thematically to provide illustrative insight into how optometrists reflect on communication in clinical practice. This qualitative component was intended to contextualise and support the quantitative results rather than to function as a standalone qualitative inquiry. Given the volume of responses, only findings directly relevant to the study objectives are presented. Themes were derived inductively, and selected verbatim quotes are included to illustrate key patterns identified in the data. Participant quotations are identified by number.

Four key themes emerged from the data: (1) Experience as a key factor, (2) Technological integration, (3) Cultural competence and (4) Empathy and listening.

Theme 1: Experience as a key factor

Participants emphasised that communication skills are developed primarily through repeated patient exposure rather than formal instruction. One participant (P85) reflected that improvement occurred ‘through seeing large numbers of patients’, whilst another (P72) noted that it had ‘taken me many years in practice to develop this skill’. These reflections reinforce the quantitative finding that optometrists reported high communication confidence despite limited undergraduate training.

Theme 2: Technological integration

Communication skill development through patient interaction was a common theme, and 40.3% indicated that communication skills outcomes were ‘seldom’ taught, whilst 18.7% reported they were ‘never’ taught (Table 4). One participant (P56) reflected, ‘limited scope and limited training’. Participant 46 confirmed this when they said, ‘I had to figure it out myself’.

Theme 3: Cultural competence

Cultural competence was frequently described in relation to language differences, which participants perceived as a key factor influencing patient understanding in practice. One respondent (P84) noted that ‘sometimes a language barrier is in place that makes instructions and explanations difficult’, whilst another (P51) highlighted that ‘inability to speak an African language can sometimes be challenging’. These reflections align with the quantitative finding that most participants recognised language and cultural diversity as influential factors in communication.

Theme 4: Empathy and listening

Listening attentively and responding empathetically was cited as equally important as explaining clinical findings (Table 3). One participant (P42) noted ‘Empathy, open-mindedness, and compassion’. This aligns with the 61.8% who reported a lack of confidence in delivering bad news. Another participant (P19) stated that ‘this includes maintaining confidentiality, displaying empathy’, which is confirmed by P63, who responded ‘Be kind and have empathy’.

Discussion

Throughout this study, communication is conceptualised as patient-centred clinical communication, encompassing case history taking, explanation of findings and management, procedural instruction and empathetic engagement during optometric consultations. Participants rated their communication skills as strong, and their confidence was primarily rooted in clinical experience rather than formal training. These findings provide insight into the complex relationship between self-assessed competence and actual communication ability, as well as the impact of training.

Limited formal training in communication

This study found that whilst optometrists highly value communication, many participants felt this competency was not adequately addressed during their undergraduate training. Although professionalism was emphasised, communication was often framed in procedural terms, such as taking a case history, rather than in terms of interpersonal engagement or emotional sensitivity. For example, whilst participants were aware of the roles outlined by the HPCSA, there was limited emphasis on developing their abilities as collaborators or communicators. This finding supports previous reports that communication is inconsistently taught in optometry programmes.^13,20 These findings highlight the responsibility of undergraduate optometry training institutions to ensure that communication skills are intentionally taught, practised and assessed as a core clinical competency.

Despite this lack of formal training, respondents recognised the value of communication and believed it contributes to better patient outcomes, suggesting a clear gap between perceived importance and curriculum emphasis. Inadequate communication training may negatively impact patient understanding, adherence to treatment, satisfaction with care, and the accuracy of clinical outcomes, particularly in contexts that require clear explanations, shared decision-making and emotional sensitivity. Prior studies that support this concern¹³ caution that optometrists risk being trained as technicians when the human connection is not emphasised. Daly et al.²⁰ observed that communication tends to be learned informally and inconsistently in clinical placements. This suggests that communication is not being regarded as a core clinical skill, with implications for patient safety, satisfaction and care outcomes. As a result of this gap in formal training, many participants rely heavily on clinical experience to develop their communication skills. To address this gap, undergraduate optometry curricula should integrate communication training as a core clinical competence by embedding structured opportunities for students to practice skills alongside technical instruction. Prior research suggests structured approaches, such as dedicated modules, simulation-based training and supervisor feedback, can reduce reliance on informal, trial-and-error training.^7,13,21

Learning communication skills through clinical experience

A key theme that emerged was that communication skills were primarily developed through clinical experiences over time. Participants described learning to adapt their language, build rapport and explain diagnoses through daily patient interaction rather than structured instruction. Such real-world encounters fill the gaps left by limited undergraduate training and help shift from uncertainty to confidence when in practice. This learning, however, was largely reactive, and skills were developed through necessity rather than through guided teaching or feedback. This highlights that, whilst experience is valuable, support with structured guidance and feedback, as well as clinical placements, should be such that learning takes place intentionally rather than by chance.

Whilst this practical model offers valuable exposure, it raises concerns about inconsistency and variability. Clinical communication competence is shaped by patient exposure, feedback and reflective practice, all of which can vary significantly across training contexts.^22,23 The 70-20-10 learning model²⁴ supports this emphasis on workplace-based learning, suggesting that most professional competence, approximately 70%, is acquired through real-life practice, with a further 20% gained through interactions such as supervision and peer feedback, and only 10% through formal instruction. However, as Schmid, Hopkins and Huynh⁷ argue, hands-on learning, whilst critical, cannot fully replace structured and deliberate teaching. Without formal opportunities to practise complex communication, such as navigating emotionally sensitive conversations, students may develop only surface-level skills, leaving them underprepared for more demanding clinical interactions. Programmes should address this gap by integrating structured teaching on complex scenarios alongside workplace-based learning for students to gain both clinical exposure and explicit skills.

Despite limited formal training, participants rated their communication abilities as good or excellent. However, this confidence may not always reflect competence. Many felt uncertain when managing complex tasks such as breaking bad news, which suggests that trial-and-error learning without feedback does not ensure preparedness. This concern points to an implicit assumption that, in many training environments, communication is a soft skill acquired passively. Without structured guidance for assessment, students may mistakenly believe they are performing well, even if they never receive critical feedback. The heavy reliance on experience also appears to influence how practitioners view their abilities, often rating themselves as high despite having little formal training. These findings indicate the need for formal assessment and targeted feedback in a clinical setting to reflect true competence.

However, a broader question emerges: Can communication be effectively taught through formal training, or is it better acquired through observation and hands-on experience? Literature suggests that formal instruction alone is insufficient, but it remains essential for providing foundational skills and frameworks.²⁵ True communicative competence develops most effectively through a blended learning approach that integrates formal training with contextualised practice, real-time feedback and reflective learning.²⁵ Therefore, whilst observation and clinical exposure are indispensable, they must be scaffolded by structured teaching to ensure consistency, depth and progression in students’ communication abilities.²⁶ Reform should therefore focus on blended learning approaches to combine early formal instruction with experiential learning.

As indicated in the responses to the Questions in Table 1 and Table 4, several participants developed communication skills informally, primarily by observing supervisors, peers, and other practitioners. Whilst observation can be a valuable learning tool, it is unreliable.^22,27 Students may adopt ineffective or inappropriate habits without explicit guidance or reflective supervision.²⁸ In programmes where communication is neither taught nor assessed intentionally, what students learn depends on whom they observe, which creates further variability and reinforces the need for structured and standardised approaches.

A related consideration is the role of the clinical supervisor in shaping students’ communication development. In the absence of structured training, students often rely on role modelling and observation, learning what to say and how to say it by watching their supervisors. As Passi et al.²² highlight, clinical teachers serve as powerful role models, intentionally or not, and their approach to communication profoundly influences how students understand and value interpersonal interactions in healthcare. However, if supervisors lack formal communication training or do not prioritise it during clinical teaching, there is a risk of reinforcing limited or ineffective practices. This speaks to the influence of the hidden curriculum, where students internalise subtle messages about what matters in practice, not from lectures but from day-to-day clinical culture.²⁷ Professional development of supervisors should emphasise the modelling of effective communication, making their approach explicit to students.

These insights suggest that improving communication competence in optometric education may require curriculum reform and targeted professional development for clinical supervisors to support more consistent, intentional teaching of communication skills. When communication is modelled inconsistently or not explicitly taught, students may develop confidence in their approach without fully grasping its limitations, contributing to the mismatch between self-rated ability and actual competence. Such findings may reflect the Dunning-Kruger effect, where students develop confidence in their communication approach without fully understanding its limitations, resulting in a mismatch between their self-assessed ability and actual competence.²⁹ Addressing the mismatch requires structured feedback and deliberate opportunities for students to practice and be assessed on their communication skills, thereby preventing overconfidence from masking gaps in competence.

Environmental and sociolinguistic factors in communication

As indicated in responses to Question 3.20 (Table 1), language barriers were frequently reported as obstacles to effective communication, particularly when explaining conditions or ensuring patient understanding in a second or third language. Afrikaans-speaking and English-speaking participants recognised the need to tailor their explanations for patients from diverse linguistic and cultural backgrounds. This challenge is not unique to practising optometrists. Hamad et al.³⁰ highlight a similar paradox in health education, where students trained exclusively in a non-native language often struggle to engage meaningfully with patients in their native language, despite understanding the clinical content. Such findings emphasise the need for explicit instruction and practice in adapting communication across linguistic and cultural contexts. This underscores the importance of incorporating multilingual and culturally responsive strategies into undergraduate communication training, ensuring that graduates are ready for diverse clinical settings.

Without tools such as interpreters, simplified explanations or visual aids, practitioners are left to manage complex conversations with limited resources. Even minor misunderstandings can affect treatment adherence, patient safety and trust in high-stakes clinical situations.^4,31 Embedding this into the curriculum, rather than leaving it to chance, would support better patient care and reduce students’ communication-related anxiety in diverse settings.^30,32 Optometric training may not adequately prepare students for the multilingual and multicultural realities of clinical practice in South Africa.^33,34 Whilst students may develop adaptive strategies through informal experiences, this cannot be a substitute for deliberate, structured preparation.^22,27 To bridge this gap, communication training must include multilingual communication strategies, culturally responsive care and practical tools for managing language diversity.^10,35

These findings are consistent with those of Flores³⁶ and Ngo-Metzger et al.,³⁷ who have highlighted the negative impact of language discordance on patient care in general health settings. In optometry, where explaining procedures and outcomes in clear, accessible terms is essential, this challenge may be even more pronounced. Jacobs et al.³⁸ found that even students who were generally confident in communication felt underprepared when required to explain clinical terms across language gaps.

Language training should not be an optional or assumed part of professional development; it must be explicitly addressed in communication education. Integrating culturally responsive strategies and multilingual communication tools into the curriculum could better equip students to navigate the complexities of real-world practice, especially in diverse and resource-limited settings. The emotional dimension of patient care is closely related to language and cultural sensitivity, where empathy and active listening play a vital role in building trust and ensuring understanding.

Empathy and listening

Another theme that emerged from the data was the importance of empathy and active listening in patient care. Participants frequently mentioned that understanding the patient’s perspective and responding sensitively could build trust, reduce anxiety and improve cooperation. Many participants acknowledged that how they listened and communicated had an influence on how patients perceived them and how well patients understood their condition and followed clinical advice.

Despite this awareness, participants felt empathy and active listening were not explicitly taught during their training. Instead, these qualities developed informally through clinical experience, particularly as students, they had already encountered the emotional complexities of patient care. The reliance on informal clinical training again aligns with the 70-20-10 model.²⁴ Some participants reported becoming more empathetic over time, whilst others described moments of emotional discomfort or uncertainty, such as when patients were distressed or when bad news had to be delivered. This suggests that deliberate opportunities should be introduced earlier for students to practice empathy and listening, especially with structured guidance and feedback.

This lack of formal instruction is concerning, especially given the evidence in healthcare literature that empathy improves patient satisfaction, strengthens therapeutic relationships and contributes to better clinical outcomes.^39,40 Rider et al.²¹ argue that empathy is not simply a personal trait, but a skill that can be taught and assessed through role-playing, feedback and reflective practice. Therefore, empathy is a teachable skill that can be strengthened through real-world experiences. These findings support that including empathy-focused exercises in the curriculum will strengthen these skills before students enter an environment of unsupervised patient care.

The emotional effects of communication, including how to listen effectively and manage emotionally charged conversations, are often overlooked in optometric education. However, these are the very skills that students later identify as essential once they are in practice. Including empathy-focused learning activities throughout the curriculum, particularly during early clinical exposure, would help future optometrists feel more prepared to handle the emotional realities of patient care.

Strengths and limitations of the study

A key strength lies in the combination of quantitative and qualitative data, along with thematic analysis, which enabled a deeper exploration of practitioners’ experiences. Open-ended questions enabled participants to reflect on their training and highlight real-world challenges that might not have been apparent through fixed responses alone. Few studies have explored how South African optometrists perceive the value of communication training. This study provides a foundation for future research and curriculum development.

The response rate for this study was low, with only 175 participants completing the survey. Several factors may have contributed to this, including survey fatigue, time constraints amongst practising optometrists and the voluntary nature of participation. The study relies on self-reported data, which may be influenced by social desirability and recall bias.

Recommendations

The findings of this study highlight the need to revisit how communication is taught in optometry programmes. Whilst real-world experience remains an influential teacher, it should be complemented by structured communication training that begins early in the curriculum and continues longitudinally throughout clinical placements. Topics such as empathy, cultural competence, conflict resolution and shared decision-making should be integrated as core competencies assessed with the same rigour as technical skills. Furthermore, incorporating feedback from patients and supervisors during training could help align self-perceived communication abilities with actual performance. Future research should investigate the long-term impact of formal training interventions on practitioner competence and patient care outcomes.

Conclusion

Whilst optometrists generally recognise the value of strong communication and often feel confident in their interpersonal abilities, many lack formal training during their education. Instead, they tend to develop these skills through firsthand experience. Although practical, this informal approach varies greatly depending on the clinical context, patient exposure and quality of supervision. Inadequate preparation in these areas can compromise patient understanding, adherence to treatment and ultimately clinical outcomes.

Despite being central to effective communication, complex factors such as language barriers, cultural dynamics and emotional sensitivity are often overlooked. These findings highlight the urgent need for optometry programmes to incorporate structured, assessable communication training such as simulation-based exercises and role-play supported by intentional role modelling by clinical supervisors. Further research should explore how such reforms influence practitioner confidence, communication competence and patient care outcomes.

Acknowledgements

This article is based on data from a larger study. A related article focusing on a narrative assessment of communication training in healthcare education and the implications for undergraduate optometry programmes has been published in African Vision and Eye Health 2026; 85(1), a1103. The present article addresses a distinct research question, examining registered optometrists’ perceptions of communication skills training and self-reported communication competence in South African undergraduate optometry education.

This article is based on research originally conducted as part of Elene Kruger’s doctoral thesis titled, ‘A framework for communication skills training of undergraduate optometry students in South Africa’ submitted to the Faculty of Health Science, University of the Free State in 2025. The thesis is currently unpublished and not publicly available. This thesis was supervised by Mathys J Labuschagne and Elzana Kempen. The manuscript has since been revised and adapted for journal publication. The author gratefully acknowledges the contributions of the registered optometrists who participated in the study by completing the questionnaire.

The authors Elene Kruger, Mathys J. Labuschagne and Elzana Kempen declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.

Elene Kruger: Conceptualisation, Formal analysis, Investigation, Methodology, Project administration, Resources, Visualisation, Writing – original draft. Mathys J. Labuschagne: Conceptualisation, Methodology, Project administration, Supervision, Writing – review & editing. Elzana Kempen: Conceptualisation, Methodology, Project administration, Supervision, Writing – review and editing. All authors reviewed the article, contributed to the discussion of results, approved the final version for submission and publication, and take responsibility for the integrity of its findings.

The authors received no financial support for the research, authorship and/or publication of this article.

The anonymised data that support the findings of this study are not publicly available due to participant confidentiality and the conditions of the ethical clearance granted by the Health Science Research Committee at the University of the Free State (UFS-HSD2022/1963/2006-0002). Deidentified data may be made available by the corresponding author, Elene Kruger, upon reasonable request, subject to additional ethical approval where applicable.

The views and opinions expressed in this article are those of the authors and are the product of professional research. They do not necessarily reflect the official policy or position of any affiliated institution, funder, agency or that of the publisher. The authors are responsible for this article’s results, findings, and content.

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