Online Faculty Development: An African Lusophone Ophthalmic Society Experience During the COVID-19 Pandemic.

PURPOSE: Faculty development for procedural specialists aims at developing both their medical education and surgical competence. This has been challenging during the COVID-19 pandemic, especially in under-resourced settings and African Lusophone ophthalmology community has been no exception. The Mozambican College of Ophthalmology (MOC) and the Continuing Professional Development Committee of the International Council of Ophthalmology (ICO) established a collaboration to enhance simulation-based clinical teaching competence in cataract surgery.
METHODS: Ten Mozambican ophthalmologists experienced in teaching cataract surgery participated in a group mentoring assisted 6 month/11 flipped-learning online experience on curriculum design, which included practice-based and social learning strategies, continuous bidirectional feedback, individual and group reflection opportunities, and the demonstration of declarative and procedural competencies. Program evaluation consisted of pre and post-test knowledge assessment; individual homework, informed by curated reading and a recorded lesson; feedback surveys for each module and one month after the program's conclusion, and a longitudinal project on creating a simulation-based education session on one step of cataract surgery.
RESULTS: Participants a) highlighted the opportunity to advance their scholarly teaching skills as facilitators; b) showed an increase in knowledge post-test, expressed commitment to improve their learning experiences´ design, include interactive educational methods, and provide constructive feedback; and c) formed a sustained community of practice of ophthalmologists educators (CoP).
CONCLUSION: This online faculty development program, assisted by group mentoring, held during the COVID-19 pandemic, facilitated the development of a CoP and was effective in enhancing teaching competence in curriculum design to apply in simulation-based learning environments. Copyright:

Introduction

Facilitating knowledge and skills to their peers is part of clinical educators’ roles.[1] They are accountable to their learners and society for developing educational products with impact on learners’ education, the organizations they work, patients’ outcomes, and public health, and their professional fulfillment.[2]

Interest in clinical education has been recently growing, and several international education agencies propose competency frameworks that acknowledge clinical teaching and scholarship.[3] Academia has additionally been recognizing medical education as a discipline with potential career opportunities and requiring effective faculty development.[4]

Experienced and better-prepared faculty will be more confident in developing learning activities with performance improvement and better patient outcomes.[5] Educators and learners recognize the benefits of formal medical education;[6] however, widespread impactful learning opportunities to enhance clinical teaching are still unbalanced for the needs,[2] especially in geographically remote low-income areas.

Communities of practice (CoP) for faculty development have been shown to effectively scaffold knowledge building, and implementing best practices based on a contextual approach to practical solutions for daily problems, and advance clinical expertise.[78] Fostering the formation of a virtual network of ophthalmologists-educators concentrated on developing clinical teaching competence is a sustainable collective strategy to longitudinally learn from each other.[9] Creating constructive long-lasting relationships is relevant for professional growth, self-accomplishment awareness, and professional identity development.[10] Engaged faculty with an ownership feeling expands international peer networking, attracts national faculty and learners, and stimulates further improvement.

Mentoring communities aim to secure the wisdom and experience of one or more people to benefit a learning community.[11] Contextualized, regional training was shown to enable knowledge translation into practice with increased likelihood of sustained national health-care professionals and better clinical performance.[12131415]

Cybersight[16] is a global, not-for-profit telemedicine platform, founded by Orbis International. By offering online education and access to international expert faculty, connecting professionals, clinical organizations, health systems, and nongovernmental organizations, Cybersight aims to mitigate the shortage of eye health professionals and geographic isolation in developing countries, to reduce avoidable progressive visual impairment.

The International Council of Ophthalmology (ICO) was formed in 1857, when 150 ophthalmologists from 24 countries met for the first International Congress of Ophthalmology. The ICO has since been working globally with ophthalmology societies and individuals to improve education, eye care delivery, and leadership. The ICO has worked with several education models[17] to implement continuing development activities, especially in low-income countries,[18] and developed worldwide experience in cross-cultural faculty development.

Mozambique is a predominantly rural sub-Saharan southeast African country spreading over 799,380 km2 with a population of over 29 million and life expectancy of 60.5 years.[19] Insufficient response to treatable blinding conditions such as cataracts and glaucoma accounts largely for 99,378 blinded people and 461,710 with moderate/severe visual impairment. With significant disparate geographical distribution, ophthalmologists represent 8.5% of the total eye care workforce and a 4 per million population ratio, which is well below the standard recommended.[20] A subset of the Mozambican General Council, the Mozambican College of Ophthalmology (MOC) has 20 registered ophthalmologists,[21] who represent over 95% of ophthalmologists in Mozambique. MOC is the ophthalmologists’ accreditation body, oversees their continuing professional development (CPD), and certifies postgraduate and CPD programs.[22]

This article describes the collaboration between the MOC and the ICO committee for CPD, aiming to develop MOC faculty in curriculum design for surgery simulation-based education (SSBE), while applying social learning principles and group mentoring. Specific objectives were to (a) Create CoP, (b) Advance competence in evidence-informed education, and (c) Prepare to implement a SSBE center.

Methods

A group of ten ophthalmologist members of the MOC accepted their president's invitation (AB) to participate. They were based in Maputo, Nampula, Matola, and Beira. All were residency program directors, residency mentors, and CPD trainers. We will designate this group as the MOCg.

Faculty consisted of an international group of experienced ophthalmologists-educators serving the ICO in education leadership positions: The Director for Education (KG), USA; the CPD Committee Chair Habitat Professionals Forum (HPF), Portugal; the Teaching the Teachers Committee Chair Grand Prix, Argentina; the Technology for Ophthalmic Education Committee Chair (EM), Argentina; and the Director of the American Board of Ophthalmology and Chair of its Maintenance of Certification Program (American language), USA. Faculty is experienced in co-creating faculty development learning experiences in English. We will designate this group as a the ICOg.

Two Cybersight professionals with expertise in online education and public health agency (AG) and in information and communication technologies (LS) made the program comply with digital best practice[23] for an enjoyable and effective navigation, assisted administratively (AG + LS), uploaded the program in the platform (LS), and lectured (AG).

The ICOg created and facilitated the online “Self-Administered Faculty Development Series: An ICO CPD Course” (FDS-ICO/CPDc). The program was created in English, as a global spoken language and considering that a fair level of English comprehension is usually required from physicians in pursuit of their continuing education.

This is a 25-h full program of 11 standalone modules on curriculum design, following the model of Kern [Table 1]. It has been freely available at the Cybersight platform since May 2020 and was designed with a particular emphasis on SSBE curriculum design. Module 10 consists of a guided tour on Cybersight catalog for potential programs’ adaptation to facilitate small group surgery skills training. Because adult learning principles cross all modules, the first one was named module 0.

Table 1

Faculty development series-International Council of Ophthalmology/continuing professional development course plan

	Month	Content	Faculty
Module 0	1	Applying adult learning principles	Palis
Module 1	2	Identifying a health-care problem. Analyzing the gap. Assessing the needs	Filipe
Module 2	2	Building an outcome-based curriculum	Golnik
Module 3	3	Lecture skills workshop	Golnik
Module 4	3	Workshop skills on simulation-based education	Filipe
Module 5	4	Techniques for teaching small and large learning groups	Mayorga
Module 6	4	Effective feedback and deliberate practice	Lauer
Module 7	5	ICO-OSCARs. VOPs and DOPs, logs and portfolios	Filipe
Module 8	5	Implementation: Teaching surgery: Simulated ocular surgery	Mayorga
Module 9	6	Assessment and evaluation: Closing the loop?	Filipe
Module 10	6	Facilitating the Cybersight online courses	Geary

ICO: International Council of Ophthalmology, OSCARs: Ophthalmology Surgical Competency Assessment Rubrics, VOPs: Video Observation Procedural Skills, DOPs: Direct Observation Procedural Skills

Modules were sequentially held (May–October 2020) bimonthly in a flipped fashion. Each 2.5-h module comprised (a) a pre- and posttest, (b) curated readings, (c) a recorded lecture, (d) an individual activity, and (e) a synchronous interactive 1-hour Zoom session. Live sessions usually commenced with reviewing participants’ activities and questions tests.

The MOCg took the program in a group mentoring-assisted manner (HPF and AB), simultaneously created a sustained WhatsApp-based virtual CoP, and additionally to the 11 modules, undertook a recurrent online 1-h synchronous session with a Portuguese native speaker facilitator HPF.

Evaluation strategy

Feedback

Participants gave online feedback after each module. The survey consisted of three open-ended questions: (a) aspects they liked best, (b) those they liked least, and (c) what they planned to implement in their practice as clinical educators; and one closed-ended question scored against a three-level Likert scale (1-totally; 2-partially; and 3-not) about expectations met.

A month after concluding the program, participants completed an online feedback survey comprising the above three open-ended questions with an addition of eight closed-ended questions. The latter included three of the four questions that constitute the critical reflection dimension of the reflective thinking survey by Kember et al.[24]

Learning improvement

Declarative

Participants completed modules’ activities and responded to a pre- and a posttest.

Activities were designed to address the content of the recorded lecture and curated readings. Once completed, they could be shared in the platform or e-mailed to each module's facilitator for feedback.

Pre- and posttests consisted of two single best answers, four options, multiple-choice questions. One was built upon the recorded lecture; the other was based on suggested bibliography and required a higher level of thinking.

Procedural

During module 4, participants were invited to practice Kern's model of curriculum development by individually designing a SSBE session on a cataract surgery step, as described in the MSICS ICO-OSSCAR@rubric,[25] using a ten-slide-deck template. Enhancements were welcome to reach a final version to upload no later than a month after the program's conclusion.

Data analysis

Qualitative data were analyzed by Habitat Professionals and subsequently reviewed (HM) according to the inductive approach (observation > patterns>hypothesis > theory), seeking to synthesize underlying meanings from the short comments of participants.[26] Quantitative data were descriptively analyzed using Google Excel tools.

Certification

Three types of certificates were planned to be awarded: (a) Attendance, for those attending the synchronous moments without homework completion; (b) Participation, for those who completed at least 80% of the tasks proposed; and (c) Commendation for those wishing to share their experience beyond the program with theirs and their mentees’ reflective logs on SSBE.

Ethical approval

The study followed the principles of the Declaration of Helsinki. All information was collected from the MOCg participants solely for academic purposes in an anonymous manner and reported in aggregate. The MOC does not have an ethics review process.

Results

A virtual CoP was formed by the ten Mozambican ophthalmologists and has been sustained through WhatsApp and the MOC website to the time of writing (May 2021). It has expanded to include four ophthalmologists who were not participants in the program. Anecdotally participants reported that regular virtual sessions in addition to the program, with a native Portuguese speaker facilitated the CoP development.

Feedback during the program

Fifty feedback survey responses were collected from a total of 100 possible responses (10 participants ×10 modules, as the 11th did not focus on medical education knowledge). Participants emphasized having enjoyed learning about (a) adults learning needs of autonomy, respect, and content relevance; (b) conducting needs assessment and clearly defining learning expectations and outcomes; (c) the structure of a workshop and how it can effectively facilitate surgery performance; (d) large group teaching and small group dynamics awareness and management; (e) the attributes of a good facilitator; (f) effective feedback; (g) teaching/assessment tools; and (g) assessment and evaluation.

Long activities, Internet connection, language challenge, and more practicing time were expressed as potential areas for improvement.

Participants stated their plans on (a) involving learners in the educational process; (b) improving goals and learning objectives; (c) crafting structured interactive lectures; (d) developing facilitation skills; (e) creating a culture of feedback; (f) using teaching/assessment tools as the portfolio and rubrics to anchor facilitated feedback; and (g) using their resources at best to facilitate SSBE [Table 2]. Expectations were 44 times expressed as totally met and 6 times partially met.

Table 2

Participants’ feedback (themes) during the program (open-ended questions, (n=50 answers)

Module title	What I liked best	What I liked least	What I plan to apply in my practice as an educator
0. Applying adult learning principles (n=7)	Learn that adults set their own study schedules, need a sense of purpose and teaching relevance	Some language challenges	Build learner-centred activities, involve learners in the learning process
		Complex prereadings and quiz	Improve educational planning-small group teaching methods, include feedback and reflection
1. Identifying a health-care problem. Analysing the gap. assessing the needs (n=5)	Conduct a needs assessment	Nil	Assess baseline learning
			Apply evidence-informed teaching
2. Building an outcome-based curriculum (n=8)	Create goals and SMART objectives	Even few opportunities to practice creating goals and objectives	Create goals and objectives to reach outcomes
	Learn about action verbs
	Discuss prior experience		Structure the lecture: Introduction (get the audience thinking and involved)
	Develop case-based learning
	Learn how to plan an outcome based educational program
3. Lecture skills workshop (n=9)	Learn about attributes of a good speaker	Nil	Include interactivity in lectures
			Be a credible presenter
4. Workshop skills on simulation-based education (n=6)	Design a simulation-based education session as a workshop	Language challenge	Principles-to run a successful workshop/surgery simulation-based education session
	The role of the facilitator
	How to maximize active learning	Internet glitch	Faculty roles in a workshop/how to be a good facilitator
5. Techniques for teaching small and large groups (n=5)	Learn to apply different educational strategies for small and large groups	Internet glitch have handouts	Plan carefully ahead the learning experience
	Advantages of planning educational activities for small groups	Language challenge	Improve facilitation competence to create a supportive and trustful learning environment
6. Effective feedback and deliberate practice (n=3)	Learn to value feedback	“Would like to have taken this course earlier to change my way of teaching”	Create a culture of feedback-provide it timely, constructively, create a relationship with the learner, seek the learner gets involved in the process to apply it I practice and demonstrate change, offer opportunities to overcome difficulties, praise accomplishments, guide personal learning plan
	Provide effective feedback
			Create safe learning spaces
7. ICO-OSCARs. VOPs and DOPs, logs and portfolios (n=3)	Learn about the portfolio as a learning and a guided reflection tool	Nil	Implement a reflective portfolio
			Use rubrics as learning/assessment tools
8. Implementation: Teaching surgery: Simulated ocular surgery (n=2)	Learn about the	Nil	Optimize surgery time and patients (break down in steps the surgical procedure and offer the resident to try)
	Competencies of a good surgeon
	Importance to optimize the Operating time and patients
	Importance of simulation-based training		Manage and implement low tech-cost wet-lab to provide guided practice in a safe learning environment
	Concept of reflection (in and on action)
9. Assessment and evaluation: closing the loop? (n=2)	Learn about	Long activity	Provide routinely quality feedback
	The concept of simulation		Teach and assess simultaneously by using rubrics and portfolios
	The diagnostic, formative and summative assessment types

ICO: International Council of Ophthalmology, OSCARs: Ophthalmology Surgical Competency Assessment Rubrics, VOPs: Video Observation Procedural Skills, DOPs: Direct Observation Procedural Skills, SMART: Specific, Measurable, Accredited, Relevant, Time-Framed

Feedback from 1 month after the program

Five participants (50%) responded [Table 3]. They enjoyed having learned about (a) improving facilitation competencies to get their learners thinking and involved; (b) translating learning theory strategies into their clinical education practice; and (c) creating a safe and supportive learning environment with a word of remark for having two mentors (and one facilitator) speaking their native language.

Table 3

Feedback given by 5 participants one month after concluding the program (open‐ended questions)

What I liked Best		What I liked least		What I plan to apply in my practice as an educator
Themes	Answers	Themes	Answers	Themes	Answers
Improve facilitator competencies to get audience thinking and involved	Create interactive lectures, formulate learning objectives with action verbs, refine slides, develop skills to be a credible presenter, develop reflection strategies, improve given feedback, apply adult learning principles, apply active learning, conduct a needs assessment	Avoid time consuming homework	“Long exercises however, having homework helps captivating interest and attention from learner”	Improve teaching methods	"Improve learning objectives building”, “Use the feedback methodology"
Ignite scholarly work and translate educational theory into clinical teaching	Design student centred experiences, link learning objectives with outcomes and use the appropriate teaching content and assessment strategies, run structured workshops, use learning and assessment tools as portfolios and rubrics, use surgery rubrics to teach and debrief, optimize time in the operating theatre to provide frequent formative feedback, teach surgery stepwise	Overcome language challenge	"It would be very useful if the full course was in Portuguese”, “This course should be translated into Portuguese”	Improve scholarly teaching	" Demonstrate behaviour change in adult education”, “Apply the acquired knowledge "
Create a safe and supportive learning environment - iterative improvement	Set the expectations at the beginning of a learning event, create positive relationships, stimulate constructive feedback, know “your” learners, develop an outcome-based curriculum map	Enhance support for enduring didactics	Little time for the interspersed live sessions in native language	Apply new teaching /assessment tools	"Use ICO OSCAR RUBRIC for MSICS”, “Start regularly using informal feedback"
					" Routinely provide feedback”, “Improve communication skills during surgery "
Overall positive opinion and disposition to enhance clinical educator competencies	“I loved the course, and it will help me in my daily practice”, “All was interesting; liked it all, all is interesting, all was well, non-applicable” …, “The course will help me be better educator “, “Good to download the materials to watch and work out offline”, …”in this particular course we had the possibility of having a facilitator who spoke Portuguese"

They remarked on the benefit of reducing self-study time and add additional synchronous time to support program activities, tests, and language challenges.

When asked about their commitments to change, four participants stated intention to improve teaching methods, advance scholarship, and use assessment/teaching tools.

All participants responded affirmatively as “agreed” or “strongly agreed” to all the closed-ended feedback survey questions. One participant disagreed on the learning method [Figure 1].

Figure 1

Participants’ feedback one month after concluding the program (closed ended questions, n=5 participants). Three of the four critical reflection questions (in commas) of the reflective thinking survey by Kember et al.21 were included

Pre- and posttests scoring averages were 67% and 87%, respectively [Figure 2].

Figure 2

Participants’ pre and post-tests scoring averages were 67% and 87%, respectively (n = 10 participants)

In a range of 3–10, participants successfully completed their modules’ activities before the synchronous moments, sometimes after their native language live session (10 for modules 1, 6, and 7; 9 for module 9; 8 for module 4; 6 for modules 0 and 3; 5 for module 5; and 3 for module 8). Seventy percent completed all modules’ activities.

Procedural

Seven participants built their SSBE session and recognized at least two differences between their first and second versions.

Certification

Ten participants were awarded a certificate of participation. At the time of writing (May 2021), at least five commendation certificates were planned to be awarded once the Théa Foundation grant awarded MOCg SSBE project is fully implemented.

Discussion

There is a shortage of ophthalmologists in sub-Saharan Africa, and a need to train more.[27] Mozambique holds one of the two Lusophone ophthalmology training programs in sub-Saharan Africa, and material in Portuguese is sparse. Associated with sustained local health-care professionals, better clinical performance, and public health,[13] training has become a priority in Mozambique.[28]

By regionally supporting human resources training, our educational strategy is consistent with the Mozambican national eye health program to reduce avoidable blindness.[20]

The FDS-ICO/CPDc aimed to develop ophthalmology trainers in Mozambique by (a) facilitating a CoP, (b) advancing competence in evidence-informed education, and (c) preparing to implement a SSBE center.

This was the program's second iteration with a sub-Saharan African ophthalmology society (report manuscript on the experience with the Congolese Society of Ophthalmology (CSO) in review) and the first delivered to a Lusophone audience.

Given the CSO participants’ positive remark on having strengthened relationships and their interest in developing communication skills, we refined the flipped learning model. The recorded lesson was included in the homework package and the synchronous sessions exclusively focused on enacting active learning and providing feedback.

The MOCg stated their preference on reducing activities’ length, extending interactive opportunities, and the full program in Portuguese.

Planned before the COVID-19 pandemic, the program was delivered online, a method which has been found to engage clinicians in nonclinical professional development. Online technology underpinned a virtual engaging learning environment with interpersonal support and a sense of community accomplishment. Our results are consistent with a recent study of online nursing faculty development during COVID-19 in Saudi Arabia,[29] a trend which potentially continues after the pandemic.

Multiple mentoring, especially involving a key regional leader (AB), builds on developing constructive relationships in a supportive environment for collaborative projects advance with mentee satisfaction and increased likelihood of becoming a mentor.[1011] The MOCg WhatsApp group facilitated developing the virtual CoP, made interpersonal communication easier to exchange experiences and comments on the topics assigned; facilitated didactic resources and administrative information sharing; and strengthened the sense of belonging and cohesive teamwork.

Results of participants’ assessments demonstrate overall improvement in knowledge across the curriculum and by implication in evidence-based teaching. Unassessed improvement in education skills was also noted. Participants were identified as leaders who would likely accept change and incorporate educational innovation in their practice scope. They authored a poster presentation and a symposium communication on their project at the virtual World Ophthalmology Congress.[30] Both faculty and participants developed cultural competence in the practice of medicine.

Our third aim was preparing a Théa Foundation[31] grant awarded SSBE project. Both the MOCg and the ICOg are confident, there was competence improvement, and the SSBE project is underway. This is contingent on COVID safety, and further evaluation is planned for 5 years hence.

Strengths of the program include its grounding in educational theory and adult learning principles. The FDS-ICO/CPDc was practice-based, included self-directed learning, and social learning strategies, continuous multidirectional feedback, flipped learning, and individual and group reflection opportunities to encourage the use of evidence-informed teaching strategies. Flipped learning ignites the participants’ responsibility for their own learning and a mentor-assisted component is usually helpful. To our knowledge, ours is one of the few virtual faculty development programs combining both peer and multiple mentoring (HPF and AB) with a regional native mentor (AB). Within the mentorship scope, the recurrent online 1-h interactive webinar with both Portuguese native speaker mentors was welcomed by the MOCg. They could best prepare the synchronous modules’ sessions by overcoming language challenges, furthering interaction with didactics, imparting homework experiences, and enacting collective reflection.

Limitations are the population dimension, lack of a control group, and being a single-center study.

If the number of participants limits statistical analysis of the trends observed, it represents, however, approximately 50% of the MOC registered ophthalmologists. Establishing a virtual, a CoP was an outcome, and this will require further follow-up. The MOCg and the ICOg partnered to cowork and developed a trustful and supportive peer-to-peer environment. International collaboration may raise language and cultural challenges asking from faculty some degree of transcultural immersion. The six African Lusophone countries are in the minority, with a dearth of medical education resources in Portuguese. English is a worldwide spoken language; however, study interpretations should mind cultural adaption. Despite the MOCg preference for having the program fully translated, their overall feedback and knowledge improvement were positive. Outcomes’ evaluation was designed to go beyond the more basic levels of programs evaluation models (Kirkpatrick's levels 1–2 and Miller's 1–3).

An international SSBE telementoring initiative to provide feedback on recorded steps of simulated surgical practice against international standards could expand mentoring the MCOg. Following up with participants, wishing to share their SSBE reflective practice would further our work. Participant's overall positive feedback, commitments to change on enhancing learning objectives formulation, feedback delivery, communication skills, using rubrics in clinic, and their learning improvement encourage us to refine our model and cowork with other professional organizations.

Conclusion

Our findings responded affirmatively to our departing research question. They are a proof of concept that sustained longitudinal virtual group mentoring can scaffold the creation of an engaging community of ophthalmologists educators. Despite practicing in challenging circumstances and during the pandemic, the MOCg established a CoP, improved their teaching competence to facilitate cataract surgery by the simulation to their peers, and enriched their emerging SSBE center project.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.