Strive to thrive—an international partnership for developing an outcome-based curriculum for cataract surgery training by simulation

Introduction

Cataract surgery is one of the most performed surgeries around the world and has attained a considerable level of mastery associated with both technique development and technology advancement (1). Nevertheless, cataract remains the leading global cause of avoidable blindness, emphasizing the need for capacity building through the training of more highly skilled and effective cataract surgeons (2). A nationally benchmarked standardization of training outcomes is therefore essential.

There is a growing demand for competency-based training in cataract surgery, and simulation-based education (SBE) holds a critical role in improving surgical competence with continuous quality improvement and patient safety. Simulation provides a safe, reproducible learning environment for surgical trainees to develop both technical and non-technical skills without compromising patient safety (3). The traditional apprenticeship model, “see one, do one, teach one”, introduced by Halsted in the 19th century, remains influential but is no longer the most effective approach. In contrast, simulation-based education follows a structured progression, from procedural skills to team-based training, facilitating deliberate practice, mastery learning, and accelerated proficiency development (4).

SBE supports the advancement of procedural, cognitive, and behavioral competencies across all levels of surgical education. To be effective, faculty must be expert in both content and simulation pedagogy (5). In ophthalmology, simulation addresses global training challenges, enhances patient safety, and fosters institutional and cross-border collaboration. Strengthening partnerships and integrating simulation into broader training frameworks that include digital, dry, wet lab and aspiringly virtual reality can significantly improve the impact of eye care programs (6).

Faculty education has been associated with better training and patient outcomes (7). Yet, many ophthalmologist educators, especially in under-served regions, lack formal training opportunities in medical education, despite teaching being a core professional responsibility.

Developing locally based learning environments that respond to the specific needs of healthcare professionals within their work and living contexts can enhance retention of faculty and practitioners, supporting long-term workforce stability (8). National and/or regional trained clinical educators will be better equipped to acknowledge their learners’ needs to design and implement educational programs and measure performance improvement with public health impact.

Equitable partnerships, established through international collaboration agreements between global ophthalmological societies (GOS) with global expertise in health professions education (HPE) and national ophthalmological societies (NOS), especially in underserved regions, have the potential to both quantitatively expand and qualitatively optimize faculty education opportunities (9). Partnerships should enable an effective bidirectional transfer of competence while keeping leadership in the host national society (10). Collaboration, innovation, and equity can help build inclusive working environments that support and empower every community (11). Technology can add a critical element to amplify access to education and help foster a culture of continuing learning and development.

Design thinking has been increasingly applied in HPE (12). Curriculum design and design thinking conceptually differ (13). Curriculum design “refers to the process of structuring educational programs to achieve quality education by defining learning outcomes, competencies, and skills aligned with professional standards, while also allowing for student development and growth over their career” (14). Design thinking is a framework for problem-solving by offering methods for curriculum design such as research, ideation, prototyping, and testing learner-centered educational experiences. Design thinking can thus be used in curriculum design to support the learning experience process. Some of the design thinking techniques most used in curriculum design include: (I) Persona development: researching and compiling detailed learner profiles to be engaged in the learning experience (Empathy), (II) Journey mapping: creating a framework to outline key steps in the learning process (Definition), (III) “How might we…” ideation: Generating quick and diverse design solutions through brainstorming (Ideation), (IV) Rapid prototyping: creating prototypes to preview the experience (Prototyping), and (V) Piloting: testing the design over time to assess effectiveness and gauge for improvement (Testing) (12).

Social constructivism is a learning theory and educational philosophy that emphasizes collaborative learning, where knowledge is built through experiences and interactions, mentorship and scaffolding (15,16). Using social constructivist online educational strategies that encourage collaboration can support virtual continuing learning environments and sustain virtual community of practice (vCoP) (17). Methodologies like a learner/user-centric approach, the development of a vCoP, group-mentoring and collaborative exercises for complex problem solving, can turn online learning environments into dynamic spaces that foster teamwork, increased engagement, deeper learning, knowledge building, and a strong sense of community and project ownership (18,19).

We established an international partnership between the Mozambican College of Ophthalmology (NOS) and the Ophthalmology Foundation (GOS). The collaboration agreement involved the NOS leading a team-oriented initiative to address their identified need for co-developing a nationally endorsed, outcome-based curriculum for simulation-based cataract surgery training.

We hypothesized that using online social constructivist strategies could support ophthalmologist-educators in developing a simulation-based, context-centered cataract surgery curriculum. The purpose of our paper is to show and tell how we designed and developed together the project that enacted this document.

Methods

A multi-step, collaborative process guided by a shared vision from the GOS and the NOS shaped our non-experimental, observational research on group mentoring participants to develop a nationally endorsed outcome-based curriculum on cataract surgery training by simulation, in a close to natural setting (20).

Design thinking

The design thinking (12,21,22) framework supported a dynamic working environment for all participants, inviting the following brainstorming sequence:

• Mapping and understanding the learning challenges of cataract surgery found by trainees in underserved settings and the growing pressure they feel to increase capacity building, ensuring patient outcomes (Empathy).
• Establishing a clear learning outcome focused on designing a curriculum to develop procedural competence improvement, confidence building, and ensure patient safety with public health positive impact (Definition).
• Brainstorming appropriate and effective educational strategies, including supportive digital, low and high-tech dry, and wet lab simulation scenarios, online education and virtual mentoring, standardized competence-based assessments based on well-defined learning expectations, clinical outcomes and public health impact (Ideation).
• Developing the first contextually adapted curriculum on cataract surgery training by simulation consisting of four sequential education modules covering the steps of cataract surgery as outlined in the Ophthalmic Simulated Surgical Competency Assessment Rubric (Sim-OSSCAR) for manual small incision cataract surgery (MSICS) (23), each aligned with Kern’s model of curriculum design (24) (Prototyping).
• Sharing, collating and peer-reviewing all modules by all participants, for curriculum cohesiveness and refinement before its implementation (Testing) (Figure 1).

Figure 1 Visual representation of the design thinking process describing the streamlined team-based workflow to design the curriculum.

The NOS and the GOS had previously collaborated to deliver a group-mentored, online educational experience on curriculum design. This initiative showed constructive feedback, individual learning improvement, team competence development, and the establishment of a vCoP (25). This vCoP comprised ten senior ophthalmologist educators of the Mozambican Ophthalmology College (MOC) their President (AB) included, all leaders in postgraduate education at their national hospitals for over 10 years. In a continuum, this vCoP aimed to apply their experience and new learnings to advance a team-based project on developing collaboratively their outcome-based curriculum on cataract surgery training by simulation.

After consulting with other vCoP members, the President of MOC (A.B.) invited six early-career (with less than 5 years of practice) Mozambican ophthalmologists interested in HPE to integrate the team of participants.

Acting as GOS through two affiliated volunteer internationally experienced ophthalmologist educators (H.P.F. and K.G.), the Ophthalmology Foundation (OF), responded affirmatively to create this international partnership supporting the NOS.

The sixteen participants were split randomly into four home working groups (HWG), each with varying experience levels (experienced and less experienced ophthalmologists) and based in various cities of Mozambique (Maputo, Matola, Nampula, Tete, Cabo Delgado). Each HWG was responsible for designing one module of the four-part SBE curriculum, based on assigned cataract surgery steps described in the Sim-OSSCAR. Group A worked on steps 1-7, Group B on steps 8-10, Group C focused on steps 11-14, and Group D concluded with steps 15-20. Based on the steps-content assigned, each module was designed following Kern’s Model of Curriculum Development.

The virtual jigsaw exercise

To emphasize deep specialization, team collaboration and interdependence, accountability, and project ownership while maintaining a holistic perspective, an online jigsaw exercise was mounted (26,27). Kern’s six steps were combined into four groups: (I) learning gap and needs, (II) goals and objectives, (III) educational strategies and implementation, and (IV) assessment and evaluation.

Each HWG (A–D) selected a participant to join a four-member Expert Working Group (EWG), with each EWG focusing on one curriculum group of steps as described (1-4). Participants then worked together online to build expertise on the specific curriculum steps assigned within their EWG for every group of cataract surgery training steps.

Once they completed their EWG tasks, participants returned to their HWGs to integrate these elements and assemble the full module using the original Kern’s six-step model (Figure 2).

Figure 2 Schematic of the jigsaw exercise workflow.

All HWG met to share insights and unify outputs into a single four-part curriculum, where each module was developed following Kern’s six steps framework and included content from the Sim-OSSCAR.

A vCoP

Zoom teleconference meetings (Zoom Video Communications Inc., USA. 2012) and a WhatsApp group (WhatsApp Media Inc. 2009) enabled a sustained NOS vCoP collaboration allowing real-time communication, troubleshooting, brainstorming, updating, resource sharing, peer mentoring and group facilitation. Regular interaction among ophthalmologist educators contributed to building relationships and developing their shared educational goal.

Virtual group mentoring

The geographical, and generational diversity of the NOS vCoP enabled a national wide and inclusive perspective, to create a systematic and comprehensive curriculum design, guided by virtual group mentoring that included group-facilitation, co-mentoring, peer and reverse mentoring.

The NOS vCoP and the GOS conducted eight structured, mentor-assisted online sessions via 90-minute Zoom meetings over the course of 2023. Three sessions were held to work with the sixteen participants, one at the start and two others at the conclusion of the project, one with the HWG and four with the EWG. The encounters were structured to include a welcoming phase and recap with further engagement of the groups into their previously set goals. Participants could interchangeably act as mentors, mentees, and group facilitators, maintaining a sense of team-based project ownership. Experienced ophthalmologist educators mentored the incoming early career ophthalmologists navigating through the nuances of outcome-based curriculum design in a collegial atmosphere. The GOS provided online group facilitation and mentoring.

Ethical considerations

This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Research Ethics Committee of the Dr. Agarwals Eye Hospital, Maputo, Mozambique, with the ethical clearance number DAEHM/23/2025. In support of the MOC, which is a constituent body of the Medical Association of Mozambique, individual consent for this retrospective analysis was waived.

Results

The main output of the team-based project of the NOS yielded an endorsed national standardized, comprehensive, and systematic outcome-based curriculum for manual small incision cataract surgery training by simulation (28). The document is context-adjusted, empirical and evidence-based.

The guidelines for cataract surgery training by simulation were officially approved and endorsed by the MOC and the Mozambican Medical Association. Participants created it as a living document that will welcome feedback and suggestions for enhancement. Future revisions may be made based on the implementation experience. The curriculum highlights the significant impact of cataract-related vision impairment on the quality of life in Mozambique and the growing need for capacity building to address this leading cause of avoidable blindness. The curriculum emphasizes the urgent need for training more cataract surgeons, both in number and proficiency. The value of SBE in cataract surgery training to protect patient safety and further improve surgical outcomes is underscored. Adhering to best practices in SBE to ensure effective learning and maximize clinical results is fundamental. The document underlines the importance of clearly defined learning goals and objectives. Participants conclude with the inclusion of supporting materials like the Sim-OSSCAR (23), the International Agency for the Prevention of Blindness (IAPB) Essential List for Simulation-Based Learning (Cataract Surgery) of the International Agency for Preventing Blindness (29), and the reference list that informed their work. The curriculum design is consistently structured following the multidirectional stepwise Kern’s Model of Curriculum Development (24). The content was organised using the Sim-OSSCAR for MSICS step-by-step cataract surgery approach (23). Each module is a structured training session (Table 1).

Modules may be taken independently, with several possible combinations for individual program tailoring and deliberate practice. Assessment methods, including formative assessment and debrief are aligned with each training phase and with national standards.

The ongoing NOS vCoP attained their mutual goal and alongside advanced their experience in peer mentoring and the practice of collective expertise. The community’s vitality was also ascertained by the “legitimate peripheral participation” (30) of the six early career ophthalmologists, who began transitioning to fully engaged members.

With a grant from the Théa Foundation (31) to fund equipment and materials for two IAPB-recommended simulation training stations, the NOS can now plan their curriculum implementation.

Discussion

Summary and significance

To our best knowledge, this is among the first studies focused exclusively on co-creating an outcome-based cataract surgery simulation curriculum entirely online, using design thinking and social constructivist strategies. Our approach aimed to minimize costs, optimize time and resources, and serve as a proof of concept for similar educational projects. The collaboration between the NOS (MOC) and the GOS (OF) demonstrated how team-based online methods can overcome geographic and resource constraints to produce meaningful educational innovations.

Collaborative approach and partnership

In accordance with evidence (32), a key element of this project’s success was genuine partnership between the NOS and the GOS, founded on mutual respect, trust, clear communication, and well-defined expectations and roles. This safe and supportive environment promoted professional growth, broadened participation at national and international levels, and strengthened the culture of shared ownership and accountability.

The MOC’s leadership was especially important: as Mozambique’s professional society responsible for postgraduate ophthalmology training, it ensured that the curriculum aligned with national priorities. Having organizational support is fundamental to create change (33,34). Following the pilot, the MOC plans a national rollout with a sustainable implementation that includes systematic monitoring of attendance, feedback from learners and faculty, learner competence and performance improvement against benchmarks for example using the Sim-OSSCAR:MSICS, supervised support in the operating room, and evaluating patient outcomes through chart reviews and epidemiological data.

Educational strategies and innovations

Design thinking offered an innovative, structured, user-centered, and iterative approach to curriculum development, enabling participants to tackle complex challenges creatively and collaboratively. Training in design thinking strengthened the NOS team’s problem-solving skills, facilitated consensus building, and promoted continuous quality improvement.

Virtual group mentoring provided sustained guidance, engagement, and alignment with project goals. By working in a team-based setting with multiple mentors and mentees, participants gained confidence, broadened their perspectives, and enhanced commitment. Mentors actively supported group dynamics through the forming, storming, norming, and performing stages, while remaining attentive to individual needs that could affect group cohesion.

The online jigsaw exercise promoted interdependence by assigning specific curriculum sections to different participants, who then collaboratively integrated their parts into a cohesive final curriculum.

Our work has several strengths such as:

• Accessibility and inclusivity: the fully online format removed financial, time, and geographical barriers, reaching participants in underserved regions.
• Customization: the curriculum was tailored to local stakeholder and learner needs, ensuring context relevance.
• Language adaptability: Portuguese as the working language promoted inclusivity and comprehension.
• Innovation: design thinking encouraged creativity and user-centered problem solving.
• Scalability: the model is adaptable to other regions, disciplines, and subspecialties.
• Sustained faculty development: training participants to become mentors by role modelling helps ensure long-term continuity.
• Technological flexibility: platforms like WhatsApp and Zoom maintained ongoing interconnectedness and engagement despite bandwidth constraints.
• Empowered collaboration: a supportive, trust-based culture facilitated collective effort and professional growth.

On the other hand, our work faced challenges, such as:

• Exclusively online collaboration required careful coordination across time zones.
• Harmonizing four curriculum modules into a single document was complex.
• Bandwidth issues occasionally disrupted real-time discussions.
• Integrating diverse viewpoints required active facilitation.

These challenges were mitigated through genuine virtual group mentoring, emphasizing individual engagement, innovation, and collective problem solving.

Limitations include:

• Lack of an international, multicentric sample; the study drew on a nationally representative group across Mozambique.
• Participant feedback was largely anecdotal, though enthusiasm and an ongoing implementation plan suggest positive reception.
• Other stakeholders were not directly consulted during development; however, the curriculum received formal approval from national medical professional bodies.

Our findings suggest that design thinking and social constructivist strategies can effectively support online curriculum co-creation in HPE. The model shows promise for broader use, provided it is essentially supported by: (I) a dedicated group of clinician educators committed to continuous improvement; (II) reliable internet access; (III) partnership with an experienced international educational organization. International collaboration can build dynamic regional educator communities connected to broader networks, ultimately enhancing faculty development and patient care.

Conclusions

Our experience highlights the transformative potential of integrating active and social learning strategies into online team projects for HPE. By fostering equitable, non-charitable international partnerships, particularly between GOS and NOS in resource-constrained contexts, we supported faculty development and curriculum design innovation through collaborative, technology-enhanced approaches.

Our mentor-facilitated model promoted trust and collaboration within a vCoP, leading to the creation of an outcome-based curriculum for simulation-based training in cataract surgery. These findings suggest that such team-based, technology-enabled strategies can effectively advance competency-based education, and may be adapted across other medical specialties and geographies to improve training especially in underserved and remote regions. Ultimately, this work underscores the value of structured, collaborative international initiatives in driving sustainable and contextually relevant educational innovation.

Acknowledgments

The authors would like to acknowledge the invaluable support of the Mozambican Ophthalmology College (https://ordemdosmedicos.org.mz/); Ophthalmology Foundation (https://ophthalmologyfoundation.org/); International Agency for the Prevention of Blindness (https://www.iapb.org/); Théa Foundation (https://theafoundation.org/); and Light for the World (https://www.light-for-the-world.org/our-work/project-countries/mozambique/).

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Annals of Eye Science for the series “Optimizing Ophthalmology Surgery Training Through Active Learning Strategies”. The article has undergone external peer review.

Data Sharing Statement: Available at https://aes.amegroups.com/article/view/10.21037/aes-25-4/dss

Peer Review File: Available at https://aes.amegroups.com/article/view/10.21037/aes-25-4/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://aes.amegroups.com/article/view/10.21037/aes-25-4/coif). The series “Optimizing Ophthalmology Surgery Training Through Active Learning Strategies” was commissioned by the editorial office without any funding or sponsorship. K.G. serves as the Editor-in-Chief of Annals of Eye Science from September 2024 to August 2026. H.P.F. serves as an unpaid editorial board member of Annals of Eye Science from October 2024 to December 2026. M.L., H.P.F. and K.G. served as the unpaid Guest Editors of the series. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Research Ethics Committee of the Dr. Agarwals Eye Hospital, Maputo, Mozambique, with the ethical clearance number DAEHM/23/2025. In support of the MOC, which is a constituent body of the Medical Association of Mozambique, individual consent for this retrospective analysis was waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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