Pedagogical strategies for specialised coursework postgraduate programmes in optometry: a mixed methods study for South Africa

Abstract

Background

Higher Education Institutions (HEI) in South Africa (SA) have no coursework postgraduate programmes to upskill the existing expertise of optometrists in any specialised optometric field. It is currently unknown what would be a suitable strategy for teaching, learning and assessment, should postgraduate educational opportunities be made available in SA. This study aimed to explore pedagogical strategies for developing specialised postgraduate coursework in optometry for South African HEIs.

Methods

A concurrent mixed methods study sequentially followed by a modified Delphi survey was conducted from March 2023 to September 2023. Four online focus group discussions (Microsoft Teams) with optometric educators from HEIs in SA was conducted concurrently with an online questionnaire (EvaSys Survey System V.8.2) with conveniently sampled optometric practitioners. After data merging, a Delphi survey with identified education experts was conducted to draw definitive conclusions from disparate findings of the merged data. A 70% consensus target was achieved through a two-round qualitative and quantitative online survey.

Results

In-person procedural skills development was preferred with online training as a supplementary modality. For content knowledge, online modalities were the option of choice. Optometric practitioners preferred a continuous assessment strategy (72.0%) but remained mostly neutral about the value of summative assessments (38.7%). Optometric educators also preferred continuous assessments but did note that for high stakes assessments, summative assessment should be retained. This notion was endorsed by the Delphi panellists.

Conclusion

The pedagogy proposed for postgraduate programmes was underpinned by the Technological Pedagogical and Content Knowledge (TPACK) model. A continuous assessment strategy imbedded in a competency-based education approach would best serve the purpose of coursework programmes within a work-integrated learning system for working professionals. The empirical evidence generated could form part of a broader framework for postgraduate coursework programmes for optometry in SA.

Background

The work done by the United Nations Educational, Scientific and Cultural Organization (UNESCO) is crucial for achieving, in particular, the Sustainable Development Goal 4 (SDG4) that advocates for “inclusive and equitable quality education and promote lifelong learning opportunities for all” [1]. Lifelong learning (LLL) has been a central focus in education since the 2030 Agenda for Sustainable Development was adopted [2]. Higher Education Institutions (HEIs) are the key drivers of building knowledge and skills, creating access to education by offering flexible teaching and learning opportunities and assessment strategies [3]. The current master’s and doctorate qualifications in optometry registered at HEIs in South Africa (SA) are entirely research-based postgraduate qualifications aligned to the Higher Education Qualifications Sub-Framework (HEQSF) [4]. The alternative educational opportunities for optometrists that fall outside of the HEQSF are workshops, conferencing, short learning programmes (SLP), and various continuous professional development (CPD) activities that are required to maintain professional licensure [5, 6].

The challenge, however, is that if optometrists wish to be upskilled in speciality areas of optometry to grow their knowledge and clinical expertise, the option through a postgraduate qualification route is not available in SA. There are no postgraduate diplomas or professional Master of Optometry degrees in any clinical speciality that embody both instructional teaching and experiential learning. An alternative to having a full postgraduate qualification is to gain access to educational opportunities through registration for individual credit-bearing modules as discrete learning units. However, even that option in optometry does not exist at HEIs. Optometry qualifications are offered by four HEIs in SA, including the University of KwaZulu-Natal, University of the Free State, University of Johannesburg and the University of Limpopo [7].

The World Health Organization (WHO) recommended in its guidelines on transforming and scaling up of health professionals’ education and training, that HEIs training health professionals should consider “streamlined educational pathways or ladder programmes for the advancement of practising health professionals” [8]. Establishing horizontal articulation pathways into structured programmes could be deemed a worthwhile pursuit if it leads the profession in a new direction that builds on optometrists’ existing skills and professional experience. Expanding the educational pathways would support optometrists who do not wish to pursue a pure research route but to enhance skills tailored for their professional practice. To explore this perspective, an appropriate pedagogy needs to be determined to ensure that a fit-for-purpose programme is designed to achieve the desired outcome of generating further skilled optometrists.

The COVID-19 pandemic has forced educationalists to visit pedagogical models due to disruptions in education and the uncertainties that HEIs faced [9]. Despite the challenges posed by COVID-19, globally and in SA, it enabled a paradigm shift in the way education and training was provided. It has forced the development of innovative and agile educational strategies [10, 11]. The rapid digitalisation of higher education with the migration to a virtual domain had been adopted on a global scale in exploring multimodal teaching and learning and designing flexible technology-driven assessment strategies [12]. These change management processes aimed to maintain the academic momentum at a time of adversity [13].

Online learning involves the use of various internet-enabled devices with synchronous and asynchronous capabilities for content sharing [14, 15]. However, online learning should not be seen as a panacea for the delivery of education and training, especially in health sciences, as skills training requires the unavoidable face-to-face engagement [16, 17]. Confronted with this conundrum of online versus face-to-face teaching and learning, research on how skills transfer can be best implemented in a post-pandemic era warrants investigation. South Africa is a middle-income country, where electricity and connectivity difficulties do exist, adding to its prevailing challenges. While undergraduate health sciences education has received more pedagogical attention than postgraduate, both stages of teaching and learning are relatable but with differences. Consequently, this situation presents a knowledge gap that necessitates investigation [18]. Beyond exploring instructional teaching and learning for content knowledge, strategies for a flexible and innovative pedagogy for skills development, as well as a ‘best fit’ assessment strategy to suit the working optometrist, are currently unknown. A pedagogical strategy should be designed that can attract enrolment, support retention and generate throughput of practising optometrists.

By benchmarking against countries in the global north and global south that have coursework postgraduate optometry programmes, a conceptual framework for postgraduate programme development for optometry in SA can be established. In establishing a strategy for structured coursework programmes, one should be cognisant of the fact that the prospective candidates would be adult learners with a primary employment and living in various geographical locations. The aim of this study was to investigate flexible teaching, learning and assessment strategies for optometric practitioners, that will incorporate the necessary 21 st century skills supportive of remote learning. These new strategies will need to be implementable by optometric educators at HEIs and applicable to adult learners. Optometric education at postgraduate level needs to maintain the necessary technological prowess in producing upskilled practitioners with the necessary attributes to remain on course with advances of the fourth industrial revolution (4IR). Currently, this novel approach towards specialised postgraduate optometric education in SA has not been explored.

Methods

Study design

A first phase convergent parallel mixed methods design connected to a second phase Delphi technique was adopted to adequately address the research questions [19]. Two distinct populations of optometric practitioners and optometric educators were purposively sampled for the first phase. Higher education experts were sourced through judgement sampling for the Delphi phase. A multiphase strategy using two phases of data collection was executed [19]. A self-administered electronic questionnaire using the EvaSys survey system, version 8.2 (EvaSys GmbH; Lüneburg, Germany), was distributed to optometric practitioners. The survey method was selected to quantitatively describe the perspectives of optometric practitioners While the online focus group discussions (FGD) using Microsoft Teams (Microsoft Corporation; Redmond, WA, USA) were conducted to obtain collective opinions from optometric educators [20]. The two study methods were conducted concurrently to seek convergence for establishing robust conclusions.

To address divergent findings found after data convergence from phase one, a modified e-Delphi technique was subsequently conducted. A qualitative and a sequential quantitative round of questionnaires were administered using the EvaSys survey system. Identified experts provided their independent and anonymous judgements on the incongruous findings to draw definitive conclusions. The first data collection phase lasted five weeks during March and April 2023. The second phase extended over six weeks during August and September 2023. Fig 1. summarises the two phases of the investigation.

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Study population

All optometrists registered with the Health Professions Council of South Africa (HPCSA) were eligible to participate. A sampling frame of HPCSA-registered optometrists (N = 4 204) on the HPCSA database, was not accessible at the commencement of data collection, hence non-probability sampling techniques were employed for all three data collection methods. Convenience sampling methods and snowball sampling were used to extend the reach of optometric practitioners who could participate. An advertisement with an embedded survey link was shared on various social media platforms and through various companies in the optometry industry sector that consented to share the survey with their constituents. All HPCSA-registered optometrists of any age, range of experience, qualification level, workplace settings, and geographic locations were eligible to participate.

Optometric educators with more than five years’ experience in academia were purposively sampled from the departments of optometry at all four HEIs. Twenty-eight (28) optometric educators were selected, of which 17 were available to participate in the FGDs. Four mixed FGDs with educators from the different HEIs were combined in groups of three to five participants. In the second phase, the independent expert panellists (n = 10) non-aligned to optometric education and practice were purposively identified from various HEIs in SA. The Delphi panellists had diverse backgrounds in postgraduate education, curriculum development and health professions education and were deemed suitable candidates to provide their unbiased insights from findings of the optometrist groups.

Online questionnaire

The survey comprised a demographic section followed by four other sections with a total of 44 items. For this investigation, the section on teaching and learning (labelled C) had eight items, while the section on assessment (labelled D) had six items. All the questionnaire statements used a 5-point Likert scale with options of strongly disagree (1), disagree (2), neutral (3), agree (4) and strongly agree (5), with one categorical statement. A pilot study with 15 participants completed the survey, conducted over nine weeks from December 2022 to February 2023 with no changes to the online questionnaire.

Focus group discussions

The 17 optometric educators were assigned to one of four FGDs according to their preferred dates and times of availability. A pilot FGD was conducted with five optometric educators, and the data were included with the subsequent three FGDs due to retention of the same questions. Only one vocabulary change was required while the essence of the question was unaltered. The FGD guide, which included the time duration, study objectives, the three main questions with sub-questions, and clarification of terms, was made available to participants in advance of the scheduled FGDs. It was optional for participants to turn off their cameras. All FGDs were recorded while allowing for automatic transcription. The duration of each FGD was approximately 90 min.

Delphi technique

A two-round iteration process using a modified Delphi method developed as an online survey (EvaSys) was implemented after results from the first phase were analysed. The merged data from the first phase guided the development of the nine open-ended statements for the first qualitative round of the Delphi technique. The qualitative findings thereafter were used to design the quantitative questionnaire with closed-ended items on a 4-point Likert scale, with options agree, somewhat agree, somewhat disagree and disagree, in order to compute the agreement percentages [21].

Data analysis

The raw data from the optometric practitioners’ survey were exported from EvaSys and computed as frequencies and percentages using R version 4.3.0 (R Foundation; Vienna, Austria). Tests of internal consistency using Cronbach’s alpha (α) and exploratory factor analysis (EFA) were computed using R, while the inter-rater reliability (IRR) using SPSS software version 29.0 (IBM SSPS Inc.; Chicago, IL, USA) was expressed as an inter-rater correlation coefficient (ICC) due to multiple raters. The content validity index (CVI) was computed using Microsoft Excel. A qualitative content analysis was conducted with ATLAS.ti 23 (ATLAS.ti Scientific Software Development; Berlin, Germany) using a deductive approach from a priori coding and predetermined themes [22]. The data transcriptions of all the FGDs were anonymised and reviewed to reflect a verbatim account against the audiovisual recordings from MS Teams. Raw data from the e-Delphi technique were extracted from EvaSys for both the qualitative and quantitative questionnaires. A consensus threshold of 70% agreement was used in the Delphi based on published recommendations from a systematic review [23].

Quality control measures in implementation of methods

Focus group discussions

A panel of five postgraduate researchers who were knowledgeable with qualitative methods were invited to evaluate the developed FGD guide as expert reviewers. The final FGD guide was provided in advance to all consenting participants to familiarise themselves with the questions. The guide included the concept clarifications, study objectives, three main discussion questions with predetermined sub-themes to steer the discussion.

All four focus group discussions (FGD) were facilitated by the same facilitator. The facilitator was not an optometrist, thereby ensuring the absence of bias in guiding the discussions. Participants were advised that they were not representing their institution or the views of their institution but were invited to share their independent perspectives. The principal researcher was in attendance to observe the FGD and refrained from actively engaging in the online discussion. To maintain the precision of the qualitative data, a thorough inspection was conducted on the auto-transcriptions of all FGDs to guarantee the accurate reflection of the online recordings discourse. Non-descript pseudonyms with a consistent format, for example, FG3p5 (focus group three, participant five) were developed to replace participants’ names for the data analysis process.

Online survey (see supplementary file)

The content validity and face validity were sequentially conducted as part of the instrument validation. A cohort of 10 content validity reviewers were purposively sampled based on their postgraduate qualifications in optometry research. The reviewers assessed the item relevance using a 4-point Likert scale [24]. The scale content validity index (S-CVI) produced a value of 0.921. The intraclass correlation (ICC) estimate of reliability was 0.916 [25].

A separate cohort of 15 optometric practitioners conducted a qualitative evaluation as face validity exercise [26]. The feedback provided encompassed a range of elements, including the length of the questionnaire, language usage, and survey completion time. The feedback was subsequently incorporated into the survey’s final version. The pilot phase of the survey was conducted between December 2022 and February 2023 by the same face validity reviewers, spanning a duration of nine weeks. As modifications were made after the pilot stage, the pilot questionnaire results were excluded from the main empirical data.

After the completion of data collection, an exploratory factor analysis (EFA) was employed to assess the construct validity. The principal axis factoring extraction method with oblimin rotation was used to perform the EFA. To ensure sufficient survey items for a reliable EFA, the researchers merged sections A and B, comprising a combined total of 32 items, and sections C and D, comprising 14 items, on account of their interrelatedness. A sample size of 393 was considered adequate for the EFA to proceed. The Kaiser-Meyer-Olkin (KMO) criterion was met by both datasets through the EFA computation, yielding values of 0.86 and 0.68, respectively. Furthermore, a statistically significant result (p <.001) was obtained from Bartlett’s test of sphericity. It was determined that the six factors identified were derived from sections A and B and demonstrated Cronbach’s alpha (α) reliability scores between 0.66 and 0.87. Four factors were identified in sections C and D, each with a reliability score between 0.53 and 0.81.

Ethical considerations

The study received HSREC approval (reference number: UFS-HSD2022/1101/2911). Permission was obtained from all the participating HEIs and Heads of optometry departments. Informed consent was received from survey participants, FGD participants and Delphi participants. Confidentiality was adhered to in line with the requirements of the Protection of Personal Information Act of 2013 (POPIA). The declaration of Helsinki was observed throughout the study.

Results

Phase one: survey and focus group discussions

Demographic profile

A total of 424 survey responses were received from optometric practitioners. There were 31 (7.3%) participants who were allowed to exit the survey after the demographic section, if they did not believe that establishing structured postgraduate programmes in specialised fields of optometry was necessary for the profession in SA. This allowed the remaining 393 (92.7%) participants to continue with the questionnaire as the target group to share their views on teaching and learning for the envisaged structured programmes.

The participants’ median age was 38 years (range 30–47 years). Regarding the modes of practice, 95.5% (n = 405) of the total participant population worked in patient-facing clinical service. Private practice setting was the predominant sector of employment for the majority of the participants (n = 386; 91.0%). Fig 2 presents the distribution of participants across the nine provinces of South Africa. Most of the participants were located in three provinces, namely Gauteng (33.9%), Western Cape (19.9%) and KwaZulu-Natal (17.4%), totalling 71.2% of all the participants. Seven participants indicated that they lived abroad.

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Figure 3. illustrates the distribution of work experience with optometric practitioners grouped into nine 5-year periods, ranging from under a year to beyond 40 years. The most prevalent duration of work experience among the participants was 11 to 15 years (n = 78; 18.4%). Collectively, more than two-thirds (n = 284; 67.0%) of the participants had work experience up to 20 years. A cumulative total of 33.1% (n = 140) of participants had more than 20 years of work experience.

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Teaching and learning strategy

Survey results: optometric practitioners

Table 1 presents findings regarding factors that could be reliable measures of competence to be considered for structured postgraduate programmes. The two statements were presented with a 5-point Likert scale, with options strongly agree, agree, neutral, disagree and strongly disagree. The findings of ‘strongly agree’ and ‘agree’ as well as the ‘strongly disagree’ and ‘disagree’ options where combined and presented as a cumulative total in Table 1. For both grouped decisions, the results showed that participants’ level of agreement exceeded 70%.

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Perspectives on usage of technology in the training of future postgraduate students were explored. A statement relating to online demonstration of skills supplemented with audiovisual teaching aids was presented, probing whether this approach was equivalent to face-to-face training with a facilitator. The selection options used a 5-point Likert scale where the ‘strongly agree’ and ‘agree’ findings as well as the ‘strongly disagree’ and ‘disagree’ findings were combined and presented as such in Fig. 4.

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Focus group discussions results: optometric educators

Using a deductive approach, a predetermined theme on the concept of teaching and learning was ‘clinical skills development’. The theme derived was from the first question of the FGD on teaching and learning for postgraduate programmes in specialised fields of optometry. The subthemes emanated from probing points pitched to the group for discussion. The textual data for each subtheme was coded to generate patterns of thought presented as summarised group opinions on a suitable pedagogical approach. Fig. 5. illustrates the a priori theme and subthemes.

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Subtheme one: clinical hours vs. clinical cases

The matter of clinical hours and clinical cases is accrued at undergraduate level; therefore, educators were consulted to see whether it is a viable approach for postgraduate level training to advance skills in a specialised field of optometry in order to be recognised for their expertise and competency. This predetermined theme was presented to all groups for exploration.

Participants felt that both clinical hours and patient numbers were important to demonstrate competency and proficiency, as reported by FG4p3, FG4p1 and FG4p2. It was further explained that the selection of the training environment for clinical exposure was important:

“Clinical aspects might be done, I guess within a hospital or university environments in clinical environments, but they could also be done within the practices … but that would need to be looked at carefully to make sure that they get the necessary clinical experience that they need in order to feel that they’ve made progress in whatever the speciality is.”

It was further stressed that there should be accredited training sites where hours could be accumulated, a sentiment supported by FG2p4, FG2p2 and FG2p1: “is actually necessary to have these accredited…so I think that if we’re gonna put a number of hours attached to this, then it does become very important to have a number of accredited private practices that can actually share that burden of helping us gain those hours for those students.”

However, FG3p3 and FG3p2 felt that clinical cases were a better indicator of knowledge and skills acquisition than clinical hours: “So you’ve clocked in eight hours, but you know the outcome of that was only two patients, whereas I think a portfolio of evidence is stronger in the sense that you’ve got the skills and you presenting it in a portfolio and defending the case that you’ve seen. So, I would probably go more for portfolio of evidence rather than hours.”

Outcome for subtheme one

Participants across the different focus groups concurred that both clinical hours and consultation of real cases was a way to develop skills though there were reservations that logging in the number of cases is a more authentic indicator of skills development than accumulating hours working in a specialised setting. Having sites vetted was also indicated to ensure maximum training to taking place and was conducive to optimal clinical skills development.

Subtheme two: mode for skills development

Because optometric practitioners are employed throughout the country, the optimum strategy for skills training was explored, as it would be a significant component of postgraduate programmes. Traditionally, in-person skills transfer was used at the undergraduate level because students were all in the same location. However, with practising optometrists located throughout the country, considerations for different teaching and learning modalities needed to be considered to ensure access and participation by all students while assuring quality of training.

Participants (FG2p2, FG2p3) believed that face-to-face contact sessions should be the preferred approach for skills training of postgraduate students. A stronger emphasis towards face-to-face sessions for skills transfer than virtual training was expressed by FG3p4 and FG1p2. “My feeling is that the theoretical components can be offered online whilst the practical components may require a kind of contact session and this would align also in terms of assessing in those two aspects”.

A block release system was recommended by FG1p5, FG1p1, FG3p4 and FG3p3 for contact sessions at different times during the year to allow flexibility for fulltime employed students whose busy periods vary at different times in a year and might affect their availability: “So if a person is working, a profession is working, to offer it in terms of little blocks, which is doable. Blocks that would work for the institution where people are employed or for the sector where people are employed, as well as to provide dedicated times or areas for the student.”

A hybrid approach, according to FG3p1, could be supportive for those residing in different geographical areas, which was similar to an opinion expressed by FG1p5.

Outcome for subtheme two

There was a strong indication across all FGDs that theoretical engagement could be online as synchronous and asynchronous sessions, with a blended approach comprising multiple teaching and learning activities. For clinical skills development, however, the traditional approach of face-to-face training should be the main modality and possibilities of some virtual observations and demonstrations as supplementary.

Assessment strategy

Survey results: optometric practitioners

Participants’ level of agreement was rated on their preferred assessment strategy to be employed in postgraduate programmes (Fig. 6) as well as their views on whether summative assessments hold any value and being necessary for postgraduate education and training (Fig. 7). The combined findings of “strongly agree” and “agree” responses as well as “strongly disagree” and “disagree” are presented in Figs. 6 and 7 respectively. While continuous assessment is clearly preferred, there appeared to be significant disparate findings about the value of having summative assessments with neutrality being the most selected option.

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Focus group discussion results: optometric educators

The second predetermined theme of ‘Assessment Strategy’ and two subthemes were derived from the FGD questions and probing points (Fig. 8). This was presented to the groups for discussion on a way forward for the envisaged postgraduate programmes.

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Subtheme one and two: continuous assessments and summative assessments

An assessment strategy was explored due to various differentiating characteristics of a postgraduate population from an undergraduate population of optometry students. A best-fit approach needed to be investigated for specific postgraduate programmes by considering the purpose and feasibility of coursework postgraduate programmes.

The optometric educators exhibited strong support for a continuous assessment strategy rather than summative assessments. This was expressed by FG4p3, FG1p4, FG1p5 and FG2p3: “I would not be too rigid about the fact that there needs to be a major summative evaluation. If continuous assessment is designed well … I think it might become redundant to have a massive summative evaluation.”

A contrasting view was expressed regarding skills assessment where a portfolio of evidence (PoE) was not considered sufficient to justify that proficiency has been developed without an assessment to audit the clinical skills. FG2P3: “My feeling is that it cannot replace the assessment component in a programme and that there should be an assessment. You know, the skills that’s been acquired in that particular programme, so for that to happen by means of some kind of a practical clinical assessment.”

It was further noted that although continuous assessment is useful, it may be a more labour-intensive approach which often gets forgotten despite the value that it may hold for both the student and the facilitator. FG3P4: “I don’t think anybody must underestimate the extra contribution that is required from facilitators in terms of continuous assessment. Whoever offers the course, whatever form it is in, it takes a lot more energy and time to manage in terms of continuous assessment.”

Outcome of subtheme one and two

Optometric practitioners strongly supported continuous assessment over summative assessment but were mostly ambivalent regarding the value and necessity of summative assessments in postgraduate education. Optometric educators supported a continuous assessment strategy or rather were not against a continuous assessment strategy provided it was well structured to not warrant a summative component. Optometric educators further cautioned that continuous assessment, though valuable for this level of study, does come with more work and planning on the part of the educators.

Phase two: Delphi technique

From the integration of findings from the questionnaire and the FGDs in phase one, divergent results that emerged between the two populations were presented to the Delphi panellists to provide their independent viewpoints through a qualitative and subsequent quantitative round in the Delphi technique. Two divergent findings were found for theme one (clinical skills development) and theme two (assessment strategy). The probing statements that were derived from the divergent findings and subsequent subthemes generated are presented in Table 2.

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The results of the first round expressed as summarised key points, as indicated in Table 2, served as the basis for developing new statements for the next round of the Delphi technique with the intent of seeking group consensus quantitatively. The Delphi panelists were provided with an online questionnaire using four closed-ended statements specific to teaching and learning and assessment. A 4-point Likert scale using agree, somewhat agree, somewhat disagree and disagree was presented for each statement with the resultant responses aggregated to measure the group consensus percentage (Table 3). No neutral option was presented as consensus was needed.

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Discussion

To provide lifelong learning opportunities for optometrists in South Africa, coursework postgraduate optometry programmes should be developed where clinical skills development is the main focus of the education. The findings of this study indicated that to encourage the participation of working optometrists in education and training, the implementation of a blended learning approach, incorporating hybrid teaching methods alongside asynchronous materials and periodic hands-on sessions, would render further education accessible to optometrists located throughout the country. With the uptrend of hybrid and blended learning models in optometry, and health professions education in general [27, 28], HEIs must capitalise on strategies that enhance lifelong learning accessibility. Working postgraduate students must be exposed to concrete learning experiences with the agency in managing their own education and work life [29]. These findings are valuable for HEIs for the preparation of postgraduate optometry programmes, as transparency on the teaching and learning approaches would ensure that students that enrol are well-informed to limit attrition in structured programmes. Although online teaching and learning is an expectation, programme facilitators need to review not only the effectiveness of these novel teaching and learning strategies in postgraduate education, but to also uphold the standards of medical education without having to compromise on quality [30]. The acceptability of using a blended learning approach with optometric practitioners was not explored, as it was already considered a current standard practice at HEIs. Instead, the focus was on determining the extent of using blended learning at a postgraduate level that was considered more important. The factor of independent self-study was also of major importance. A programme that is labour-intensive with significant volume and content would also be a deterrent to enrol, as work-home balance is a major challenge. Similar barriers in terms of time constraints were reported in studies with nurses, physiotherapists and dental hygienists regarding postgraduate education [31,32,33].

In examining the factors that may have a potential to impact optometric practitioners’ enrolment decisions, three factors were regarded as highly important, which were face-to-face versus online education, how skills training will be arranged in the programme, and the amount of self-study. Al Rawashdeh et al. reported that e-learning afforded students flexibility to engage with the learning material without the restrictions of physically being present, saving significant time and travel costs to include other daily responsibilities; hence it represents a large economic benefit [34]. Regarding both factors, time constraints and geographic location were major findings in optometrists’ decision to enrol for postgraduate studies. Furthermore, it would be beneficial to have insight prior to registration, if the format and modes of delivery would be feasible for them.

More than 70% of optometric practitioners indicated that both clinical hours and clinical cases would be beneficial to build competency and proficiency. Optometric educators mostly supported exposure to clinical cases as being a more authentic indicator of competency development than the accumulation of clinical hours. However, as a work-integrated learning system (WIL) supports experiential learning, such activities need to be structured and monitored, placing the issue of clinical hours in question. The lack of agreement between practitioners and educators led to Delphi panellists considering the matter and the supported exposure to real clinical cases as a reliable strategy to build competency. Lavafe and Yeo found that athletic therapy students’ confidence growth improved with the volume of cases exposed to, whereas time alone had no influence [35]. Hallas et al. challenged the nursing student requirement of clinical hours and attainment of core competence, and concluded that although minimum hours were met, not all core clinical competencies were established [36]. An optometry residency programme in Hong Kong indicated 1000 clinical hours working within the specialty field as a requirement [37]. In the UK, however, a minimum number of clinical cases ranging from 150 to 250 cases based on the speciality areas, is required [38]. A possible explanation for a larger percentage of practitioners supporting both clinical hours and cases in this study might stem from their undergraduate training, where professional registration requirement by the HPCSA in SA is the accrual of a minimum number of clinical hours and clinical cases.

A continuous assessment strategy providing the flexibility for practising optometrists should be the approach of choice for appraisal of competency, while summative assessments and portfolios of evidence are used where necessary. This was the key finding in this study on the assessment strategy at postgraduate level. Most optometric practitioners preferred continuous assessments to a summative assessment. However, when questioned on the value of a summative assessment, there was uncertainty with a high level of neutrality. To interpret such a finding, it implies that although continuous assessment is preferred, it does not mean that optometric practitioners saw no value in summative assessments. Optometric educators concurred that continuous assessment is a better approach, although it was noted with caution as being more labour-intensive for the educators. With an ambivalent finding towards a single approach in phase one, the Delphi panellists subsequently indicated that continuous assessment representing low-stakes assessments would be a superior measure of achievement of learning outcomes. As stated by Sharma et al., summative assessments are losing ground in medical education with formative assessments gaining ground; however, it was noted that formative assessments were difficult to implement due to time constraints [39]. Shebeshi and Baheretbeb concurred that extensive instructional time and content volume in medical education affected continuous assessment implementation [40].

Chimea et al. reported that emotions and negative experiences of summative assessments can affect achievement of the learning outcomes [41]. This view was similar to the opinions expressed by optometric educators in the current study. High-stakes assessments could be done but to a lesser extent when required and could be discipline-specific. This implies that a blanket approach to assessment does not have to be adopted. With flexibility should come consistency between HEIs. For the same programme and specialised field offered across different HEIs, consistent assessment strategies and teaching and learning modalities should be implemented as it supports interinstitutional mobility and quality assurance standards.

Interinstitutional collaboration would be a way forward to mitigate challenges of limited educational tools in terms of equipment and online learning resources, as well as skilled educators to support more than one institution [42]. As both human resources and educational material are unequally distributed between HEIs, in part due to historical inequalities [43], sharing and collaborating in the delivery of postgraduate education can be a way to ensure sustainability in the delivery of education and training between institutions. International collaboration and transnational collaboration in higher education activities [44] are opportunities to foster cohesion in optometric education across the global North and South. Given that the current undergraduate programmes are resource-constrained in terms of optometric educators, it would be sensible to carefully investigate outsourcing assessments to identified optometrists to serve as proctors. The added benefit would be that postgraduate students could be assessed at sites nearest to their location rather than continuously traveling to the HEIs. Innovative strategies need not only refer to technology integration but also exploring non-traditional or non-conventional approaches to sustain the academic project. In doing so, access to higher education becomes a lower hanging fruit to those who reside remotely and in rural areas.

If continuous assessment was supported and practical skills assessment was deemed critical, it is believed that a competency-based education (CBE) model would be a best-fit despite the specific phrase not being verbalised during the FGDs. A CBE model encompasses a core assessment strategy based clearly circumscribed competencies to track progress and proficiency rather than being a time-dependent measure of competency. This model is outcome-driven and focusses on learner achievement [45, 46]. Entrustable Professional Activities (EPAs), an emerging pedagogy in middle-income countries like SA, could be a strategy for clinically structured postgraduate programmes. Defined as a unit of professional practice that can be entrusted to an unsupervised trainee once an adequate level of competency has been achieved [47], EPAs could be used as a tool for the desired continuous assessment strategy where different speciality programmes would establish a set of competencies to be achieved. As EPAs are outcome-driven with a series of low-stake assessments involving multiple assessors to award competence at different stages of the learning cycle, this approach could be applied as complementary to the PoE that could be summative in nature.

All the optometric educators in this study felt that the compilation of a PoE complemented with a practical assessment should be mandatory to evaluate competence in skills, rather than a portfolio alone which may not adequately impart competence in skills. However, in a systematic scoping review, Lim et al. [48] placed significant value on portfolios in postgraduate medical education and how it should be designed and structured to authentically impart learner achievement, transparency and accountability. These authors further cited that portfolios continue to struggle to find its role in how it is used, which weakens its value [48].

The Technological Pedagogical Content Knowledge (TPACK) model as a theoretical framework would underpin the aspects proposed as the most plausible approach, because technology is grounded within content building, knowledge acquisition, pedagogy, design of learning and teaching activities, and enhancing the learning experience. Koelher and Mishra formulated a new approach integrating three intersectional components of technology, pedagogy and content [49]. The TPACK framework is a construct that guides the relationship between technological knowledge (TK), pedagogical knowledge (PK) and content knowledge (CK) [49, 50]. With a paradigm shift in education through the lens of constructivism, technology integration in education has become more a necessity rather than a ‘nice to have’ concept. Because students’ learning methods have changed, educators need to use newer and more relevant educational frameworks to adapt and even discard traditional approaches to knowledge and skills transference [51]. Educators, programme designers and policymakers are the driving force to champion the pedagogical change [50]. The tenets of this model can be applied to postgraduate education in optometry.

Boedeker et al. stated that little has been done to employ pedagogical content knowledge into health professions education [52]. It is for this reason that when developing new educational streams for optometrists, it would be prudent not to initiate such planning through technological integration into health professions education. This would position South African optometric education to align with the Council on Higher Education (CHE) directive of incorporating technology in teaching and learning [53]. Innovative pedagogies such as student-centred teaching and learning are appropriate for adult learners as it provide them with opportunities for critical thinking and agency in their own education [54].

Establishing new educational opportunities for optometrists hold value on multiple fronts. Educating and upskilling the health workforce can improve human capital development in Africa, foster economic growth and improve health outcomes for those requiring specialised care [55]. This would strengthen South Africa’s position in the Global South to pioneer specialised postgraduate optometric education for the African continent.

Limitations and recommendations

The online format of the FGDs had its disadvantages. Turned off cameras limited robust dialogue between participants, with uncertainties about who should speak, while waiting to be called upon by the facilitator, thereby slowing the pace of the FGD. Although it is generally recognised that power dynamics impact active participation in FGD and the exchange of ideas, the practical implementation of group diversity was impeded by participants’ work schedules and availability, in addition to the fluctuating national power outage schedules in the different cities from which participants connected. The Hawthorne Effect or ‘participant reactivity’ [56] could have influenced FGD participants’ behaviour with the knowledge that the researcher was able to listen in on the discussion despite prior disclosure from the information sheet that the researcher would remain as an observer. A limitation of note was the participants challenged with expressing and conceptualising future postgraduate programmes that are not yet available, as there was no pre-existing programme to reflect on and benchmark to assert a view. This occurred when increased neutral responses were reported, indicating a noticeable level of ambiguity in certain survey questions related to technology in education, and similar trends with ambivalent views in FGDs. However, it is noteworthy that more experienced educators were able to conceptualise and articulate their responses with notably more depth and substantiation. The use of non-probability sampling techniques limited representativeness and could potentially lead to bias in terms of data collected.

It is recommended that with the oversight of the Professional Board for Optometry and Dispensing Opticians (PBODO), the heads of departments of optometry engage on the plans for collaboration and do so by describing the areas and ways in which this collaboration could materialise. Measures to be taken to ensure long-term sustainability of new programmes should be discussed with educators involved in the development process. Stakeholder engagements are imperative for finding an achievable approach that would sustain these programmes for optometrists in SA.

For the curriculum planning and interinstitutional collaboration, it is recommended that a standards generating body (SGB) under the auspices of the regulatory authority be constituted for the development and application of education and training standards across all coursework postgraduate programmes for HEIs, guided by a postgraduate programme framework in optometry. A future recommendation for the profession would be the formation of multiple communities of practice (CoP) for the different speciality areas involving various stakeholders from SA and abroad, to ensure knowledge building, sharing of resources, and advocacy towards growing the profession in different speciality areas of optometry.

Conclusions

The inclusion of optometric practitioners’ voices as both end users and service providers was a valuable outcome of the study. As a result, the findings should be interpreted as evidence-based recommendations. The development of coursework postgraduate programmes in optometry specialities should be supported by a technology-driven pedagogy underpinned by the TPACK model. Lifelong learning opportunities should be available to all optometrists in South Africa, regardless of their location or proximity to an HEI. For this reason, leveraging technology to enhance teaching and learning should make further education accessible. A WIL system where proficiencies are harnessed from the application of learnt skills and knowledge, would be a suitable strategy for working optometrists. A CBE model would then serve as the competency framework of the theory-practice integration.

Establishing EPAs for working optometrists under the CBE umbrella may support a paradigm shift from assessment of learning to assessment for learning. These measures may improve enrolment, retention, and throughput rates. To enable HEIs to sustain such postgraduate programmes, interinstitutional collaboration encouraging resource sharing in various ways would be an innovative and viable option. Extending beyond a postgraduate pedagogy, a broader overarching framework should encompass programme qualification type, specialised fields, programme design elements, programme qualification type, training duration, and accreditation. This framework and the empirical evidence generated has been shared with the HPCSA’s Professional Board of Optometry and Dispensing Opticians to assist HEIs to expedite the process towards their programme and curriculum development processes. The aim is for institutions to investigate expanding of their Programme Qualification Mix (PQM) and investigate internal policies for collaboration. Professional Board would have oversight on the development of new programmes for optometrists and facilitate the planning sessions with all four HEIs. The goal should always be to ensure that patients and society at large ultimately benefit from this venture of upskilling the health professionals.

Data availability

Data are available from the corresponding author upon reasonable request.

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