Volume 19, Issue 3 p. 235-238
PERSPECTIVES IN HOSPITAL MEDICINE
Open Access

Peer observation to promote a culture of teaching and learning

Lester James Nixon MD

Corresponding Author

Lester James Nixon MD

Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA

Correspondence Lester James Nixon, MD, Department of Medicine, University of Minnesota Medical School, 401 East River Pkwy, VCRC 154, Minneapolis, MN 55455, USA.

Email: [email protected]; Twitter: @nxon007

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Sophia P. Gladding PhD

Sophia P. Gladding PhD

Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA

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First published: 30 July 2023

INTRODUCTION

Academic hospitalists have a complex and important role in teaching learners in the clinical environment.1 However, they often report feeling unprepared or unsupported for this role.2 To support hospitalists in their teaching roles, department leaders must choose between approaches varying in effectiveness and resource intensiveness as they consider how best to prepare their hospitalist educators.3

Workshops offer efficiency but require clinical teachers to translate complex knowledge and skills from the classroom into a complicated clinical environment. For developing the complex skill of clinical teaching, an ideal model for faculty development is likely one situated in the workplace that includes timely and specific feedback on performance.3, 4 Peer observation, in which a physician is observed teaching on rounds in the clinical environment by a peer who provides feedback, meets these standards while promoting a supportive environment for hospitalists in their teaching roles. This type of peer observation has been shown to increase confidence in critical teaching domains,5 and improve teaching skills and learning climate.5, 6

LEARNING FRAMEWORKS TO CONSIDER WHEN STRUCTURING PEER OBSERVATION OF TEACHING

We recommend guiding the development of peer observation programs using key principles from three learning theories and frameworks: Social Learning Theory, Growth Mindset, and Deliberate Practice. Peer observation programs aligned with principles from these frameworks can promote co-learning with both the observer and observed benefiting from insights gained into potential areas for growth as teachers; allow flexibility about who performs the observation; and support teaching relationships between hospitalists through collegial observation and feedback. The success of such programs likely also requires leadership to help build a culture of psychological safety.7 This requires acknowledging the uncertainty surrounding teaching in the clinical environment, that we all make mistakes, and that curiosity makes us better.8

SOCIAL LEARNING THEORY

Key principles

Social learning theory explains that learners can assimilate new information through social interactions that include observing, modeling, and imitating others.9 For social learning to occur, learners must: (1) pay careful attention to the behavior they are observing and want to reproduce, (2) internalize and retain what they have observed, utilizing cognitive processes to mentally rehearse the desired behavior, (3) reproduce the desired behavior by transforming information from the first two steps into action, and (4) have the motivation to imitate the desired behavior.10 One such motivation is vicarious reinforcement, which comes from seeing how others respond (negatively or positively) to what is being observed.10 Whereas many peer observation programs focus only on the benefit to the observed clinical teacher who receives feedback, social learning theory provides a framework to also consider the benefit for the observer.

Applying principles to peer observation program

We recommend providing the observed hospitalist with a selection of preobservation readings about best practices in clinical teaching targeted to meet most educators' needs. Having the hospitalist choose one or two of these readings before their observation provides them the opportunity to reflect on and self-assess their teaching. This can help them determine what teaching behaviors they want to try during observation and the opportunity to mentally rehearse. Having the observed hospitalist set a targeted area for observation and sharing it with their observer facilitates active observation by bringing the observer's focused attention to this behavior. For the observer, seeing a learner respond positively to a teaching technique provides strong positive (vicarious) reinforcement to try this same technique in the future.11

Following the observation, a debriefing session should utilize a balanced conversation about what went well and opportunities for improvement. Encouraging the observer to share something they observed and want to try in the future, provides a clear role for the observer to benefit from following the tenets of social learning theory. This sharing of ideas creates a co-learning environment where hospitalists gain insights and inspiration from each other further strengthening collegial relationships.

GROWTH MINDSET

Key principles

A growth mindset can be contrasted with a fixed mindset.12 Within a fixed mindset, a new challenge is an opportunity to fail, whereas, in the growth mindset, any new challenge becomes a chance to improve. One reason hospitalists may avoid peer observations is out of fear of failure within a fixed mindset.13

Applying principles to peer observation program

Nonevaluative peer observations are more likely to promote a growth mindset and be seen as an opportunity to improve. Whereas, evaluative peer observations may feel more like an external judgment thus promoting a fixed mindset.12 We suggest allowing hospitalists to select their own observers to promote a growth mindset. When hospitalists choose observers who are trusted peers and establish observation boundaries within a structure that promotes a collaborative relationship, they are more likely to share specific teaching skills they are working on and for which they would like feedback. Conversely, assigning “expert” observers can feel judgmental and may reinforce a fixed mindset.13 Some may worry more junior observers lack the experience needed to be effective observers, but there is evidence they can be successful in their roles without formal training.14 Additionally, as a practical consideration, a model supporting junior hospitalists performing peer observations can decrease the need for more senior-level hospitalists (who may be in short supply) to perform peer observations.

DELIBERATE PRACTICE

Key principles

Deliberate practice suggests continued performance improvement likely requires: 1—engaging in a task with a well-defined goal, 2—motivation to improve, 3—feedback on performance, and 4—opportunity for repetition and refinement of performance.15 Without intentional practice, teaching skills will likely plateau early in a hospitalist's career.

Applying principles to peer observation programs

We recommend promoting deliberate practice within peer observation programs by including the opportunity for hospitalists to select targeted areas for their observation. The observation should be followed by immediate feedback from the observer and the opportunity to reflect and make specific plans to improve and practice the skill. A formal check-in after several months provides the observed hospitalist time to practice the targeted skill and reflect on any improvement. Structuring peer observation as an iterative process with peer observations at regular intervals should promote deliberate practice and ongoing development throughout their career.

PUTTING IT TOGETHER

Figure 1 details a model structure for peer observations of teaching on clinical rounds which incorporates these principles and the experiences of previously published programs.5, 14, 16, 17 On a practical note, providing centralized processes for sharing materials, collecting documentation, and tracking participation will facilitate this peer observation process.

Details are in the caption following the image
Peer observation of the teaching process.

ENCOURAGING PARTICIPATION

While mandatory peer observation programs ensure participation, they are unlikely to promote the culture you are striving for as they tend to foster concern and mistrust about how observations will be used.18 In contrast, voluntary programs which are more aligned with a supportive culture have the potential for participation to drop off.5 While there are few studies examining the longevity of peer observation programs, there is evidence suggesting that building relationships and networks in the context of a supportive voluntary program may enhance their sustainability.14, 19 Participation may be further enhanced through support structures such as a departmental incentive program (including a financial bonus for participation) and assistance in organizing observations.20 Supportive measures like these demonstrate value for hospitalists' time acknowledging they have many competing interests for this limited time.

Common reasons cited for nonparticipation include lack of time, the belief that their teaching skills are already strong, or anxiety about someone watching them teach and these should be considered when designing programs.18 Allowing hospitalists to select a trusted colleague as an observer takes advantage of existing relationships and may enhance participation by creating a less intimidating and more encouraging environment.19 Sharing with hospitalists the equal benefit to both the observer and observed hospitalist11 will also help lower the stakes, and thus the activation energy to participate in the peer observation, and promote psychological safety.8 While the observed hospitalist benefits from feedback on their performance, the observing hospitalist will create a comparison to their own prior performance leading to reflection.10 This process may strengthen the observer's self-efficacy to apply new strategies to their own teaching.9

Unfortunately, those who are struggling in their role as clinical teachers may avoid professional development programs.13 So, try the following measures to make the program appeal to all hospitalists including those who are insecure about their abilities or who are performing poorly. Emphasize that the observer does not have all the answers, but rather is facilitating a reflective conversation between peers with the shared goal of improving everyone's teaching.11 Promote the idea that participants enjoy the activity, and that peer observation encourages peer-to-peer collegiality and provides an opportunity to learn what their colleagues do on rounds.17 Additionally, keeping peer observation feedback confidential can further remove barriers for those reluctant to participate by lowering the stakes.

CONCLUSION

Peer observations of teaching can be an effective and efficient model for professional development in clinical teaching. Programs guided by the key principles of Social Learning Theory, Growth Mindset, and Deliberate Practice can promote co-learning between the observed and observer hospitalists, provide flexibility in terms of who can act as the observer, and encourage participation through a voluntary, low-stakes approach that promotes psychological safety.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflict of interest.