Running Head: Peer coaching
Peer Coaching as a Technique to Foster Professional Development in Clinical Ambulatory Settings* by Leslie E. Sekerka, Ph.D. Department of Organizational Behavior Case Western Reserve University
and
Jason Chao, M.D., Associate Professor Department of Family Medicine Case Western Reserve University Cleveland, Ohio
All correspondence to: L. Sekerka 1200 Andrews Avenue Lakewood, Ohio 44107 Telephone: (216) 622-2644 ~ Fax: (216) 621-5941
[email protected]
*
This research was supported by a predoctoral grant, 5 D05-PE 85058, from the Division of Medicine, Bureau of Health Professions, Health Resources and Services Administration.
Running Head: Peer coaching Abstract Background: Few studies have examined how peer coaching is an effective educational and development technique in contexts outside the classroom. This research focuses on peer coaching as a platform to study the process of professional development for physicians. The purpose is to identify perceived benefits coaches received from a coaching encounter and how this relates to their own process of professional development. Methods: Critical Incident Interviews with thirteen physician coaches were conducted and taperecorded. Themes were identified using a thematic analysis technique. Results: Themes emerged clustering around two distinctive benefit orientations. Group 1, Reflection and Teaching coaches, tended to focus on others and discuss how positively they experienced the encounter. Group 2, Personal Learning and Change coaches, expressed benefits along more personal lines. Findings: Peer coaching contributes to physicians’ professional development by encouraging reflection time and learning. Peer coaching affords positive impact to those who coach in addition to those who receive the coaching. The two clusters of benefits support the Performance, Learning, and Development Theory in that there are multiple modes to describe adult growth and development. Programs of this type should be considered in medical faculty development activities associated with medical education. Key Words: Peer coaching; faculty development; ambulatory teaching; adult learning and development; thematic analysis. Lessons for Practice: Peer coaching fosters medical educators’ professional development. Physician peer coaches may benefit in several ways: 1) reflection and teaching and 2) personal learning and development.
2
Running Head: Peer coaching Peer Coaching as a Technique to Foster Professional Development in Clinical Ambulatory Settings For physicians, called to a profession to help others, it is important to understand what techniques are conducive to fostering their own learning, well being, and growth as they give care. This research identifies peer coaching (PC) as a platform to study this process. Coaching features an intense focus on learning that includes physicians working together to learn models of teaching or to address specific improvements. Peer coaching has been described as a “structured process by which trained faculty voluntarily assist each other in enhancing their teaching repertoires within an atmosphere of collegial trust and candor.”1 Few studies have examined how this technique is an effective educational and development process in contexts outside the classroom.2 Prior research is often of a descriptive nature, looking at PC in general and discussing outcomes in broad strokes. This study extends the current literature by not only ascertaining how coaching helps the coach, but also by examining PC in a clinical ambulatory setting, a nontraditional learning environment. Peer coaching is important to continuing medical education as it builds upon teachers’ knowledge and strengthens skills for teaching in a clinical environment. The technique was introduced to medical education in the early nineties3 and now highlighted as an important part of a comprehensive program for ongoing faculty development.4 It can be used in a variety of settings to empower educators as it bolsters learning for both physicians and students.5 The major functions of PC are to: 1) provide companionship; 2) stimulate feedback; 3) promote analysis of applications to internalize tools; 4) foster adaptation; and to, 5) facilitate trial by providing support.6
3
Running Head: Peer coaching The purpose of this investigation was to look at the role of professional development by interviewing physicians who have been peer coaches in a clinical ambulatory setting. Current literature suggests PC relationships are mutually beneficial, fostering learning for both coach and coachee.7-8 Unexamined are what happens to the coach and how perceived benefits of the encounter relate to their own development. This research aims to broaden knowledge of PC literature and explore what positive outcomes occur when physicians coach other physicians—by answering the following research questions: RQ1: What perceived benefits do coaches receive from their peer coaching experience? RQ2: Does peer coaching contribute to the coach’s professional development? By featuring the benefits of PC, the aim of this research is to foster interest in longitudinal approaches for preceptor development. As demands on medical faculty increase, if teaching and learning are expected to improve, institutions must provide programs not only focused on clinical subject matter but on teaching skills as well. This study adds depth to our understanding by attending to outcomes experienced by the coach. We hope to illustrate how PC may provide benefits, previously unnoticed. Background Joyce and Showers articulated the framework for PC in the early 1980s, with the goal to edify educator staff development.9-12 Education experts have underscored that coaching processes differ from other peer techniques.13 In educator PC, teachers learn about the theoretical foundation of a skill, observe it demonstrated, and then practice the skill with feedback. Coaching models vary and generally emphasize a technical, challenge, or collegial focus.14-17 Technical is designed to help master specific teaching methods.18 Challenge is directed toward resolving a problematic situation and helps pairs concentrate on individual areas
4
Running Head: Peer coaching where they desire improvement.19 Collegial is relational and promotes shared reflection, leading to enhanced trust and communication. Some researchers of professional development have hypothesized a sequential progression of skill attainment for effective physician development.20 Alternatively, building upon the life stage works of Piaget and Levinson, the Performance, Learning, and Development Theory postulates three non-sequential modes describing adult development.21 Individuals are predominantly in one mode during any one time in their life/career and current mode affects one’s process of growth. The three modes are performance, learning, and development, with no advanced orientation. Individuals have a dominant mode, but there is no sequential movement and modes are expected to be revisited. The Setting Since PC made its debut in the education arena, professional development programs emphasizing peer-centered options have emerged.22 One example is the Physician Peer Coaching Program (PPCP) at the Department of Family Medicine at the Case Western Reserve University (CWRU) School of Medicine. Since 1991, the mission of the PPCP was to improve the clinical teaching skills of faculty. Peer coaching was adopted because observations of clinical precepting revealed physicians’ did not possess basic teaching skills such as asking questions, providing constructive feedback, and active listening. With over a decade of involvement, this program was ideal for examining physicians’ perceptions about their experiences as coaches. PPCP trains preceptors as coaches so they can help other physicians with ambulatory teaching practices. It is a vehicle for improving instruction and to enhance clinicians’ understanding and use of new teaching skills, or improve existing competencies. This is learned
5
Running Head: Peer coaching by demonstration, practice, and via non-evaluative feedback between coaching colleagues.23 While resembling a Kurthian coaching model24 (i.e., collegial interaction rather than supervisory evaluation), PPCP blends various forms of coaching to generate maximum effectiveness. Key elements include voluntary participation, collaboration and parity of colleagues, shared identification of goals, focused observation of teaching with the provision of feedback analysis, and ongoing coach instructor support.3 Methods Participants were members of the CWRU, Department of Family Medicine, PPCP (N=26). To become a coach, physicians agreed to participate in workshops where small interactive cadres met to role-play coaching scenarios while being videotaped. Reviewing their tapes, coaches examined processes and shared reflections. Physicians were trained in two personal coaching sessions (i.e., observed and coached on teaching skills). Partnered with another physician they began their coaching role in a ambulatory setting. Payment was $175 per session when attending a workshop or serving as coach. An inductive qualitative method using grounded theory and thematic analysis was used to perform an in-depth analysis of coaches’ experiences.25-26 Coaches in the sample frame were contacted (two were not available). Critical Incident Interviews were conducted (i.e., an interviewing technique used in medical education research).27-29 Each physician was asked to think of a time when they assumed the role as coach (in a coaching session) and to respond to the following: “What are you getting out of being a coach?”; “To what extent has this coaching experience affected your role as a physician preceptor?”; and “What happens to you as a result of your coaching experience?” The tape-recorded interviews ran from 50-70 minutes and were transcribed verbatim.
6
Running Head: Peer coaching The coach and physician he/she coached were asked to evaluate the session referenced in the interview. Twenty-four questions using a 5 item Likert Scale (1=na or not observed; 2=poor; 3=fair; 4=good; 5=excellent) were asked to evaluate the session as a whole and the coach's contribution and effectiveness in teaching. Items included questions about helping the coachee to learn and how effectively coaches asked questions, listened, used humor, and provided feedback. Each of the coach’s ratings were averaged for an overall self-reported effectiveness score (similarly, coachee’s ratings for an overall coachee-reported effectiveness score). Scores represented how effective each coach was in their encounters—from both viewpoints. To avoid long-term memory bias, eleven coaches citing encounters from more than two years ago were dropped from the analysis (n=13). Three randomly selected transcripts were used to identify manifest and latent themes. Through a compare-and-contrast process the senior researcher identified themes from transcript data. Indicators for each Benefit Theme were found through an intensive iterative process, leading to the creation of a preliminary codebook. The codebook was used to identify the presence of themes in other transcripts, with frequency of indicators for each theme reflecting the strength of each Benefit Theme for each physician. A draft codebook now complete—a research assistant was trained to learn the code. Three additional transcripts (randomly selected from the remaining ten) were independently coded by researcher and assistant. After adjusting several indicators, an interrater reliability of .87 was achieved. Percentage of agreement was calculated by the number of times both coders agreed divided by the number of times coding was possible. To test the validity of the codebook the
7
Running Head: Peer coaching remaining seven transcripts were independently coded and an interrater reliability of .91 was achieved. Results Twenty-four interviews were conducted with board-certified family physicians. Twenty-one were Caucasian, 2 Asians, and 1 African American. Characteristics of participants are in Table 1. Ten Benefit Themes were identified; Table 2 lists major themes and definitions with sample quotations. Benefits clustered around two general orientations. Group 1, toward Reflection and Teaching and Group 2, Personal Learning and Change. Group 1 reflected a greater presence of themes 1-5 and Group 2, themes 6-10. An independent-samples t test showed the clustering of themes 1-5 (Reflection and Teaching) and 6-10 (Personal Learning and Change) were significant at p < .05. Differences Between the Groups Seven coaches carried themes predominantly from Group 1 and six coaches from Group 2. Seventy-five percent of the female coaches fell into Group 1, whereas males were distributed between the two groups. Group 1 considered benefits not as distinct, but as integrated concepts. They processed the experience through a lens focused on others—putting collective orientations ahead of their own. Themes 1-5 exemplify centering on others, coupled with a conscious awareness of reflection time used to meet learners’ needs. Group 1 embraced the “bigger picture” and often referenced ongoing learning. They viewed learning as a cycle—cognizant of multiple levels of the teaching-learning process. Group 1 linked comments with expressions of concern or empathy toward the student or preceptor. They framed outcomes around how to enhance their role as an educator. These coaches enjoyed the session and described how it contributed to their overall positive outlook.
8
Running Head: Peer coaching Themes 6-10, predominantly associated with Group 2, were along more personal lines. References were concrete learnings, tangible outcomes, and/or examples of direct benefit. In general, outcomes were related to personal change with attention directed on their own learning or growth process. They enjoyed sharing the experience, especially when discovering they made a contribution. This frequently included positive self-assessment and enthusiasm about seeing personal progress. They were pleased to be engaged in a process that facilitated their learning and offered self-affirmations in conjunction with notice of growth. This group expressed the importance of challenge and that coaching added something “new” to their practitioner experience—keeping things “interesting.” The mean coachee composite score was 4.2 (1-5 point scale; 5=excellent), suggesting merit was found in the experience (coaches rated themselves slightly lower; mean self-reported coach composite score was 3.8). Comparing the groups, there was virtually no difference in the coaches’ effectiveness scores. Coaches in Group 1 (Reflection and Teaching), however, were rated slightly higher overall than those in Group 2 (Personal Learning and Change); 4.4 and 4.0, respectively. Discussion This study provided information about the perceived benefits of PC and insights on how coaching contributes to physicians’ professional development. Coaches perceived differentiated benefits centered around two orientations. Group 2 expressed more engagement in their own learning and personal change. With a greater focus toward themselves, this introspective stance may have been used to facilitate the success of their learning process. Benefits seemed to be in service of their own change, to give confirmation of proceeding in good form. By pointing out their contributions, they bolstered self-confidence and underscored personal mastery. While
9
Running Head: Peer coaching coaches in Group 2 demonstrated reciprocity, this mutuality was expressed quite differently in Group 1. These coaches made little mention of engagement in new learning or change but referenced making improvements and sustaining ongoing learning. They focused on what their involvement could do to contribute to the learner’s process or to advance teaching—and were consciously engaging in reflective practices. Since all of the coaches in this study were board-certified physicians, it is not clear if further development is linear. The two orientations found in this study may not necessarily be in stepwise progression. Using the Performance, Learning, and Development Theory,21 it is feasible that coaches’ reference point contributed to the group differentials. The physicians may have started from different modes of growth when entering the PPCP. This explanation serves as rationale for why the coaches perceived benefits of their encounters so differently. This inquiry illuminated the coaches’ current mode vis-à-vis their Benefit Themes. Thirteen physicians of relatively equal status and experience were engaged in a partnered learning situation yet they experienced it quite differently. We contend this was an expression of the growth mode they were in at the commencement of their involvement. Specifically, coaches with Benefit Themes 1-5 (Group 1) were likely to have started in the Development Mode and coaches with Benefit Themes 6-10 (Group 2) were likely to have started in Learning or Performance Modes. This would explain the emergence of very different Benefit Theme orientations. Worth noting is that both groups displayed effective coaching, regardless of orientation. This suggests that so long as the coach maintains a focus on the learner, coachees are likely to receive effective help. The physicians engaged in the PPCP were willing to broach education and growth, which for some included experiences of personal change. As a result, preceptors received benefits
10
Running Head: Peer coaching contributing to both learning and development. While important to consider expert and novice level of abilities in technical competencies,30 caution should be used in applying these terms to other areas of learning as the language implies hierarchy. Limitations A limitation of the study was a small sample size, based upon the fact that 11 of the coaches referenced encounters from 5-9 years ago. While all of the data was valuable, trying to associate memories was problematic for those referencing an encounter that occurred years ago. At the time of the interviews, those coaches citing earlier reference points were approximately 4 years older and had that same number of additional years teaching experience over the subsample analyzed. Finally, with participation based upon self-selection, we recognize a degree of bias. One cannot presume individuals participating in PC will perceive the same benefits or that all potential benefits have been identified. Future Research Future research should assess development modes before and after participation in PC programs. This may help distinguish experiences and what types of helping behaviors warrant increased attention. By considering individual differences in professional development, those responsible for continuing education can create the most beneficial educational programs for physicians. In addition, the questions that guide the direction of future investigators are important because they will determine the extent specialized integrated programs can be used to enhance faculty education, especially for clinical teaching in ambulatory settings.31 As PC contributes to both coachee and coach, programs of this type should be considered in activities associated with medical education. We believe this technique can be used in a variety of settings and has the potential to bolster learning at multiple levels.
11
Running Head: Peer coaching The broader implications of this research are that PC serves as a vehicle for ongoing learning, personal and profession growth for medical educators—empowering physicians to excel as educators. This study exemplifies that even in the busiest of teaching environs, coaching offers as an elegant framework for engendering cross learning and support.
12
Running Head: Peer coaching Table 1. Characteristics of Coaches Interviewed Group 1
Group 2
(n=7)
(n=6)
3 female, 4 male
1 female, 5 male
11.6 (SD 6.7)
11.7 (SD 6.8)
40.9 (SD 5.6)
45.0 (SD 7.1)
Associate Clinical Professor
2
1
Assistant Professor
4
1
Assistant Clinical Professor
0
1
Instructor
1
1
0
2
Gender Mean Number of Years as a Teacher * Mean Age * Academic rank:
Clinical Instructor
* No statistically significant difference between groups for coaches’ time as a teacher or age.
13
Running Head: Peer coaching Table 2. Major Themes and Definitions with Representative Quotes Cluster 1: Reflection & Teaching Theme 1: Use of Reflection Skills
Quote I get protected time for reflection. I think any time
Engages in reflection on what
you step back and observe someone else’s teaching
happened in the encounter.
behavior you begin to reflect upon your own. And, so it just puts you more into that reflective mode. I’ll mentally step back from time to time and think about which teaching skills I’m using and where, maybe certain parts of the teaching process have been covered and I need to focus on others.
2: Sees the Bigger Picture
It improves my ability to look at teaching
Expresses interest in wanting to
relationships from multiple levels. So when they’re
make improvements, sustain
not going well, I’m better at figuring out what it is
ongoing learning, or enhance the
that’s not working, and changing course...trying
quality of education on a broader
something different.
level.
14
Running Head: Peer coaching (Table 2 Continued) 3: Focus on the Learner
So I’m teaching from as many different methods as
Desire to create a positive
possible. Which ever the student will react to.
atmosphere in a teaching encounter, while considering what is important for the learner’s situation to foster understanding 4: Enhances Well-being
I just enjoy it…it’s pleasurable for me to have
Expresses feeling good or having people feel more comfortable. I like the fact that if a heightened positive experience. they have more knowledge they’re going to feel more comfortable. 5: Motivation to Teach
I feel like my purpose is in developing my career and
Desire or motivation to teach
still get me involved as my identity as a teacher… I
well.
guess paramount to that full identity is being someone who kind of really spirits…a positive influence…is an initiator and enabler. It’s like a cycle and the more you feed into it the better it becomes. Cluster 2:
Personal Learning & Change
15
Running Head: Peer coaching (Table 2 Continued) 6: Notes Own Contribution
Many had positive feedback, on the technique I
Mentions when they helped,
offered. It has strengthened my belief that I have
made a contribution, or discuss
something to contribute.
how they did something that was recognized as a contribution. 7: Learns Something New
I see things that I could possibly do when I’m
Recognizes that they learned
precepting a student. I am able to try out some
something new because of the
different styles.
coaching encounter. 8: Experiences Change
It helped me to make a lot of changes in myself.
States awareness that their views or behavior have changed. 9: Positive Self-assessment
I enlightened myself, became more involved.
Makes a positive assessment evaluation of his/her own process. 10: Seeks Challenge
It is a growing experience for me…keeps it more
Experience provided them with a interesting for me. This is a new challenge for challenge, which engaged his or
me…this fits with my desire to look for something
her interest.
different and challenging and keeps what I do interesting.
16
Running Head: Peer coaching Acknowledgements Special thanks go to Dr. Francine Hekelman for her steadfast dedication to medical education and whose support helped guide this research. We also extend our appreciation to Dr. Diana Bilimoria, Dr. Richard Boyatzis, Mr. David Bright, Dr. David Cooperrider, Dr. Vanessa Druskat, Dr. David Kolb, Ms. Tracey Messer, and Dr. Gil Preuss for their kindness in offering research and review assistance. A note of sincere gratitude is extended to the physicians who took part in this study. Without their determination to enhance medical education and steadfast commitment to help others, this work would not have been possible. Finally, we thank Dr. Susan Flores for her faith and vision.
17
Running Head: Peer coaching References 1. Kinsella K. Peer coaching teaching: Colleagues supporting professional growth across the disciplines. In: To Improve the Academy. Stillwater, OK: New Forums Press, 1995;14:107124. 2. Blase J, Hekelman FP, Rowe M. Preceptors’ use of reflection to teach in ambulatory settings: An exploratory study. Academic Medicine. 2000;75:947-953. 3. Flynn SP, Bedinghaus J, Snyder C, Hekelman FP. Peer coaching in clinical teaching: A case report. Educational Research and Methods. 1994;26:569-570. 4. Wilkerson L, Irby DM. Strategies for improving teaching practices: a comprehensive approach to faculty development. Acad Med 1998;73:387-96. 5. Mott MC. Cognitive coaching for nurse educators. Journal of Nursing Education. 1992; 31:188-90. 6. Showers B. Transfer of Training: The Contribution of Coaching. Eugene, OR: Center for Educational Policy and Management, University of Oregon, 1982. 7. Harnish D, Wild LA. Mentoring strategies for faculty development. Studies in Higher Education. 1994;19:191-201. 8. Hekelman FP, Blasé JR, Bedinghaus J. Discourse analysis of peer coaching in medical education: a case study. Teach Learn Med. 1996;8:41-7. 9. Joyce B, Showers, J. Improving inservice training: The messages of research. Educational Leadership. 1980;37:379-385. 10. Showers B. School improvement through staff development: The coaching of teaching. In Making our schools more effective: Proceedings of three state conferences. San Francisco, CA: Far West Laboratory for Educational Research and Development, 1984.
18
Running Head: Peer coaching 11. Showers B, Joyce B. The Evolution of Peer Coaching. Educational Leadership. 1996;53:12-16. 12. Showers B. Peer coaching: A strategy for facilitating transfer of training. Eugene, OR: Center for Educational Policy and Management, University of Oregon, 1984. 13. Glatthorn A. Cooperative professional development: Peer-centered options for teacher growth. Educational Leadership. 1987;45:31-35. 14. Costa, A. L. & Garmston, R. (1994). Cognitive coaching: A foundation for renaissance schools. Norwood, MA: Christopher-Gordon. 15. Hitchcock, MA, Bland CJ, Hekelman, FP, Blumenthal MG. (1995). Professional Networks: The Influence of Colleagues on the Academic Success of Faculty. Academic Medicine. 1995;70(12):1108-1116. 16. Hudson FM. The handbook of coaching: A comprehensive resource guide for managers, executives, consultants, and human resource professionals. San Francisco, Jossey-Bass, 1999. 17. Weasmer J, Woods AM. Programs in practice peer partnering for change. Kappa Delta Pi Record. 1999;Fall:32-34. 18. Berry SE, Garmston RJ. Become a state-of-the-art presenter. Training and Development Journal. 1987;41:19-23. 19. Sparks G. Synthesis of research on staff development. Educational Leadership. 1983;41:6774. 20. Stritter FT, Baker RM, Shahady EJ. Clinical instruction. In: McGaghie CD, Frey JJ (eds). Handbook for the Academic Physician. New York: Springer-Verlag, 1988: 98-124.
19
Running Head: Peer coaching 21. Boyatzis RE, Kolb DA. Performance, learning, and development as modes of growth and adaptation throughout our lives and careers. In MA Peiperl et al. (Eds.), Career frontiers: New conceptions of working lives (pp. 76-98). New York: Oxford University Press, 2000. 22. Kurtts SA, Levin BB. Using peer coaching with preservice teachers to develop reflective practice and collegial support. Teaching Education. 2000;11:297-310. 23. Hekelman FP, Kikano GE, Tapolyai AA, Flynn SP, Phillips JA, Gorosh MR. Peer coaching on medical education: A resource manual. Cleveland: Department of Family Medicine, Case Western Reserve University, 1997. 24. Kurth RJ. Using Faculty Peers To Improve Instruction in Diversified College Classrooms. Paper presented at the Annual Meeting of the American Educational Research Association, New Orleans, 1994. 25. Strauss A, Corbin J. Basics of qualitative research: Grounded theory procedures and techniques. Newbury Park: SAGE, 1990. 26. Boyatzis RE. Transforming qualitative information: Thematic analysis and code development. Thousand Oaks: SAGE, 1998. 27. Spencer L, Spencer S. Competence at work: A model for superior performance. New York, John Wiley & Sons, 1993. 28. Flanagan JC. The critical incident technique. Psychological Bulletin. 1982;4:327-358. 29. White JA, Anderson P. Learning by internal medicine residents: Differences and similarities of perceptions by residents and faculty. Journal of General Internal Medicine. 1995;10:126132. 30. Berliner DC. The development of expertise in pedagogy. Charles W. Hunt Memorial Lecture, American Association of Colleges for Teacher Education. New Orleans, 1988.
20
Running Head: Peer coaching 31. Bordage G, Burack JH, Irby DM, Stritter FT. Education in ambulatory settings: Developing valid measures of educational outcomes, and other research priorities. Academic Medicine. 1998;73:743-750.
21
