peer observation case study

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A case study of instructional improvement through peer observation in a suburban high school.

Helen Jean Hanna , Portland State University

Portland State University. School of Education

First Advisor

Michael E. Carl

Date of Publication

Document type.

Dissertation

Degree Name

Doctor of Education (Ed. D.) in Educational Administration and Supervision

Educational Leadership and Policy

Observation (Educational method), High school teachers -- In-service training, Video tapes in education

10.15760/etd.1251

Physical Description

3, ix, 181 leaves 28 cm.

This two-year case study investigated the effects of a peer observation process in a high school on the six selected areas listed below. Peer observation is a process to improve instruction by having teachers observe and critique other teacher's videotapes of classroom teaching. 1. Changes in norms and expectations for sharing instructional ideas among teachers. 2. The perceived value of self-evaluation of videotapes and related peer discussions about teaching. 3. The perceived value of peer feedback exchanges for instructional improvement. 4. The use of other teachers as models for effective teaching. 5. The perceived value of peer exchanges in stimulating a desire to improve. 6. The effect of peer interaction on the school climate for teacher improvement. The case study design was effective for investigating subjects in their natural setting which was a faculty of approximately 65 veteran teachers who had participated in one or more activities of the peer observation process. Research methods included the use of multiple sources of data from observations, questionnaires, surveys, peer discussion reports, and interviews. Lines of inquiry were triangulated across methods to strengthen the results and to search for divergent findings. Descriptive analyses were used to present and discuss the findings. Seventy-three percent of the staff participated the first year, 43% participated in the second year. Results from the findings indicated that peer observation had the following effects in this setting: 1. Standards of behavior among teachers changed from closed to open after experience with the process. Teachers exchanged ideas on teaching beyond that requested and in situations outside the process activities. 2. Videotape replay of classroom teaching and peer group discussions were perceived as valuable for both observed and observing teachers. 3. Teachers preferred feedback from peers because of the varied ideas from credible sources, the time to exchange teaching strategies, and the nonthreatening environment. 4. Teachers used other teachers as models for generating effective methods for immediate classroom use. S. Teachers perceived exchanges to have stimulated a desire to improve on three levels; awareness, effort, and implementation. 6. A climate for instructional improvement evolved where teachers perceived a need to share information and generate ideas in a non-threatening manner. The peer observation process was found to be an effective program for teacher improvement of instruction in this setting.

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Persistent Identifier

http://archives.pdx.edu/ds/psu/4604

Recommended Citation

Hanna, Helen Jean, "A Case Study of Instructional Improvement through Peer Observation in a Suburban High School" (1988). Dissertations and Theses. Paper 1252. https://doi.org/10.15760/etd.1251

Since September 18, 2013

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Frederick Atienza Andal New World International School, Prince Sultan Bin Fahad Bin Abdulaziz Road, Al Imam Al Nawawie Street, Al Khobar, Saudi Arabia

Frederick A. Andal is a faculty member under the Biology Department at New World International School, Al Khobar, Saudi Arabia. His main research interest includes topics related to methodology and evaluation, humanities and social sciences, and environmental sciences.

E-mail address: [email protected]

ORCID: orcid.org/0000-0003-2341-4604

Azra Nayeem New World International School, Prince Sultan Bin Fahad Bin Abdulaziz Road, Al Imam Al Nawawie Street, Al Khobar, Saudi Arabia

Azra Nayeem is the Academic Director at New World International School, Al Khobar, Saudi Arabia. Her main research interest includes topics related to leadership and supervision, curriculum and policy development, methodology and evaluation.

E-mail address: [email protected]

Noel Invento New World International School, Prince Sultan Bin Fahad Bin Abdulaziz Road, Al Imam Al Nawawie Street, Al Khobar, Saudi Arabia

Noel M. Invento is a faculty member under the Computer and Technology Department at New World International School. His main research interest includes topics related to data analysis and technology integration in education.

E-mail address: [email protected]

Amina Aslam Aga New World International School, Prince Sultan Bin Fahad Bin Abdulaziz Road, Al Imam Al Nawawie Street, Al Khobar, Saudi Arabia

Amina Aslam Aga is the Academic Coordinator at New World International School, Al Khobar, Saudi Arabia. Her main research interest includes classroom management, methodology and planning.

E-mail address: [email protected]

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PEER OBSERVATION OF TEACHERS: EXPLORING TEACHING EXPERIENCES

Article visualizations:

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Exploring a synchronous hybrid observation approach for supporting student teachers during school placements.

1. Introduction

2. background, 2.1. virtual supervision of student teachers on school placements, 2.2. towards a synchronous hybrid supervision approach, 3. study design, 4. findings, 4.1. theme 1: enabling enhanced observation practices.

“At times when I was [observing] student teachers in my job, I would think, I wish I could have somebody here who had a little bit more K–2 experience than what I’ve got … I’ve seen situations where I wish I [had] somebody, particularly in the younger years [of schooling], with strong experience in the teaching of reading” (AU FG1).

“There is this professional conversation [between tutors] as the class goes on. What can we see? What are we hearing? What is happening? What do you think of that? And we have that professional [text-based] conversation … It does give you a really good insight into the classroom” (IE FG1).

“The chat feature in Zoom is really good … There were three of us, two of us on Zoom and one in the class with the student [teacher]. So, it’s like a private conversation sharing observations … we’re saying: ‘did you see that? What did you think was going on there?’… And the other tutor can say, well, I think this is what they meant” (IE FG2).

“So, when our colleague was in the classroom and we were ‘Zooming in’ [virtual observation], we sent a chat, saying ‘what’s going on now?’; ‘I don’t understand what that is’; ‘We can’t see the blackboard’ … And she would say ‘she’s put some slides on the whiteboard’; or ‘she’s written on the whiteboard’…” (IE FG2).

“I’ve had a few examples where the [in classroom observer] picks up on things that I certainly wouldn’t have picked up on” (AU FG1).

“Somebody might notice something that someone else hasn’t noticed” (IE FG2).

“I might be writing a note about something that I’ve observed and miss something else that’s happening. [I can] ask the team what I missed” (IE FG2).

4.2. Theme 2: Enabling Enriched Feedback Practices

“I love having the second person there all the time. I think it’s very rich … we could actually discuss what was happening in the classroom ourselves on the other side and start forming opinions and start refining our advice and feedback to students [teachers]” (IE FG2).

“It would be really beneficial for a subject specific teacher [tutor] to be able to Zoom into this [post-lesson session]. If I had had somebody there virtually with me, that [post lesson] conversation could have really helped the student [teacher]” (IE FG1).

“We would have a professional [online] conversation from start to finish [of the lesson]. So, by the time it came to us giving feedback to the student [teacher], we knew exactly what supportive feedback we were going to give, how we were going to give it, and how that was going to work” (IE FG1).

“It [synchronous hybrid approach] is a tool that can be used when we feel the student [teacher] is struggling and needs … extra support and an extra bit of advice” (IE FG2). Support for the tutor providing feedback for student teachers was also identified: “I think in difficult cases, there [are] advantages of having two people involved” (AU FG1) and “It is an extra level of support, especially if … [you] know it’s going to be a difficult visit and the feedback is going to be tricky” (IE FG2).

4.3. Theme 3: Facilitating Rigorous Assessment Procedures

“It [synchronous hybrid approach] really helps us to standardise our practice… we’ve seen that when we do collaborative cross marking or corrections … we’re on the same page” (IE FG2).

“It’s very validating for the tutor to know that another tutor has the same opinion. They’ve seen the same thing, and especially when you want to be critical… or there’s something that wasn’t great in the past, and it’s great that somebody else has seen that, too. And it takes the whole personal bias out of it.” (IE FG2).

“It really is the validation of what you think and your own opinions as a tutor. I think that’s really powerful for the tutor and very valuable to know that, because sometimes we do have personal bias one way or the other towards a student [teacher] …” (IE FG2).

“I think from the student [teacher] point of view, it would also come across that they were being treated fairly so that there wasn’t any bias as far as one tutor is concerned” (AU FG1).

“I felt that maybe I was being a bit harsh on the student [teacher]. It was reassuring for me that I wasn’t doing the student any injustice … because we [tutors] came to the same agreement” (IE FG1).

“The thing that I grapple with when I’m giving feedback to students [student teacher] is … their pedagogical approach. [For example, if] I’m trying to get them to move away from a chalk and talk kind of transmission of information [approach] to a more transactional, ‘getting the [school] students involved’ [approach]. And then I’m like, ‘is this my bias? Is this something that I’m just interested in?’ … It’s your bias that you kind of focus on …” (IE FG2).

“Two people at the back of the classroom is very difficult for a student teacher and for the [school] students because they can see that there’s two adults here, there’s two adults watching … It changes the atmosphere within the classroom where you take one of those people out … The atmosphere of the classroom is much more natural [with a synchronous hybrid approach], and you see the student teacher in a more realistic sense” (IE FG1).

“It’s a bit of pressure to have two people watching them. They seem to be far more comfortable with the person who’s contacted them and had a few conversations on the phone … they feel comfortable with one person” (AU FG1). Tutors felt that both the student teachers and their school students in the classroom quickly became comfortable with the camera in the room, and “quickly forgot that the camera was there” (AU FG1).

4.4. Theme 4: Supporting Novice Tutors’ Professional Learning

“In terms of my own context starting out, … it ended up being a very affirming process… there’s learning for everyone. I think when you’re doing it [supervision] collaboratively, it makes sense on so many different levels” (IE FG2).

“Initially for me, I was very nervous that I wouldn’t have the same opinion as the other tutor and that I’d be wrong. And as it turned out, I have found it only helpful” (IE FG2).

“It’s very encouraging that I might have the same opinion or that I can add to somebody else’s opinion. That really made me feel more competent in my own opinion and more confident when I was learning how to do supervision” (IE FG1).

“So, for me it was really helpful as somebody who’s starting out in my first year working in initial teacher education and looking at preservice teachers … I observed them online on Zoom and I was able to hear from more experienced colleagues the feedback and the comments that they had” (IE FG2).

“Just to listen into the conversation after the class and the feedback session [was beneficial]. And since then, this has just been building and building on that to give me more experience and more confidence and feel more competent” (IE FG1).

4.5. Theme 5: Improved Formal Guidelines and Policies Needed

“It’s a pity that we don’t have a very straightforward policy… so that we’re not trying to manage the leadership community from school to school and be unsure as to how they may react when we suggest that we’re going to have a Zoom streamed lesson happening. The lack of understanding of exactly what we’re doing in some cases can be difficult” (IE FG1).

“I think sometimes schools still see … ‘Zoom may equal video recording’. And sometimes our students [teachers] have sometimes said that as well. They’re going: ‘Are they going to film me?’ We’re going: ‘no, we’re not. We’re going to Zoom in…” (IE FG1).

“The main issue I’ve seen is schools that have been pessimistic about… the children being filmed. No, they’re not. All that’s happening is I’m watching them [teachers] teach. Their parents are worried that their faces will be public. No, they won’t” (AU FG2).

“I would just fear that if we were openly allowed to do it [hybrid supervision] without really strict guidelines and policies, that a lot of the students’ [teachers’] lessons would end up being observed via Zoom instead of it being used as a hybrid model, if that makes sense” (IE FG2).

5. Discussion

6. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

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Agnew, A.; Kearney, M.; Ó Grádaigh, S.; Mac Mahon, B.; Connolly, C. Exploring a Synchronous Hybrid Observation Approach for Supporting Student Teachers during School Placements. Educ. Sci. 2024 , 14 , 991. https://doi.org/10.3390/educsci14090991

Agnew A, Kearney M, Ó Grádaigh S, Mac Mahon B, Connolly C. Exploring a Synchronous Hybrid Observation Approach for Supporting Student Teachers during School Placements. Education Sciences . 2024; 14(9):991. https://doi.org/10.3390/educsci14090991

Agnew, Annie, Matthew Kearney, Seán Ó Grádaigh, Brendan Mac Mahon, and Cornelia Connolly. 2024. "Exploring a Synchronous Hybrid Observation Approach for Supporting Student Teachers during School Placements" Education Sciences 14, no. 9: 991. https://doi.org/10.3390/educsci14090991

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• Published: 07 September 2024

Student involvement and innovative teaching methods in a biophilic design education pilot elective course in interior architecture

• Fulya Özbey   ORCID: orcid.org/0000-0001-5902-2165 1 , 2 &
• Simge Bardak Denerel 1  

Humanities and Social Sciences Communications volume  11 , Article number:  1155 ( 2024 ) Cite this article

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• Environmental studies

Biophilic design has gained popularity in interior design areas owing to its numerous advantages. Nevertheless, globally, Interior Architecture/Interior Architecture and Environmental Design departments lack adequate biophilic design courses in their curricula. This research investigates the impact of involving students in syllabus design and applying innovative teaching methods in a pilot elective course focused on biophilic design in interior spaces on student engagement and course sustainability. A new pilot elective course was introduced in the 2022–2023 Spring Semester at the Interior Architecture Department, Faculty of Architecture, Near East University, aiming to establish an enduring and captivating learning environment for students. Initially, a focus group study was conducted to measure students’ awareness of biophilic design and integrate their ideas regarding innovative learning methods into the syllabus for an engaging elective course. Strategies like interactive learning tools, group tasks, and peer assessments were incorporated throughout the course to enhance engagement. Analysis of end-of-course surveys and student observations revealed an augmented awareness of biophilic design among students and a positive influence of innovative learning methods on course sustainability. Thus, the study suggests that an elective course offers the potential to mitigate the deficiency of biophilic design integration in undergraduate programs, augmenting students’ awareness in this field. Moreover, new elective courses could deliver more sustainable and engaging learning experiences for enrolled students when structured through student involvement and innovative learning methods.

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Introduction.

The historical human-nature relationship has been disrupted by industrialization, leading to a growing recognition of the need for a mindful approach in the 21st century. Biophilia, our innate connection with nature, has evolved into Biophilic Design, enriching constructed spaces with natural elements. This design approach has proven advantages, enhancing workplace productivity, stress reduction, education outcomes, and healthcare recovery while aligning with sustainability efforts (Browning et al. 2014 ). Therefore, the incorporation of biophilic design in educational curricula has accumulated significant attention due to its confirmed benefits and to prepare students to meet industry demands because when considering the practice of interior architecture in the 21st century, it is observed that the understanding of biophilic design has been embraced by designers more than ever before in interior spatial design (Demirbaş & Demirbaş, 2019 ). Despite its acknowledged benefits, undergraduate education in biophilic design remains scarce, notably in Interior Architecture (IA) and Environmental Design (IAED). Few universities globally, in Türkiye and the Turkish Republic of Northern Cyprus (TRNC), offer specific courses in this field. According to the QS World University Rankings by Subject 2022: Art & Design indicates that out of the top 10 universities with IAED or IA departments, five universities do not offer any courses related to biophilic design. While one university includes a course on biomimicry, three lack accessible detailed course content. Only Aalto University offers an explicit course on biophilia, which is called “Biofilia ABC,” and a biophilia lab that emphasizes the integration of biophilic design into research and learning environments through interdisciplinary collaboration. The gap in biophilic design education is no different in Türkiye and the TRNC, where there are 84 universities with IAED or IA departments (41 having IAED departments 41 having IA departments, and 2 universities offering both), biophilic design education is significantly lacking. Out of these institutions, only 1 offers a dedicated “biophilic design” course at the undergraduate level (starting from 2023 to 2024 Fall Semester in İstanbul Galata University), and only 4 universities include the term “biophilia” in any course syllabus. Most universities have courses that focus on sub-topics of biophilic design, such as indoor landscaping, biomimicry, or the nature-human relationship and its representation. Surprisingly, 40 universities do not include any terms or subjects related to “biophilia” in their course names within the curriculum, further highlighting the scarcity of biophilic design education in the region. However, there’s a high demand for this knowledge among interior architects, indicating an educational gap that requires attention also supported by the survey conducted by Doğan ( 2021 ) targeting interior architects and space users, with a sample size of 285 respondents (139 interior architects and 146 general space users). The results indicated that 107 of the participating interior architects had not received formal education in biophilic design, underscoring the absence of biophilic design within many Turkish universities. However, 111 of the participants possessed knowledge of biophilic design, suggesting that they had sought information from external sources. To bridge the gap and promote biophilic design education at the undergraduate level, a dedicated elective course covering theoretical foundations and practical applications of biophilic design principles is crucial. By establishing a comprehensive biophilic design course, universities can equip students with the knowledge and skills needed to create sustainable, nature-inspired interior spaces and foster a deeper connection with the natural world. However, understanding students’ course selection motives, such as interest and perceived benefits, is crucial. Involving students in syllabus design enhances communication and caters to diverse learning styles, making courses more effective. This research investigates the impact of student involvement in creating a pilot elective on biophilic design for interior spaces. It explores how innovative teaching methods and course preparation influence student engagement and course longevity. Also, this research uses qualitative and quantitative methods, while delving into three key questions:

What is the awareness/knowledge level of undergraduate IA and IAED students in Türkiye and the TRNC regarding Biophilic Design?

Does a student-involved course syllabus preparation process enhance the sustainability and student commitment in biophilic design courses?

What challenges do instructors face in elective courses for Generation Z (Gen Z) students in IA and IAED programs? How can these be addressed to establish participatory course structures and enhance learning outcomes?

Literature review

Biophilic design is currently a popular topic, but its full integration into IA and/or IAED curricula is still lacking. In addition, the content and method of teaching the designed course are important for the biophilic design to take its place in education because elective courses in the curriculum offer students the opportunity to explore their interests and develop their individuality. Since this study delves into the effects of students taking part in developing a trial elective focusing on biophilic design for interior spaces, it aims to examine the influence of creative teaching approaches and course planning on student participation and the sustainability of the course this literature review includes two sections. The first one is biophilic design and its applications in interior architecture, and the second one is the role of elective courses in architectural education.

Biophilic design and its applications in interior architecture

Throughout history, humans have coexisted with and drawn valuable insights from the natural world (Turner et al. 2004 ; Wilson, 1996 ). However, the industrial revolution and global urbanization have severed this connection, resulting in significant environmental damage (Çorakçı, 2016 ). The civilizations that once dominated nature in the 18th and 19th centuries faced dire consequences for their environmental exploitation in the 20th century, leading to a growing realization in the 21st century of the need for a more conscientious approach to nature (Çorakçı, 2016 ). Erich Fromm introduced the concept of “biophilia,” signifying a deep love for all living beings (Heerwagen et al. 2012 ). Edward O. Wilson and Stephen R. Kellert expanded on this concept, proposing in “The Biophilia Hypothesis” (1993) that humans possess an innate inclination to connect with nature and other life forms (Kellert and Wilson, 1993 ). Biophilia is not an instinct-like breathing but emerges from biological tendencies shaped by learning and experiences, including emotions such as love, hate, and fear. Sociocultural factors influence its expression, evident in the symbolic use of nature in myths, religious beliefs, and meditations (Kellert and Wilson, 1993 ). Stephen Kellert’s research on biophilia led to its integration into architectural design, exemplified in “Building for Life” (2005). This laid the foundation for “Biophilic Design,” solidified in the initial edition of “Biophilic Design” (2008) with contributions from various researchers, defining it as “an innovative approach emphasizing the essential preservation, enrichment, and restoration of the positive human-nature connection within built environments” (Kellert et al. 2011 ).

Based on various research and perspectives, the principles and applications of biophilic design have been subject to numerous categorizations (Kellert et al. 2011 ; Browning et al. 2014 ). Nonetheless, at the core of all predominant categorizations lies the central theme of seamlessly incorporating elements of nature and natural phenomena into the constructed environment. In their seminal work, “Biophilic Design: The Theory, Science and Practice of Bringing Buildings to Life,” Kellert et al. ( 2011 ) delineated six fundamental principles of biophilic design, which encompass “Environmental Features, Natural Shapes and Forms, Natural Patterns and Processes, Light and Space, Place-Based Relationships, and Evolved Human-Nature Relationships.” These principles collectively offer a comprehensive framework for the establishment of harmonious human-built environments.

The application of biophilic design principles within interior spaces involves the deliberate integration of nature-inspired elements to foster a more harmonious and productive milieu. Common manifestations of biophilic applications include the utilization of natural lighting, incorporation of indoor flora, utilization of natural materials, the inclusion of water features, and the provision of vistas that connect with natural settings. The empirical evidence underscores the multifaceted advantages of biophilic design on human well-being and productivity. For instance, a study conducted by Sanchez et al. ( 2018 ) substantiates the notion that biophilic design features enhance workplace performance. In a subsequent study by Aristizabal et al. ( 2021 ), it was established that a multisensory biophilic environment not only improved cognitive performance but also mitigated stress levels while enhancing overall satisfaction with the workplace environment. Furthermore, research conducted by Sayed et al. ( 2021 ) has demonstrated that the incorporation of biophilic principles into educational spaces engenders improved concentration levels, higher attendance rates, and enhanced academic performance among students. Beyond the realms of work and education, the beneficial impact of biophilic design extends to healthcare settings, as underscored by studies conducted by Samir ( 2021 ) and Totaforti ( 2018 ). These studies reveal that biophilic design elements contribute to alleviating patient fatigue and expediting the healing process. Lastly, Newman et al. ( 2012 ) underscore the potential economic advantages associated with the integration of biophilia into design practices. This includes reduced energy consumption, enhanced biodiversity, and, in addition, improvements in well-being and productivity, ultimately aligning with sustainability and ecological preservation efforts.

The role of elective courses in architectural education

Universities offer students various opportunities to pursue their academic goals. Elective courses, in particular, allow students to pursue their aspirations, develop virtual goals, and broaden their educational content (Movchan and Zarishniak, 2017 ). Also, elective courses enable students to study subjects that satisfy their interests, abilities, and career determination while seeking to develop the individuality of each student (Ghonim and Eweda, 2018 ). Architectural education is a multidisciplinary field that imparts both technical knowledge and social responsibility to students. Integrating elective courses into the curriculum can ensure a well-rounded education and exposure to a diverse range of subjects. This is essential for developing a holistic understanding of the role of architecture in society and the importance of ethical principles and values for architects (Ghonim and Eweda, 2018 ). Thus, there arises a compelling need to establish a novel pedagogical framework emphasizing self-directed learning among graduating architects guided by their mentors. Consequently, educational models must emphasize the cultivation of imaginative thinking, keen observation, and active engagement, especially when incorporating innovative instructional resources aligned with these objectives (Fernandez-Antolin et al. 2021 ). The flexible nature of the elective factor allows for dynamic updates to reflect contemporary issues and developments in the field, marketplace, and society. When offering new elective courses, considerations should include program orientation, student interests and needs, and faculty specialization (Ghonim and Eweda, 2018 ).

Additionally, to provide an effective elective course in architectural education, it is crucial to not only consider the students’ interests and needs but also their reasons for selecting an elective course. In the study conducted by Ting and Lee ( 2012 ), an investigation was undertaken to explore the various factors that exert an influence on students’ selection of elective courses. The researchers identified a multitude of determinants, which include the perceived level of interest in the subject matter, the perceived difficulty of the course content, the perceived leniency of the instructor, the potential acquisition of future career skills, the impact of external influences, the instructor’s popularity or personality, the timing of the class in terms of the day of the week and meeting hour, the reputation of the university, the suitability of the subject matter, and the class size. Another aspect of an effective elective course is the level of student involvement in the course. This process is not only limited by the course duration but might start from the syllabus design process. Research conducted by Cook-Sather ( 2014 ) has underscored the significance of involving students in the design of syllabi, highlighting its positive impact on teacher-student communication and collaboration. This proactive approach has enabled educators to gain a deeper understanding of students’ motivations and learning styles, facilitating the tailoring of instructional methods to better suit individual needs. Furthermore, a study conducted by Bovill et al. ( 2011 ) has demonstrated that the inclusion of students in syllabus design has resulted in heightened levels of self-regulation and metacognitive awareness. Students have become more attuned to their learning strategies, fostering an increased propensity for engaging in self-directed learning practices. Practitioner-researchers Zereyalp and Buğra ( 2019 ) have ascertained that the incorporation of students’ voices in syllabus development substantially contributes to the efficacy of the syllabus. This contribution manifests in the form of fostering open and constructive communication with students, thereby better aligning the syllabus with their needs and expectations.

Methodology

This study adopted a mixed-method research approach, which integrated focus group studies, interviews, case studies, and participant observation methods. Since this research involves gathering both qualitative and quantitative data together into a single platform to obtain a comprehensive understanding of the topic from various perspectives, including those of students and instructors, a mixed research approach is considered well-suited for this study (Mulisa, 2022 ). The research methodology consisted of three distinct sequential steps.

In the initial step, the emphasis was on preparing the syllabus of the pilot elective course (case study) and addressing the first two research questions. Data collection was primarily facilitated through focus group studies and interviews, with subsequent qualitative analysis applied.

The second step involved data collection during the course period, treated as a case study for addressing both the second and third research questions. During this phase, participants (comprising students enrolled in the pilot elective course) were subject to observation, alongside the administration of concise questionnaires. Subsequently, the results obtained from these questionnaires, encompassing both qualitative and quantitative data, underwent rigorous analysis.

The third and final step entailed comprehensively analyzing the amassed data to substantiate the study’s hypotheses.

A succinct summary of the research methods and evaluation techniques utilized throughout the study is presented in Fig. 1 , the research methodology flowchart.

Methodology flowchart.

Data collection

In the initial phase of data collection for this study, a pilot focus group investigation was undertaken with five sophomore students from Yaşar University’s (YU) Department IAED. These students were selected for their qualifications aligning with the primary focus group participants. The purpose of this pilot study was to assess the reliability of the research questions, as outlined by Nagle and Williams ( 2013 ), which had been prepared for the forthcoming focus group studies. The designated questions were sequentially presented to the students, and their responses were meticulously evaluated. The outcomes of this pilot focus group analysis indicated that the formulated questions were sufficiently effective in eliciting the necessary data for the subsequent primary focus group study. The selection of participants for the focus group sessions was carried out through the convenience sampling method to have individuals with characteristics of the overall population (students who enrolled in the elective course), proposed by Nagle and Williams ( 2013 ). The focus group inquiries were methodically administered to the students, and the ensuing responses were subjected to qualitative analysis. These focus group sessions were conducted on November 22nd and 23rd, 2022, involving ten students from Near East University (NEU), and subsequently on December 1st and 2nd, 2022, with the participation of eight students from YU.

The interview phase of the research was executed on November 22nd and December 2nd, 2022, involving three instructors from the Faculty of Architecture, each responsible for teaching various elective courses at YU and NEU. During these interviews, the instructors were probed about their approaches to curriculum development, the selection of assessment methods, strategies employed to foster student engagement, utilization of innovative pedagogical techniques, and their course adaptation procedures based on end-of-semester feedback.

The insights garnered from both the instructor interviews and the focus group sessions constitute the primary data sources for the case study under investigation. The subsequent step in the data collection process for this study was designed to coincide with the case study. During this stage, the students enrolled in the pilot elective course served as subjects of observation, while periodic administration of concise online but with clear, targeted questions that aligned with the learning objectives and teaching effectiveness of the course questionnaires allowed for ongoing data acquisition. The reason for choosing the online survey method for the end-semester feedback is that online surveys are straightforward, anonymous, and time-efficient (Moss & Hendry, 2002 ). Also, emphasizing the anonymity and confidentiality of responses can encourage students to provide honest feedback to have more reliable results even with a small group of sample. Last but not least, the necessary permissions were obtained from the NEU Scientific Research Ethics Committee for all stages requiring data collection.

Data analysis plan

In the initial phase of data collection, a comprehensive data analysis plan was formulated, which encompassed the incorporation of data derived from primary and secondary sources. The data amassed during this first step underwent a rigorous evaluation employing qualitative methodologies. Subsequently, an insightful case study was methodically created, drawing from the analytical findings obtained from the gathered data.

In the subsequent phase, which unfolded within the context of the aforementioned case study, the participants were subjected to systematic observations, and periodic surveys were administered to solicit their responses. Data collection culminated upon the conclusion of the case study. To facilitate a comprehensive analysis of these diverse data sources, a well-structured approach was devised, combining qualitative techniques for the assessment of participant observations and a blend of both qualitative and quantitative methods to scrutinize the results derived from the periodic surveys. In addition, the reliability of the course evaluation results was validated by triangulating the survey findings with other assessment measures, such as students’ academic performance or assignment quality.

Ultimately, the data at hand was subjected to a robust interpretative process, and it was the intent to engage in a thoughtful deliberation of the hypotheses in accordance with the insights gleaned from the case study.

Focus group study and interviews

For this study, pilot elective courses titled “TMF 444 İç Mimarlıkta Biyofilik Tasarım “ and “FAE424 Biophilic Design in Interior Architecture” were offered in both Turkish and English language departments during the 2022–2023 Spring Semester at the Faculty of Architecture, Department of Interior Architecture, Near East University. However, before opening the courses in line with the stated objectives and methodologies of the research, students were actively involved in the curriculum development processes of these courses, with the aim of creating a more efficient and dynamic elective course. Additionally, the opinions of various faculty members were sought.

Initially, a focus group study with open-ended questions was conducted with a total of 18 students, 10 from NEU’s and 8 from YU’s Faculty of Architecture. The responses from this study were evaluated using the MAXQDA 2022 (VERBI Software, 2021 ) program and subjected to the keyword analysis method. The study sought to ascertain the student’s familiarity with the concept of biophilic design, their expectations for an upcoming elective course on this subject, their preferences for course activities and assessment methods, their views on effective teaching techniques, and their integration into academic courses, as well as the motivating factors driving their active engagement in these courses. The analysis highlights from the focus group study are summarized in Table 1 .

The highlights from the interviews with the instructors indicated that it is important to approach students in a friendlier manner and use innovative teaching techniques to create a more engaging class environment while considering students’ voices to develop the course in general.

Course period

After evaluating the data in Table 1 and the interview outputs, course contents for TMF 444 and FAE 424 were developed following the NEU course content development rules. An overview of the course syllabus is presented in Table 2 .

The 14-week course commenced with an introductory week, determining the student demographic, midterm and final assessments, and administering a survey on students’ perceptions of biophilic design, innovative learning methods, and in-class motivations. Weeks 2–8 predominantly focused on various topics such as the concept of biophilia, patterns and health impact of biophilic design, differences and similarities between biophilic design and sustainable design, the concept of biophilic cities, and some practical ways of incorporating biophilic design principals to the interior spaces as well as the examination of example case studies. Week 9 centered around the midterm presentation, involving the analysis of a chosen structure based on biophilic design criteria. Weeks 10–14 were allocated for the creation of an interior design project emphasizing biophilic design, followed by desk critiques. Ultimately, developed projects were submitted as the final assessment.

In the proposed pilot elective course, 26 students enrolled in the Turkish section, while 11 students registered for the English section. Among these, 20 students attended the Turkish course, and 7 students attended the English course for the whole semester. The overall distribution of students by department and class includes 16 Interior Architecture students (14 undergraduate 3rd year, 2 undergraduate 4th year) and 9 Architecture students (1 undergraduate 1st year, pursuing a double major, 1 undergraduate 2nd year, 4 undergraduate 3rd year, and 3 undergraduate 4th year). Given that a substantial proportion of students enrolled in both FAE 424 and TMF 444 courses are representative of Generation Z, this study also investigates the challenges encountered by instructors in this demographic context. As the course unfolds, the difficulties of being an instructor in a class dominated by Gen Z learners are explored. The paramount question becomes: how can these challenges be effectively addressed, and what methods can be employed to construct a participatory course structure that enhances learning outcomes? Drawing inspiration from contemporary educational research, including works by Orr et al. ( 2021 ), Saxena and Mishra ( 2021 ), Szabó et al. ( 2021 ), Chan and Lee ( 2023 ), Mohr and Mohr ( 2017 ), Marie and Kaur ( 2020 ), and Jaleniauskiene and Juceviciene ( 2015 ) this study consolidates diverse strategies to enhance the student engagement and participation for teaching Gen Z in higher education. As, Orr advocates for an academic coaching model, emphasizing transformational learning. Saxena proposes gamification as a motivational tool, and Szabó underscores the significance of incorporating various information technologies, such as e-learning and gamification, to boost student motivation and skill development Chan’s study delves into Gen Z students’ perceptions of generative AI in higher education, noting their optimism for its benefits—enhanced productivity and personalized learning. However, it emphasizes the concerns raised by Gen X and Gen Y teachers regarding overreliance and ethical implications, highlighting the importance of integrating technology with traditional teaching methods for a more effective learning environment. Mohr’s study emphasizes the significance of understanding generational profiles to improve course assignments and communication approaches. The findings emphasize the need for instructors to adapt teaching methods to align with Gen Z’s preferences for technology-driven and visually engaging educational experiences, and Marie’s research highlights Gen Z’s inclination towards a digitized learning environment, emphasizing the importance of adapting academic opportunities to meet their diverse needs and foster critical 21st-century skills like critical thinking and creativity. Finally, Jaleniauskienė's study focuses on reshaping educational environments to cater to Gen Z’s learning preferences. The recommendations span from redesigning physical and non-classroom spaces to accommodate diverse learning styles, integrating active learning methodologies, fostering collaborative environments (both physical and virtual), and leveraging technology as mindtools to enhance cognitive functions and engage visually oriented learners. In summary, advocation for a multifaceted approach that integrates technology, personalized coaching, gamification, and varied pedagogical strategies to create engaging, transformative, and inclusive learning environments for Gen Z learners.

Therefore, interactive presentations were prepared during the course, leveraging Genially (Genially Web, S.L., 2021 ) and Gamma (Gamma Tech, Inc., 2022 ), as they facilitated engagement, aligning with the 5 students who identified the fluidity of course delivery as a significant motivator for participation. To maintain interactivity and motivation, quizzes at the end of the course were conducted through Quizizz (Gupta and Cheenath, 2015 ), with a 10-point bonus awarded to the student with the highest quiz average throughout the semester. Moreover, practical exercises were conducted utilizing Miro (Khusid and Shardin, 2011 ) to incorporate active learning strategies, thereby cultivating collaborative learning settings. A specific instance of the Miro exercise is illustrated in Fig. 2 .

In-class exercise by Miro.

While implementing the assignments, based on the findings from the focus group study, even if the majority of students expressed a preference for being able to choose assignment types, it was acknowledged in interviews that this approach might lead to potential issues, such as providing enough sources for each type of assignment or concerns related to students blaming each other for grades, finding others’ assignments easier, etc. Consequently, for this pilot course, it was decided that the assignment types would be determined by the course instructor, and for midterm and final assessments, students would be consulted at the beginning of the course to reach a decision by majority agreement. Additionally, as 8 of the students expressed the utility of peer evaluations, and recognized their potential to enhance motivation and interest in the course, a 10-point peer evaluation criterion was incorporated into one of the assignments and midterm presentations. The assignment incorporating peer assessment was a brief research task, designed to encourage students to share their findings during class and contribute to each other’s ideas. The assignment brief and grading criteria are outlined in Fig. 3 .

Assignment 1 brief and grading criteria.

For the midterm assessment, students were expected to select a structure and analyze it based on the principles of biophilic design, presenting their analysis during class. Peer assessment was incorporated during the midterm too, where students evaluated each other’s presentations. Last but not least, in the final assessment, influenced by both the preference for project submissions by 2 of the students and the suggestion of integration with project or studio courses 2 students were required to choose an area from project courses. They were expected to develop their designs for three weeks based on the desk critics, express them through technical drawings, and provide a written explanation of how they integrated biophilic design principles. The midterm and final briefs, along with grading criteria, are illustrated in Fig. 4 .

Midterm and final briefs.

Additionally, although field trips were identified as a factor that could enhance student motivation and contribute to achieving the learning outcomes of the course, they could not be added to the course content due to financial constraints. Nonetheless, an exploration of a diminutive village distinguished by a plethora of biophilic attributes in the TRNC was undertaken in collaboration with two students from the course. The ensuing research findings were subsequently disseminated and made publicly accessible via the webpage hosted by the biophilic cities network (Özbey et al. 2023 ).

This section includes the results of qualitative and quantitative assessment surveys conducted at the beginning and end of the course. The findings in this section are broadly analyzed in the discussion section.

Pre-course expectations and motivations

A brief survey was administered to 27 enrolled students within the initial week of the course to measure their awareness and expectations concerning biophilic design, the course syllabus, and innovative learning methodologies. Furthermore, the delineation of a course syllabus was elucidated to students, and the impact of a student-contributed syllabus on enrolled students was examined. Out of the enrolled students, 25 participated in the survey, and the outcomes, encompassing their knowledge levels and application of biophilic design principles, have been consolidated in Fig. 5 .

Summary of pre-course survey (Biophilic design knowledge).

According to the table, participants’ familiarity with biophilic design varied across the terms “biophilia” and “biophilic design,” with a higher level of recognition for the former term than the latter. However, awareness of the “Six Principles of Biophilic Design” was notably lower, indicating a more diverse range of responses across the spectrum from familiarity to unfamiliarity with these principles. There’s a strong consensus among respondents that biophilic design should be integrated into interior design, particularly in emphasizing the importance of designs that amalgamate nature, humanity, and architecture. Participants largely acknowledge that the weakening of connections between nature and humanity can adversely affect human life. There’s substantial agreement on the positive impact of natural light and ventilation on health, success, and work productivity in spaces. The use of “plants” as a design element in interiors garners notable agreement, while the inclusion of a “water element” seems to have a mixed response.

When examining students’ expectations regarding course syllabus and innovative learning methods, a majority of respondents concur that the provided learning outcomes and resources exhibit direct relevance to the course. Furthermore, there is a prevailing consensus indicating that the assessment methods delineated in the syllabus maintain a sense of equilibrium. A significant majority of students express confidence in their ability to extrapolate and apply the course content to other academic subjects. The recognition of abundant opportunities for peer interaction, notably through group discussions and activities, is acknowledged by a substantial number of participants. Regarding familiarity with interactive learning tools such as Sli.do, Padlet, Kahoot, and similar platforms, respondents exhibit varying degrees of awareness and experience with these tools. A comprehensive summary of the distribution of students’ survey responses is outlined in Fig. 6 .

Summary of pre-course survey (evaluation, of course, syllabi, and innovative learning methods).

Post-course reflections and feedback

Feedback on the co-design process, learning environment, and their influence on student engagement.

Out of the 27 students attending the course, 23 voluntarily responded to the survey conducted at the end of the semester. When considering the effects of the student-contributed course syllabus and the interactive course format on student obligations, it becomes evident that students derive pleasure from the interactive format and perceive the course as a conducive space for engaging with their peers. Moreover, students found the short quizzes administered at the end of the course both enjoyable and beneficial. The evaluation methods, such as assignments, midterms, and finals determined based on the preferences of students enrolled in the class and who attended focus group sessions, have been deemed sufficient by a significant majority of students for assessing and presenting their knowledge. Additionally, students expressed enjoyment and perceived usefulness from the group activities and peer assessments conducted during the course. The responses of students regarding the co-design process and its impact on their engagement have been summarized in Fig. 7 .

The responses of students regarding the co-design process and its impact on their engagement.

Feedback on the biophilic design knowledge, learning outcomes, and course instructor

In the end-of-term evaluation survey responded to by 23 students, in addition to gathering insights on students’ perspectives concerning the course period and assessment methods, inquiries were also posed regarding their understanding of biophilic design concepts, perceptions of the course’s learning outcomes, and the instructor’s behavior during the class.

In the students’ end-of-term survey regarding biophilic design, a notable pattern emerges: the respondents consistently exhibit a significant degree of familiarity and comprehension spanning a wide range of biophilic design concepts. This pattern underscores a robust knowledge improvement within the surveyed group, showcasing a comprehensive understanding of various aspects of the biophilic design domain. According to the survey results, there is a high level of agreement regarding the awareness of specific terminologies associated with biophilic design. However, there are slight differences in the degree of familiarity with specific aspects of biophilic design. Additionally, a substantial majority expressed confidence in their capability to extrapolate and apply the course content to other academic disciplines. Furthermore, students conveyed a sense of acquiring substantial knowledge and awareness about biophilic design during the course, enabling them to engage in comprehensive discussions on the subject and confidently evaluate the built environment using biophilic design principles by the course’s conclusion. The participants’ responses regarding their knowledge of biophilic design have been summarized in Fig. 8 .

The responses of students regarding the biophilic design knowledge.

About the evaluation of learning outcomes and instructor’s performance, there was a notable consensus among respondents. Nineteen students strongly agreed, and four students agreed that the learning outcomes were intricately linked to the course content. Moreover, a significant majority of students strongly agreed or agreed that the course provided pertinent resources aligning with the subject matter. Notably, students exhibited high positivity towards the course instructor, indicating satisfaction and understanding in various aspects. They strongly agreed or agreed that the instructor’s explanations regarding assessment methods were lucid, demonstrating a clear grasp of evaluation criteria. Moreover, students found the instructor’s approach in the course to be fitting and the responses indicate a high level of endorsement for the course. Twenty respondents strongly agreed, while three respondents agreed that they would recommend the course to others. The responses related to students’ perceptions of learning outcomes, the instructor, and the overall quality of the course are presented in Fig. 9 for reference.

Evaluation of learning outcomes, instructor’s behavior, and course quality.

Findings from the student co-design process

In the context of IA/IAED teaching, the integration of student co-design processes into elective courses is not a deeply studied area. As mentioned in the introduction part, while there are several courses addressing biophilic design principles, there’s a noticeable gap in the literature regarding specific content and teaching methodologies employed in these courses. Therefore, this study not only delves into students’ perceptions and preferences but also aims to bridge this gap by showcasing how student input can enrich course content and delivery. The findings from the student co-design process provided valuable insights into various aspects of the course, including the students’ familiarity with biophilic design, their expectations for the elective course, their preferences for course activities and assessment methods, their views on effective teaching techniques, and the motivating factors driving their active engagement in the course. The majority preferred a practice-based course, indicating a desire for hands-on learning experiences. Additionally, suggestions for field trips, theory-based learning, online delivery, workshop sessions, multimedia, and flexible design options were also mentioned. These preferences highlight the importance of incorporating a variety of teaching methods and activities to cater to different learning styles and interests. The students’ preferences for course activities and assessment methods were also explored. Field trips, model-making assignments, discussion and debate sessions, and group work were suggested by the students. The majority of students found group work highly beneficial, while some expressed uncertainty. Peer evaluations were perceived as essential by a significant portion of students, although reservations were also expressed. End-of-course quizzes were valued by half of the students, but reservations were also present. These findings indicate the importance of incorporating a mix of individual and collaborative activities, as well as diverse assessment methods, to cater to the preferences and needs of the students. In terms of assessment type and selection preferences, project-based assignments and presentations were favored by the majority of students. Written assignments were also preferred by a significant portion of students, while research assignments were less favored. The students’ preferences for assignment types and their involvement in the selection process were also explored. The majority of students preferred to select their own assignment types, while some preferred a collective decision through group discussion. Only a small percentage believed that course instructors should determine the assignment types. These findings suggest that involving students in the assignment selection process can enhance their engagement and motivation. The students’ preferences for assessment methods were similar to their preferences for assignment types. Project-based assignments, presentations, and written assignments were the most preferred methods. Some students expressed a desire for a diverse array of assignments to be valued equally, while others had no specific preference. These findings highlight the importance of incorporating a variety of assessment methods to cater to the diverse preferences and strengths of the students. Based on the findings from the focus group study, interactive presentations, online quizzes, practical exercises, and peer evaluations were incorporated into the course. These strategies aimed to enhance student engagement, motivation, and collaborative learning. The findings from the student co-design process provided valuable insights into the students’ preferences, needs, and motivations, which were incorporated into the course structure. The incorporation of interactive and innovative teaching methods, diverse assessment methods, and opportunities for peer interaction aimed to enhance overall student engagement, motivation, and learning outcomes. Those preferences of the students including emphasis on interactive and innovative teaching methods, as well as opportunities for peer interaction and feedback, not only enhance student engagement and motivation but also reflect the changing educational environment in IA/IAED. By focusing on collaborative learning, student-centered methods, and incorporating real-world experiences into the curriculum by embracing the student co-design process, educators can create more dynamic and responsive learning environments that prepare students for the complexities and challenges of contemporary design practice.

Findings from student evaluations

Overall student satisfaction and engagement.

The findings from this study highlight the importance of incorporating diverse pedagogical strategies and technology tools to create engaging and inclusive learning environments for Gen Z learners. The recommendations provided for the course implementation, such as redesigning physical and non-classroom spaces, integrating active learning methodologies, fostering collaborative environments, and leveraging technology as mindtools, align with the preferences and motivations expressed by the students in this study. One of the key findings is the positive impact of interactive presentations prepared using Genially and Gamma. These tools facilitated engagement and were particularly appealing to the 5 of the students who identified the fluidity of course delivery as a significant motivator for participation. This suggests that incorporating interactive elements in presentations can enhance student engagement and motivation. To maintain interactivity and motivation throughout the course, quizzes were conducted using Quizizz. The inclusion of a 10-point bonus for the student with the highest quiz average throughout the semester further incentivized participation. The positive response from students indicates that gamification elements can enhance motivation and make the learning experience more enjoyable. Practical exercises conducted using Miro incorporated active learning strategies and fostered collaborative learning settings. This aligns with the recommendations for fostering collaborative environments, as students expressed a preference for group discussions and activities. The use of Miro allowed students to actively participate and contribute to each other’s ideas, further enhancing the collaborative learning experience. The findings also highlight the importance of considering potential issues when implementing certain assignment types. While the majority of students expressed a preference for being able to choose assignment types, concerns were raised about providing enough sources for each type of assignment and potential issues related to grades and comparisons among students. To address these concerns, the assignment types were determined by the course instructor, with student consultation for midterm and final assessments. This approach allowed for a balance between student preferences and practical considerations. The inclusion of peer evaluations in one of the assignments and the midterm presentation was well-received by students. Peer evaluations were identified as a utility by 8 of the students and were seen as a way to enhance motivation and interest in the course. The assignment incorporating peer assessment encouraged students to share their findings and contribute to each other’s ideas, fostering a collaborative learning environment. The positive response from students suggests that peer evaluations can be an effective tool for enhancing motivation and engagement. In the final assessment, students were given the opportunity to choose an area from project courses and develop their designs based on the principles of biophilic design. This aligns with the preferences expressed by 2 of the students for project submissions and integration with project or studio courses. By allowing students to apply their knowledge and skills to a real-world design project, the final assessment provided a meaningful and relevant learning experience. Although field trips were identified as a factor that could enhance student motivation and contribute to achieving the learning outcomes of the course, financial constraints prevented their inclusion in the course content. However, an exploration of a diminutive village with biophilic attributes was undertaken in collaboration with two students from the course. These research findings were disseminated and made publicly accessible, providing an alternative way for students to engage with real-world examples of biophilic design.

The survey results regarding students’ understanding of biophilic design concepts indicate a high level of familiarity and comprehension. The respondents consistently exhibited a significant degree of knowledge improvement, showcasing a comprehensive understanding of various aspects of biophilic design. This suggests that the course content and interactive learning methods were effective in enhancing students’ knowledge and awareness of biophilic design. The evaluation of learning outcomes and the instructor’s performance received a notable consensus among respondents. Students strongly agreed that the learning outcomes were intricately linked to the course content and that the course provided pertinent resources aligning with the subject matter. The high positivity towards the course instructor indicates satisfaction and understanding in various aspects, including the clarity of assessment methods and the instructor’s approach to the course. Overall, the findings from this study support the recommendations for a multifaceted approach that integrates technology, personalized coaching, gamification, and varied pedagogical strategies to create engaging, transformative, and inclusive learning environments for Gen Z learners. The incorporation of interactive presentations, quizzes, practical exercises, peer evaluations, and real-world design projects was well-received by students and contributed to their engagement, motivation, and knowledge improvement.

Impact of the course on biophilic design knowledge and skills

The analysis of students’ familiarity with the terms “biophilia” and “biophilic design” at the beginning and end of the term indicates a notable shift in their comprehension. At the start of the term, a majority of respondents were not acquainted with these terms, with a significant number either undecided or expressing disagreement with their familiarity. However, by the term’s conclusion, there was a remarkable increase in familiarity with both concepts. For “biophilia,” the number of respondents familiar with the term rose considerably, from 9 at the beginning to 23 by the term’s end, with no disagreement or uncertainty recorded at the conclusion. Similarly, for “biophilic design,” familiarity surged notably, with 22 respondents indicating acquaintance at the term’s end, compared to 10 at the outset. These shifts underscore a significant improvement in students’ understanding and awareness of these fundamental concepts related to biophilic design throughout the course duration. This finding is supported by the strong consensus among the respondents, with 21 students strongly agreeing and 2 agreeing that they feel confident in their understanding of biophilic design. This indicates that the course has effectively imparted the necessary information and concepts related to biophilic design, enabling students to engage in discussions about it with others. This is an important outcome, as it demonstrates that the students have not only acquired knowledge but also the ability to communicate and share their understanding of biophilic design with their peers and beyond. Furthermore, the majority of respondents also expressed confidence in their ability to assess the built environment using the principles of biophilic design. This finding is significant as it suggests that the course has not only provided theoretical knowledge but has also equipped students with practical skills to apply these principles in real-world scenarios. The high number of students who feel confident in their ability to evaluate environments based on biophilic principles indicates that they have developed a strong understanding of how to analyze and assess the built environment through the lens of biophilic design.

Implications for IA and IAED education

The insights derived from the student co-design process within the interior architecture course present a rich tapestry of students’ perspectives, expectations, and preferences, offering profound implications for the realm of interior design education. Student’s alignment of assessment method preferences with specific assignment types, notably favoring project-based tasks, presentations, and written assignments, underscores the need for a diverse array of evaluation techniques catering to varying student preferences and strengths. These findings emphasize the importance of incorporating multifaceted assessment approaches to accommodate diverse student needs effectively. Leveraging the insights gleaned from focus group studies, the course structure was revamped to integrate interactive presentations, online quizzes, practical exercises, and peer evaluations, aiming to augment student engagement, motivation, and collaborative learning experiences. These adjustments reflect an alignment with students’ identified preferences and requirements, enhancing the overall pedagogical environment. In the realm of interior design education, these findings bear pivotal implications. The involvement of students in shaping course elements not only empowered their engagement but also streamlined the course content to meet their needs and motivations. The integration of interactive teaching methodologies, diverse assessment strategies, and avenues for peer interaction aimed to foster heightened student engagement, motivation, and ultimately, enriched learning outcomes within the IA and IAED curriculum. Moreover, the study’s broader implications resonate beyond the educational sphere. The students’ strong confidence in discussing biophilic design and applying it to varied contexts underscores the significance of interdisciplinary approaches in design education. Equipping students with transferable skills cultivates a comprehensive understanding of design principles, essential in the multifaceted domain of IA and IAED, where considerations encompass human well-being, spatial functionality, and environmental sustainability. The findings also suggest a potential cadre of competent professionals poised to advocate for and implement biophilic design principles within the industry. In conclusion, this study delineates the success of the course in imparting knowledge, nurturing critical thinking abilities, and enabling practical application of learning. Moving forward, it underscores the importance of continuous exploration and development of innovative teaching methodologies, advocating for immersive and experiential learning activities to enhance students’ grasp and application of biophilic design principles within the sphere of IA and education.

The purpose of this research was to investigate the impact of an elective course, designed collaboratively with student contributions and integrated with innovative learning methodologies, focused on biophilic design for interior spaces. Addressing specific research questions, this study examined the preparation process of the course, the influence of innovative learning methods on student participation, and the enduring impact of the course.

First, the study assessed the curricula of IA/IAED programs in Turkey and TRNC and found a significant educational gap, which was also supported by literature (Doğan, 2021 ). Only one university offered a dedicated course (Galata University, starting from 2023 to 2024 Fall Semester) and a few as part of sustainability-related courses. Therefore, to improve the improved student awareness and confidence in understanding biophilic design, indicating effective education advancement and real-world application readiness a newly introduced elective course was offered.

Additionally, the study aimed to evaluate how effective a course structure designed by students was in enhancing the long-term retention of biophilic design knowledge in interior spaces. It drew from research advocating for student-driven content to increase engagement and commitment, focusing on creating a more interactive learning environment. The study emphasized collaborative learning methods, group work, presentations, project-based assignments, and peer interactions by involving students in designing the course syllabus and analyzing their expectations through group sessions. The student-influenced course structure received positive feedback from end-of-term surveys, with students expressing satisfaction and active engagement, particularly appreciating group activities, peer assessments, and interactive formats such as quizzes.

Lastly, the research investigated the specific hurdles encountered by instructors teaching elective courses primarily attended by students from Gen Z enrolled in IA or IAED programs. These challenges encompassed addressing short attention spans, tendencies towards multitasking, and the need for technical proficiency. To mitigate these challenges, the study proposed potential solutions, including incorporating frequent breaks, employing interactive teaching methodologies, and providing targeted, concise assignments tailored to accommodate the unique traits of Gen Z learners. The study underscores the importance of utilizing an interactive course format, highlighting the significance of diverse teaching methods and technology in effectively engaging Gen Z students. The recommendations put forward, such as promoting active learning, creating collaborative spaces, and integrating technological tools like Genially and Gamma, are aligned with the preferences of these students. The integration of interactive presentations and quizzes on platforms like Quizizz served to motivate active participation, while the use of Miro for exercises fostered collaborative learning, resonating with students’ preference for group engagement and discussions. These strategic approaches significantly elevated student engagement and contributed to cultivating an inclusive and enriching learning environment.

Lastly and significantly, summarizing the instructor’s observations and dialogs with students during the pilot course, the use of interactive materials and methods significantly contributed to students’ engagement levels. Student feedback reflects a positive reception towards the interactive quiz format, contrary to their anticipation of traditional or system-based exams, finding the interactive format enjoyable and engaging. Personal observations indicate that students, being accustomed to short quizzes at the end of classes, consciously ensure their phones are charged before class and quickly review their notes or discuss potential questions during breaks. Furthermore, the activities conducted on Miro transformed into templates and content used by students in midterms and finals. Students have taken peer evaluations seriously, demonstrating fairness in the assessment process. Notably, there is alignment observed between the instructor’s grading and the grades derived from peer evaluations, even among students who have reported personal issues. Some students have gone above expectations, opening additional subsections for thorough grading in peer evaluations. However, despite these positive aspects, the success achieved in midterms was not replicated in finals due to scheduling conflicts during the final exam period and students’ prioritization of mandatory courses. Despite being informed that desk critics before the final submission influence their final grades, only a minimal group actively participated in all critiques.

Conclusively, this research underscores the vital role of student-inclusive and innovative courses in addressing educational gaps, emphasizing the need for dedicated biophilic design education in IA or IAED programs. By fostering interactive learning and addressing Generation Z’s learning needs, tailored courses can significantly enhance engagement and knowledge acquisition. This study encourages the integration of innovative teaching methods to create inclusive and engaging learning environments in design education.

Limitations of the pilot study

Since the course was offered as a faculty elective course in Near East University for the 2022–23 Spring Semester, only the proposed pilot elective course attracted a total of 26 students in the Turkish section and 11 students in the English section. Out of these, only 20 students attended the Turkish course for the entire semester, while 7 students attended the English course consistently. The relatively small sample size and the imbalance between the two language sections may affect the generalizability of the findings. However, while the numbers do highlight a relatively small sample size and an imbalance between the two language sections, these factors might not entirely undermine the validity of the findings. The consistent attendance of 20 students in the Turkish section and 7 students in the English section throughout the semester might actually provide a focused understanding of how interactive activities impact a committed subset of students. Furthermore, while the sample size could restrict the application of these findings to a wider population, it does not invalidate the insights gained from this specific group. Other research studies, as highlighted by Fernandez-Antolin et al. ( 2021 ), have also utilized similar approaches with smaller student cohorts. These attendance figures could still offer meaningful qualitative data regarding the effectiveness of hands-on activities in engaging students within the context of this pilot elective course. Also, the lack of technological infrastructure in the classrooms constrained the effortless delivery of innovative learning methods by requiring rapid solutions for those issues and another limitation despite high demand for a class trip, logistical constraints, including insufficient public transportation and a lack of support from the university, prevented the planning and execution of the trip. Last but not least, during the final exams, clashes with mandatory courses and students’ prioritization of these compulsory subjects resulted in a lack of success in finals. The limited time and attention dedicated to the elective course due to conflicting schedules may have impacted students’ performance and hindered a comprehensive assessment of their understanding and application of biophilic design concepts.

Recommendations for further course development and research

To pave the way for future course enhancements and comprehensive research there are several recommendations gathered from this study.

First of all, the inclination of 12 students towards selecting their own assignment types, while acknowledged during focus study and surveys, raises concerns about potential issues like sourcing adequacy for diverse assignment types or apprehensions regarding mutual grading accountability and perceived workload disparities among peers. Consequently, for the pilot course, assignment types were structured by the instructor. Moreover, for mid-term and final evaluations, student consultation at the course outset, leading to consensus-based decisions, was adopted. However, a future course iteration might permit students to choose their assignment types, necessitating the formulation of an assessment methodology. Additionally, as a recommendation for future terms, setting clearer final expectations earlier in the semester might allow students more time to prepare for finals. However, integration issues with other courses could arise, and students, due to their workload, might still defer final preparations until the last weeks or, as an alternative solution, reduce the percentage weight of finals and emphasize greater participation and completion of assignments throughout the term is believed to elevate the overall success level of the course.

Secondly, ensuring the successful integration of student-contributed syllabi and innovative pedagogical methods warrants a focused inquiry into teacher training and support mechanisms. Investigating the efficacy of teacher training initiatives and devising strategies to augment educators’ proficiency in fostering student engagement and learning within these frameworks would be pivotal. Moreover, the incorporation of more qualitative research tools such as interviews or focus groups for post-course reflections and feedback might diversify the nuanced perspectives, experiences, and hurdles encountered by students regarding student-contributed syllabi and innovative learning methods and those pedagogical methodologies implemented in this course, could potentially find applicability in other elective courses across the academic spectrum.

Last but not least, based on the instructor’s observation, it is advisable specifically for the biophilic design course to customize this course for upper-year students majoring in Architecture, IA/IAED. This is because students in their 1st and 2nd years may have limited technical knowledge and project development skills. Also, over time, students can cultivate their interest in elective courses with specific content such as this one, thereby the application of the course material in their project courses or their professional lives easier. In addition, if this course is offered during the Semester when the weather conditions are more favorable, it could facilitate more interaction by conducting classes outdoors and organizing field trips more easily.

Data availability

The data is accessible through Dataverse https://doi.org/10.7910/DVN/SFEGA5 .

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Özbey, F., Bardak Denerel, S. Student involvement and innovative teaching methods in a biophilic design education pilot elective course in interior architecture. Humanit Soc Sci Commun 11 , 1155 (2024). https://doi.org/10.1057/s41599-024-03559-4

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Avita Katal

Date Written: February 22, 2022

Peer observation demands the teaching community to observe each other’s teaching practice followed in classrooms and to learn from it. It focuses on individual requirements and learning by receiving and providing constructive feedback. This study gives detailed information about the purpose and principle of peer observation along with the steps followed in the peer observation cycle. The data gathered are from postobservation forms and meetings. Feedback from peers is used to demonstrate the importance of peer observation in improving the overall teaching experience. The results indicated that there is a significant improvement in the teaching style of the instructors. The category of attaining student attention and engagement grew by 28.8 percent, while the category of students demonstrating passion and motivation climbed by 15.27 percent. Peer observation is seen as a beneficial tool for teachers’ professional development. Teachers stated that peer observation reduced their worry, hesitancy, and pressure throughout the teaching process, making it more dependable and real. However, participants identified time constraints and teachers’ lack of observation expertise as barriers to peer observation.

Keywords: Teaching and Learning, Peer Observation, Feedback, India

Suggested Citation: Suggested Citation

Faculty of Law SRM University Delhi-NCR Sonepat ( email )

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Avita Katal (Contact Author)

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• Open access
• Published: 11 September 2024

Implementing peer support into practice in mental health services: a qualitative comparative case study

• Steve Gillard 1 ,
• Rhiannon Foster 1 ,
• Sarah White 2 ,
• Rahul Bhattacharya 3 ,
• Paul Binfield 3 ,
• Rachel Eborall 4 ,
• Sarah L Gibson 5 ,
• Daniella Harnett 3 ,
• Alan Simpson 6 ,
• Mike Lucock 7 ,
• Jacqueline Marks 8 ,
• Julie Repper 9 ,
• Miles Rinaldi 10 , 11 ,
• Anthony Salla 1 &
• Jessica Worner 12  

BMC Health Services Research volume  24 , Article number:  1050 ( 2024 ) Cite this article

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Peer workers are people with personal experience of mental distress, employed within mental health services to support others with similar experiences. Research has identified a range of factors that might facilitate or hinder the introduction of new peer worker roles into mental health services. While there is mixed evidence for the effectiveness of peer worker delivered interventions, there are no studies exploring how implementation might be associated with effect.

This was a qualitative comparative case study using data from interviews with 20 peer workers and their five supervisors. Peer workers delivered peer support for discharge from inpatient to community mental health care as part of a randomised controlled trial. In the trial, level of participant engagement with peer support was associated with better outcome (hospital readmission). Study sites with higher levels of engagement also had higher scores on a measure of fidelity to peer support principles. We compared data from sites with contrasting levels of engagement and fidelity using an analytical framework derived from implementation theory.

In high engagement-high fidelity sites, there was regular work with clinical teams preparing for working alongside peer workers, and a positive relationship between staff on inpatient wards and peer workers. The supervisor role was well resourced, and delivery of peer support was highly consistent with the intervention manual. In low engagement-low fidelity sites peer workers were employed in not-for-profit organisations to support people using public mental health services and in rural areas. Supervisors faced constrained resources and experienced barriers to joint working between organisations. In these sites, peer workers could experience challenging relationships with ward staff. Issues of geography and capacity limited opportunities for supervision and team-building, impacting consistency of delivery.

Conclusions

This study provides clear indication that implementation can impact delivery of peer support, with implications for engagement and, potentially, outcomes of peer worker interventions. Resourcing issues can have knock-on effects on consistency of delivery, alongside challenges of access, authority and relationship with clinical teams, especially where peer workers were employed in not-for-profit organisations. Attention needs to be paid to the impact of geography on implementation.

Trial registration

ISRCTN registry number ISRCTN10043328, registered 28 November 2016.

Peer Review reports

Peer support in mental health services

People with personal experience of mental distress, often referred to as peer workers, are increasingly employed within mental health services internationally to support others with similar experiences. An extensive literature explores a range of implementation issues that might dilute the distinctive qualities of peer support when introduced into public mental health services [ 1 , 2 ]. These include adequate provision of role specific training for PWs, [ 3 , 4 ] support and supervision for PWs, [ 5 ] clarity of expectation around the way in which PWs bring experience-based knowledge to mental healthcare, [ 2 . 6 ] and preparation of clinical teams to work alongside PWs [ 7 ]. It has been argued that ‘over-professionalisation’ or ‘institutionalisation’ of the PW role constrains the distinctive contribution of peer support [ 8 , 9 , 10 , 11 ].

Trials of peer support in mental health services continue to demonstrate inconsistent results, with some studies indicating that peer support might be superior to care-as-usual or a comparator intervention, [ 12 , 13 ] while others indicate no difference in effect [ 14 , 15 ]. Some of this variation might be explained by heterogeneity of interventions, population or outcome, but it is also possible that the quality of implementation of peer support into mental healthcare settings is associated with the effect of peer support interventions [ 16 , 17 ].

It has been noted that peer support is often poorly described in the trial literature, [ 17 , 18 ] with a lack of research assessing association between implementation and outcome. A recent review of one-to-one peer support in mental health services categorised peer support as being well implemented where at least two of the following criteria were reported: dedicated peer support training; clear description of the underlying processes of peer support; well-defined support structures for PWs (e.g. supervision) [ 19 ]. However, only a small number of studies reported sufficient data to conduct an analysis and results were unclear. There is a need for research that explicitly considers the possible relationship between quality of implementation and the outcomes of peer support.

Implementation theory

Implementation science offers a range of frameworks for understanding the facilitators and barriers to successful implementation of healthcare innovation into practice [ 20 ]. There is a clear recognition that the effects of any intervention will always depend on successful implementation [ 21 ]. The well-established Promoting Action on Research Implementation in Health Services (PARIHS) framework conceptualises successful implementation of research-based innovation into healthcare in terms of the nature of the evidence on which the innovation is based, the context or environment into which the innovation is placed, and the method by which implementation is facilitated [ 22 ]. In recent years, the co-design [ 23 ] or coproduction [ 24 ] of new interventions in mental health has gained prominence, with people who use mental health services bringing experience-based knowledge to the process, alongside the professional and practice-based knowledge brought by healthcare professionals. Given that this experiential knowledge is core to peer support, and that a number of members of the research term brought their own experiences of mental distress and/ or of using mental health services to the design and conduct of the research, we adapted the PARIHS framework for the purposes of this study. An earlier scoping review of implementation literature and an empirical case study, [ 25 ] undertaken by members of the team (SG and RF), identified five domains where experiential knowledge might impact research implementation, and we mapped these domains directly onto the framework (Table  1 ).

The ENRICH trial

A trial of peer support for discharge from inpatient to community mental health care indicated that peer support was not superior to care-as-usual (follow up by community mental health services within seven days of discharge) in terms of either the primary outcome – readmission within 12 months of discharge – or a range of secondary outcomes [ 26 ]. PWs received eight days of training focused on individual strengths and connecting to community, met the people they were supporting at least once while still inpatients and then weekly for up to four months post-discharge. Peer support was flexible and collaborative, informed by a peer support principles framework [ 27 ]. PWs received group and individual supervision from an experienced peer worker coordinator (PWC) who had access to an action learning set with other PWCs across study sites. The trial and intervention are described in detail in a protocol paper [ 28 ].

Findings from the trial indicated that 62.5% of participants offered peer support had at least two contacts with their PW, at least one of which was post-discharge, and that those participants were significantly less likely to be readmitted than a similar group of PWs in the care-as-usual group [ 26 ]. There might be many reasons why people chose not to, or were unable to engage with their PW, including the possibility that peer support was not always well implemented into practice in the trial.

This paper aims to explore if and how levels of engagement in a new peer support intervention were associated with implementation of the intervention, and therefore how implementation of peer support in mental health services might be optimised in the future.

Study design

We take a comparative case study approach, informed by case-orientated Qualitative Comparative Analysis [ 29 ] and pattern-matching [ 30 ] techniques, considering the seven sites where the study took place as cases. Sites were National Health Services (NHS) mental health trusts (public healthcare provider organisations) in England, where the new peer support intervention was delivered as part of the ENRICH trial. Sites were selected to provide contrast in urban, town and rural localities, geographical spread across England, and where mental health trusts were committed to introducing new PW roles into mental health services. In most sites PWs were directly employed by the mental health trust, while in others a much smaller, voluntary (not-for-profit) sector organisation was sub-contracted by the trust to employ PWs to provide support to people using mental health trust services. Information about each site is given in Table  2 below.

To inform case selection for the comparative analysis we charted level of engagement at each site – percentage of trial participants offered peer support who had at least two contacts with their PW, at least one of which was post-discharge – against site fidelity score, measured using an index designed to assess fidelity of delivery of peer support at site level against a set of principles articulating what is distinctive about peer support compared to other forms of mental health support [ 31 ] (Fig.  1 ). Fidelity was assessed through a semi-structured interview with PWs, the people they supported and their supervisor, rated by researchers against criteria based on the principles framework. A high fidelity score indicates that peer support had been implemented according to those principles. Fidelity was assessed after peer support had been delivered for at least six months at each site.

Relationship between engagement with peer support and fidelity

Figure  1 is indicative of a direct relationship between engagement with peer support and fidelity, offering rationale for selecting sites with higher or lower levels of both engagement and fidelity as cases for comparative analysis. There was one outlier, site 2, where fidelity was high (11) but engagement was mid-range (51%). We included this site in the comparative analysis as engagement might be explained by implementation issues not related to fidelity of delivery.

We report on the Evidence domain of the framework in a paper describing how experiential knowledge was central to developing the ENRICH peer support intervention [ 32 ]. Our research questions here are based on the Context and Facilitation domains of the framework, with context referring largely to the NHS Trust in which implementation took place (question 1), and facilitators being the PWs and PWCs who delivered the peer support (questions 2–4):

How did the culture of organisations, leadership (including issues of access and authority ) and monitoring and feedback impact implementation of peer support?

How did PWs and PWCs feel that their roles were characterised?

How did PWs and PWCs feel they were able to exercise flexibility while remaining consistent in their approach to delivering peer support?

How did experiential knowledge underpin peer support as it was delivered at each site?

Data sources

Peer worker interviews. Thirty-two PWs delivered peer support in the ENRICH trial and were invited to give written informed consent to participate in the research. All 32 consented and were interviewed after 12 months of delivering peer support. Interviews explored how well training prepared them for the role, their experiences of working as a PW, the support they received in the role and their relationship with clinical teams they worked alongside.

Peer worker coordinator interviews. Eight PWCs supervised PWs in the trial. Seven PWCs were themselves experienced PWs and one was a mental health nurse who shared the role with an experienced PW. All 8 PWCs gave informed consent to participate in the research and were interviewed at the same timepoint as PWs. Interviews explored PWCs’ experiences of supporting PWs, how well they thought the role was supported and organisational issues impacting delivery of peer support.

Interviews were conducted by researchers working from a perspective of having experienced mental distress and/ or having used mental health services, and played a key role in schedule development. Interview schedules can be found in the Supplementary Material file.

Data analysis

Interviews were audio-recorded, pseudonymised at the point of collection and transcribed verbatim.

Interview data were analysed using a framework approach [ 33 ] based on the Context and Facilitation domains of the modified PARIHS framework (see Table  1 ). Data were first coded to the constructs within those domains, with inductive space retained to code factors not related to the framework that participants described as impacting delivery of peer support. Second, a comparative, cross-case analysis was used to look for patterns of implementation that were: A, shared across cases; B, characterised high fidelity-high engagement cases; C, characterised low fidelity-low engagement cases; D, described implementation in the outlier case [ 30 ]. Preliminary analyses were undertaken by the first author and refined through iterative rounds of discussion with the whole team.

Characteristics of included cases

The two high engagement-high fidelity cases (sites 3,5), and the outlier high fidelity-low engagement case (site 2), were in urban areas with PWs directly employed in mental health NHS Trusts (see Table  2 ). The two low engagement-low fidelity cases (sites 4,6) were in areas that were a mix of rural localities with small towns or urban localities respectively. In both the latter sites PWs were employed by voluntary sector organisations outside of the NHS.

Characteristics of participants

A total of 20 PWs were included in the analysis, five each from sites 3 and 4, three each from sites 2 and 5, and two from site 6. Twelve PWs were female, seven were male and one preferred not to say. Three PWs were aged under 35 years of age, 12 aged from 35 to 55 years, one over 55 and four preferred not to say. Eleven PWs were White British, two were White Irish, one White other, one Black/ Black British, one Asian/ Asian British, one Arab, one Mixed White Asian with two preferring not to say.

There were five PWCs, one from each site. Four PWCs were female and one was male; two were aged from 35 to 55 and three over 55; all were White British.

Participant quotes presented below are identified with a site code (e.g. S1 = site 1) and role identifier (PW = Peer Worker; PWC = Peer Worker Coordinator) plus an additional number to distinguish between PWs at each site.

Implementation across cases

A number of implementation features were evident across all five cases, including characterisation of the PW role as largely consistent with the principles that were used to inform development of the intervention; [ 27 , 32 ] taking a non-judgemental approach and sharing experiences to create a safe space, make connections and build relationships:

‘We’re not going to be judgemental so to speak. It’s a safe place really for people to be themselves regardless of what their mental health issues are or mental health diagnoses are.’ (S5PW2). ‘I’m always sharing lived experience, whether that’s just generally or whether that’s personally with mental health … obviously you share when appropriate but you try to match that experience together so you have something in common, and then there is that mutuality and reciprocity and creating that trusting relationship.’ (S3PW3).

On the whole, training – as specified in the ENRICH manual – was consistently delivered and worked well to provide PWs with the range of skills they felt they needed for the role:

‘We did a lot about strengths-based approaches and I think that’s really informed the way that I interact with people, so I think I’m always trying to bring it back to what can you do, what is strong for you … we did a lot about active listening and also about discussing difficult issues … I think it’s been very helpful the stuff we did in training … definitely the boundaries and relationships sessions that we did …’ (S3PW1).

The importance of group supervision facilitated by the PWC, as well as individual supervision where required (both specified in the handbook), was indicated across sites, providing the opportunity for PWs to share experiences and receive feedback from one another as well as from the PWC:

‘I will hold these feelings until supervision and that’s when I let it out, offload it to my colleagues. And it’s been great because we’ve been bouncing it off each other and I’ve noticed that it’s not just me that was going through it, so it’s such a relief …’ (S2PW2). ‘… [PWC] will always ask how I am, if anything has triggered me or anything like that and she’s quite easy to talk to and it’s OK to be open with her.’ (S6PW3).

Participants in all sites described differences between the culture of clinical services in the host trust and the ethos underpinning peer support:

‘…it’s about the values because what I find with the other types of support, it all tends to be clinical and deficits based … very directive and judgemental … some of the clinical teams are stuck in that way of seeing things, that deficit-based thing and they don’t really know too much about peer support.’ (S5PW1).

At all sites, there was a perceived lack of contact with, and feedback from, community mental health teams, sometimes accompanied by a lack of understanding of the PW role:

‘Whenever I got a new service user, I’d email their [Community Psychiatric Nurse] or care coordinator … to give them more information about it and nobody, apart from I think one person, got back to me. So that’s been quite challenging, not really having any communication or contact really with the mental health teams that are working with the service users …’ (S5PW3).

Interviewees in all sites remarked that the timing of the offer of peer support - prior to discharge from hospital - was particularly challenging for some, especially in relation to maintaining contact with the PW following discharge. This represented a barrier to engagement that was related to the clinical context, rather than implementation:

‘… they are being introduced to it as soon as they come out … they are going through a tough period of fear, of not knowing what’s next for them. The last thing they want is to commit to 16 weeks of meeting someone that they don’t even know.’ (S2PW2). ‘I suspect that the post-discharge needs more targeting, that would be my sense. There are people who really get so much out of it, but then there are an awful lot who just disengage. It’s another stress for them I think.’ (S4PWC).

Implementation in high fidelity-high engagement cases

There was evidence of features supporting implementation in the high fidelity-engagement cases which contrasted with low fidelity-lowengagement cases (see below). In high fidelity cases, cultural differences between clinical services and peer support were generally seen as an asset and were valued, rather than as a source of tension:

‘… you need a values-based practice and how important it is, as opposed to the clinical based practice and how helpful that is … I’m not saying the clinical approach is wrong or anything like that, what I’m saying is we need to complement each other, we need to take a holistic approach.’ (S5PW1).

Some aspects of organisational culture were seen as supportive of peer support, including the role of recovery colleges in preparing PWs for the role or providing additional training once in post (recovery colleges employ an adult education model to supporting people with their mental health, often co-delivered by people using mental health services [ 34 ]):

‘… we were in a really fortunate position being linked with a Recovery College, that, where later in their work they then wanted to do specific recovery focused training around diagnosis we were able to provide that for people.’ (S3PWC).

In these cases, staff on the wards (inpatient units) were reported as largely familiar with and valuing the role of peer support:

‘… when I’d go on the ward … they seemed to see great value in the transparency of people being there because they’ve got lived experience. That aspect of it was really nice … good for the culture of the organisation in many ways.’ (S5PWC). ‘… the clinical teams are aware … they’re very excited that we’ve got peer workers on the ward. They’re very positive about it.’ (S3PW3).

PWCs described PW recruitment as having followed the process specified in the intervention handbook, and as such the PWs who were appointed were well equipped to deliver the role:

‘… we had the right people to execute these roles effectively really … we had quite a diverse selection panel … we had the right people that expressed the interest I think …’ (S5PWC).

There was evidence that PWs and PWCs – as intervention facilitators - had worked hard in delivering clinical team preparation sessions, as specified in the handbook, offering repeat sessions where necessary, and that this had supported a good relationship with ward teams:

‘… [in] the early days we went in to talk about ENRICH and then if they’d had significant staff turnover, which is really happening a lot … we’d then go back to the teams just so that they were aware of what ENRICH was about, what their role was … it certainly meant that staff were much more welcoming of the ENRICH peer workers when they came onto the wards.’ (S3PWC).

PWCs reported being well resourced in their leadership role, both in terms of having sufficient time to do the work and having sufficient supervision themselves around any difficult issues that might arise:

‘… [my role] was two days a week and that was plenty of time…’ (S3PWC). ‘I have had unconditional support from my manager … it’s been part of my regular monthly supervision … any kind of difficulties I’ve had or frustrations or whatever that has come up, that has been an ideal time to go through it. But I’ve also been supported to discuss things as and when they come up …’ (S5PWC).

In these sites, there was evidence that delivery of peer support was highly consistent with the manual. There was notable emphasis on flexible application of peer support, especially around pacing support in response to the individual’s needs, spending as much time as necessary alongside the participant to build a trusting relationship:

‘… it doesn’t necessarily follow a linear path a lot of the time. Sometimes, somebody might be having a really bad week and they actually want you to listen to what’s been going on for them … at the beginning, because you are getting to know the person as well, I think the kind of conversation you’d have is a bit more general … and then it might actually take a completely different path however many meetings down the line and they’ll actually go … “I haven’t told anyone about a particular issue, but I want to talk it through with you and see what you think”.’ (S3PW1).

PWs at these sites demonstrated confidence in taking a lead from the person they were supporting, consistent with the principles of choice and control that underpinned the intervention:

‘… I’m kind of getting to know things that they’re interested in and this is influencing where I signpost them to … it’s just about giving them the option and then they can make their own decision then whether they want to go, and again that’s putting them back in control, which is all about helping people to recover really and take control back of their lives.’ (S5PW2).

PWs also described learning from the people they were supporting, and the importance of validating their experiences, consistent with the principle of reciprocity in the underpinning framework:

‘There are people who I’m supporting who … realise that the medication is very important to them and that they will probably always be on it. So, I gain insight from that, just because maybe I found that medication in my own lived experience wasn’t particularly fantastic but for others it’s very important. So, you learn from other things … you’ve got to validate their experience because … they know what works for them and you can’t tell somebody else what will work for them …’ (S5PW1).

Implementation in low fidelity-low engagement cases

There was evidence of barriers to implementation in low fidelity-lowengagement cases. In both, PWs were employed in not-for-profit organisations, resulting in organisational context-related barriers to implementation. Resource issues impacted leadership of the intervention with, in one site, the organisation not having capacity to provide cover or suitable supervision for the PWC:

‘… we’ve had different staff line managing me over the past year because of maternity. But to be fair none of them really knew about ENRICH … there was nobody who could have covered my role here … it’s felt like a bit of pressure to continue doing it because I took a bit of time off … I couldn’t physically go out and do anything when I wasn’t well …’ (S6PWC).

Support for PWCs at these sites, including an Action Learning Set with other PWCs, was difficult to access because of lack of sufficient funding to travel to meetings:

‘I think the action learning sets worked really well … maybe they should have been planned for a bit more financially … because ultimately we had to go back to our Trust and say we need to find more money or I’m not going.’ (S4PWC).

Being outside of the NHS also created issues of access and authority for PWCs:

‘I would have thought there should be regular team meetings, but we never seemed to be able to get in on them … an additional disadvantage from being an organisation outside of the Trust …’ (S4PWC). ‘… it’s been difficult with the [NHS Trust], some of the staff there … I don’t want to say too much, but that’s been difficult.’ (S6PWC).

This extended to PWs being able to communicate with clinical teams about the people using:

‘A few times they didn’t want to talk to me because I didn’t have enough information for them … to establish who I was … I just wanted to know whether they were seeing [participant] or whether they’d stopped seeing him, and they wouldn’t tell me.’ (S4PW3).

At these sites there was, generally, a challenging relationship with ward-based clinical staff, potentially impacting on the initial relationship building phase of the peer support:

‘There were certainly, on that site, a lot of suspicious looks and “what on earth is this all about” type conversations. However much we tried to prepare the staff team, and we’d gone in and visited and talked to them all, but there was still that “what’s this all about”? People didn’t get it straight off.’ (S4PWC).

Cultural differences with the host NHS Trust were keenly felt by PWs employed in not-for-profit organisations:

‘… the ward environment is, well obviously it’s clinical. It sometimes feels some staff, but not all staff, who work on the wards are not really sure what my role is or have a vague understanding. There’s perhaps a little bit of a difference in terms of pecking order and me in the pecking order.’ (S6PW2). ‘… they will be looking at the patient’s files … they can build up a judgement before seeing you … when the patient sees the peer support worker they might talk to us because we’re non-judgemental, we don’t feedback unless there is a safeguarding issue or danger to themselves or others … I don’t think peers should be seeing files …’ (S4PW44).

Both sites also combined rural localities with urban areas, with issues of geography hindering timely delivery of peer support at remote hospital sites:

‘… the geography issue was a great challenge in itself in our area because I was one bit of the triangle and the [hospitals] were in two different places … I’d have had an hour or so travelling and then get there and “oh, they’re on leave until 10pm tonight”.’ (S4PWC).

Geography could also impact on building a strong sense of PW team:

‘I did lots of talking to [the PWC] but not so much my fellow peers. There was one fellow peer that I talk quite a lot to … the other two were very close to each other and so they were almost functioning as one … I got on OK with the people at [the other town] … it’s just that we had differences of opinion.’ (S4PW3).

There was some inconsistent delivery of training, with one PW reporting having received a truncated version of the training programme as a result of capacity issues:

‘I didn’t actually do [the full training] … because I was covering a maternity leave it was the girl did all the training. So, I basically had a morning with the coordinator where we went through the whole bumph together … ’ (S6PW3).

While the importance of group supervision was acknowledged in these sites, there was disruption leading to inconsistency with the pattern of weekly group supervision as a result geography in one site, and capacity in the other:

‘We don’t generally do weekly anymore … generally we do monthly although I check in by phone with them.’ (S4PWC). ‘… a lot of the supervision has ended up being one-to-one just because it’s a small team here … sometimes I would be able to meet with them together but often because my day, I’ve only got one a day week, I’d have to fit them in if one of them couldn’t do it that day …’ (S6PWC).

Possibly as a result of disruption to supervision or opportunities to support each other as a team, PWs at these sites at times appeared to lack confidence in delivering peer support:

‘… it made me feel that I was getting it all wrong … she didn’t really talk at all about, and I felt that I couldn’t, I just felt that I had to wait for her to give information to me … because that’s what I understood you are supposed to do, is wait for them to give you information to talk about their problems …’ (S4PW3). ‘… I’m imagining it’s going to be quite hard for a long time because the expression that I’ve used that comes to mind is pulling teeth. It’s going to be probably like that every time we meet … it is frustrating because you want to help them.’ (S6PW2).

Implementation in the outlier high fidelity-low engagement case

The outlier case shared contrasting sets of features with the other cases. Like high fidelity and engagement sites, the outlier case reported feedback from management describing a positive impact of peer support on culture in the NHS trust:

‘… within senior management they’ve seen the power of peer working and they really like it … we’re in discussions on when ENRICH finishes, that we’re going to have a number of peer workers within teams, exactly to try and change the nature and change the culture …’ (S2PWC).

PWs in this site also demonstrated a more confident, patient approach to relationship building:

‘… trying to build that friendly rapport, getting them to trust you, showing them that you understand them in a way … creating that safe space environment for them to be able to talk about how they are feeling or what’s going on for them … just finding out what they want to do for themselves not someone else telling them what to do … ’ (S2PW0).

However, as in the two low fidelity-low engagement cases, in the outlier site barriers to implementation included a challenging relationship with ward staff:

‘… [I feel] looked down upon sometimes, “oh, you’re just a peer support worker” … it’s the environment. The days that I do go for ward meetings are usually the days I need a long break, I’ll be honest with you …’ (S2PW2).

In this site there was also disruption to group supervision, with some PWs needing considerable additional support from the PWC and a challenging team dynamic emerging:

‘I was definitely doing weekly one-to-one supervisions with the peer workers when they first started … it kind of came apparent that it was what people needed … for me it didn’t work very well, I was exhausted … people want one-to-one sessions to talk about colleagues and issues they are having with their colleagues … I think there are two other peer workers who are less, they don’t see themselves as much as part of the team.’ (S2PWC).

The PWC indicated that they would have benefitted from additional support for their role:

‘I feel like we could have done more support around, more training kind of stuff on managing people with lived experience … … maybe one thing would have been more meetings with other peer worker coordinators and just see how other people are doing it … more guidance on what group supervision actually was … ’ (S2PWC).

This study used a qualitative, comparative case study design to explore how implementation of a peer support intervention might be associated with engagement with peer support and, as indicated in results elsewhere, [ 26 ] with outcomes. We noted clear differences related to organisational context between high fidelity-high engagement cases and low fidelity-low engagement cases. Lack of a positive working relationship between PW and ward (inpatient) clinical teams, exacerbated by lack of awareness of the potential role of peer support, is likely to be crucial to engagement where people begin peer support in hospital. Levels of engagement were highest in cases where those relationships were reported as largely positive and where differences in approach (between clinical practice and peer support) were highly valued [ 6 , 35 ].

We note that the two low fidelity-low engagement sites employed PWs in the not-for-profit sector rather than within the NHS. Elsewhere, research has indicated that the principles underpinning peer support might be better maintained within peer-led or not-for-profit organisations, [ 7 ] and that doing so might provide an opportunity to bring a change of culture into statutory services [ 35 ]. However, we observed constraints on resourcing for leadership roles, and lack of access and authority for managers in the not-for-profit sector, compounded, perhaps coincidentally, by the additional challenges of geography. Neither did we observe, in those sites, evidence of leadership for peer support from within the host NHS organisation that might have facilitated better implementation [ 36 ]. In our outlier high fidelity-low engagement case, resourcing for leadership also impacted support for PWs. Proper resourcing for PWCs has been identified elsewhere as crucial to providing good peer support [ 5 , 37 ]. PWCs at sites that struggled with levels of engagement identified the need for a wider network of mutual support beyond their immediate organisation, with work elsewhere highlighting the need to develop communities of practice around lived experience leadership roles in mental health services [ 38 , 39 ]. As such, our findings reinforce the link that has been observed elsewhere between leadership in implementation, and the outcomes of a newly implemented intervention [ 40 ].

At the two high engagement-high fidelity sites, PWCs noted that robust recruitment processes resulted in a PW team that were well equipped to deliver what was a challenging role. An experience of the PW team as mutually supportive, complemented with group supervision led by a PWC bringing experiential knowledge to their role, was identified as important at all five sites included in our analysis, as it is in the wider literature [ 2 , 5 ]. The PW training programme was equally valued across all sites with PWs indicating that it prepared them well for their roles. Again, the importance of training that is specifically tailored to peer support having been widely noted [ 3 , 4 ]. In sites where there were inconsistencies in delivery of supervision and training, this appeared to impact confidence among PWs in offering peer support that reflected the underpinning principles framework. Sites with high fidelity scores were indicative of a clear focus on relationship and trust building, characterised by spending time alongside the individual offered peer support, learning from them, before taking their lead in exploring new possibilities. These values have been identified as fundamental to peer support, [ 41 ] and our own analysis of data from the trial indicated that relationship building at the beginning of the peer support was predictive of ongoing engagement [ 42 ].

It is worth noting here that not all challenges to engaging people with the peer support were attributable to implementation issues. Across sites, interviewees felt that discharge from hospital was a challenging time for some people to consider taking up peer support. Other trials of peer support for discharge have also struggled in this respect, [ 43 ] especially where participants were those with a higher level of need (people with multiple admissions) as they were in our study [ 15 ].

Strengths and limitations

We employed a robust, theoretically informed comparative case study design, with case selection determined by a priori measures of fidelity [ 31 ] and engagement [ 26 ] made independently of this analysis. We analysed a complete data set – interviews of PWs and PWCs – in all sites included in the analysis, although we might usefully have also interviewed NHS clinicians and managers as they also played a role in implementation. Analysis of in-depth interviews exploring the experiences of people offered peer support will be reported elsewhere. Our original interview schedules were not directly informed by the PAHRIS framework [ 22 ] and so may not have elicited a full range of data relating to implementation variables. Other frameworks might have been indicative of different barriers and facilitators of successful implementation. Nevertheless, we note the work adapting the PAHRIS framework to elucidate the role of experiential knowledge in implementation was particularly suited to a study of peer support and informed by lived experience on the research team [ 25 ].

Implications for policy, practice and research

Mental health workforce policy in England, as elsewhere, is encouraging employment of large numbers of PWs into mental health services.[ 44 ]. A range of training programmes have emerged [ 45 ] that, to some degree, share a set of principles similar to those that informed ENRICH. This study suggests that specific supports for PWs need to be properly resourced as integral to the offer of peer support in mental health services. These include supervision from an experienced PW, opportunities for group supervision, and an emphasis on relationship building in PW training that is consistent with a principles-based peer support framework. While it has been suggested that peer support can drive cultural change in mental health provider organisations, [ 46 ] our research suggests that lack of supportive culture can constrain delivery. Peer leadership, provided with sufficient support and authority, is needed to support change work with clinical teams, in hospital and in the community, so that peer support and clinical care are part of a complementary offer.

This study identifies policy and practice implications when peers are employed through not-for-profit organisations to work in partnership with public mental health providers. Research elsewhere highlights the potential challenges and opportunities of this ‘hybrid’ approach, [ 35 , 47 ] indicating a need for strategies that effectively align implementation expectations between the not-for-profit organisation and the mental health provider.

Further research to develop and evaluate the introduction of peer support in mental health might usefully be informed by a change model that incorporates this range of implementation variables to optimise delivery of peer support. We also note that in our study, PWs were employed to, and supervised within a dedicated PW team that provided peer support across several clinical teams, while in many mental health services internationally PWs are employed as embedded members of multi-disciplinary clinical teams. There is a need for research that considers the implications for implementation and outcome of these contrasting organisational configurations.

This study provides clear indication that implementation issues can impact delivery of peer support, with implications for engagement and, potentially, outcomes. Resourcing can impact consistency of delivery, alongside challenges of access, authority and relationship with clinical teams, especially where PWs are employed outside of the mental health service. Attention needs to be paid to the impact of geography on implementation.

Data availability

The datasets used and analysed during the current study are available from the corresponding author on reasonable request.

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This study was funded by the UK National Institute for Health Research (NIHR), Programme Grants for Applied Research funding programme (grant number RP-PG-1212-20019). This paper presents independent research funded by NIHR. The views expressed are those of the authors and not necessarily those of the UK National Health Service (NHS), the NIHR or the Department of Health and Social Care.

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SG, SW, SLG, AlS, ML, JR, MR and JW contributed to the conception of the original study. SG, RF, SW, RB, PB, RE, DH, AlS and AnS contributed to the design of the work reported here. SG, RF, SW, RB, RE, AlS, ML, JR, MR and JW contributed to interpretation of the data. SG, RF, SW and JM contributed to the acquisition and analysis of data. SG, RF and SW drafted and substantively revised the work. All authors approved the submitted version of the study.

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Gillard, S., Foster, R., White, S. et al. Implementing peer support into practice in mental health services: a qualitative comparative case study. BMC Health Serv Res 24 , 1050 (2024). https://doi.org/10.1186/s12913-024-11447-5

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Students’ Experiences of Peer Observed Teaching: A Qualitative Interview Study

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Development of teaching skills is an important aspect of medical student training. One method of developing teaching skills is participation in peer teaching with observation and feedback from peers. This study aims to explore student teachers’ experiences of peer observation of teaching and how they intend to utilize this feedback.

We conducted individual semi-structured interviews with peer tutors who had experienced peer observation of their small group teaching and subsequent feedback. The interviews were conducted by a medical student peer not involved in the peer observation of teaching scheme. They were audio recorded and transcribed. The pseudonymised transcripts were coded independently by two researchers using thematic analysis.

Nine students participated in interviews lasting a mean of 42 minutes. We identified three main themes: motivations for observation, experiences of observation, and responses to feedback. Students were motivated to have their teaching observed by both intrinsic and extrinsic factors: to develop their skills and competence as a teacher, in recognition of the important role this plays in their career, to provide reassurance that they are providing good quality teaching, to ensure the content of their teaching is appropriate and accurate, and to provide evidence of engagement in, and development of, teaching. Students described feeling nervous before the observations and preparing more for their teaching than they might normally, however, during the observations they felt more comfortable which they attributed to the peer-peer relationship. Students described finding the narrative feedback more useful than the quantitative elements as it provided more detail as to how they might improve. Several students described how they have used the feedback they have received on their teaching to improve subsequent sessions.

Peer observation of teaching is a useful and acceptable method of providing feedback on student teaching and recipients intend to use this feedback to improve their teaching.

Recently, recognition that medical students require support and development to prepare for their future role as teachers has come to the fore. This is reflected in the inclusion of teaching competencies set out by international regulatory bodies. In the United Kingdom, the General Medical Council stipulates in Outcomes for Graduates that newly qualified doctors must be able to ‘work effectively and appropriately as a mentor and teacher for other learners in the multi-professional team;’ Citation 1 (p10) in Canada, teaching competencies are described within the CanMEDS domain of ‘scholar’; Citation 2 in Australia and New Zealand, the Australian Medical Council state that graduates should be able to ‘demonstrate […] fundamental skills in educating colleagues.’ Citation 3 (p4)

It is clear then that medical students should be developing skills in teaching during their undergraduate programmes. In response, numerous authors have developed educational programmes to develop this competency in students. Marton et al. categorize these programmes into three broad types: experience of peer teaching, teaching skills workshops, and participating in outreach programmes. Citation 4 Amongst 19 accounts of peer teacher training programmes identified in a systematic review, only two employed direct observation of peer teaching to provide feedback. Citation 5 While peer observation of teaching (POT) is recognized to be an effective means of developing faculty skills in teaching, Citation 6 it is seldom used for developing undergraduate peer tutors’ teaching skills. Citation 7

POT is a process where an individual observes a colleague’s teaching and provides them with feedback. The process aims to stimulate mutual reflection in the tutor and observer, ultimately leading to improved teaching. Citation 8 There are three described models of peer observation; evaluative, developmental, and collaborative. Citation 9 The ‘evaluative model’ relies on senior review of junior colleagues teaching, making a judgment on their performance, often with implications for promotion. The ‘developmental model’ involves expert educators providing feedback to develop a teacher’s competency. Finally, the ‘collaborative model’ relies on peers observing each other’s teaching providing feedback to stimulate reflection and improve teaching.

Naturally, being observed by a peer does not necessarily lead to improvement in teaching. Citation 10 Feedback and reflection following observation are the interventions most likely to change teaching practice. In a study of clinicians receiving POT, tutors valued feedback most when the feedback was delivered immediately after teaching, identified key features, was non-threatening and promoted reflection. Citation 11 In a survey of 24 residents who had received feedback after POT, 62% demonstrated changes in their teaching and 57% felt that the process made them better teachers. Citation 12 This suggests that feedback on teaching can be useful for developing the competencies of novice teachers. Conversely, a study of more experienced teachers identified variability in their acceptance of feedback on teaching, highlighting perceived credibility of the feedback provider and competing priorities as barriers to acting on feedback. Citation 13 There are several factors influencing whether teachers accept and utilize feedback on their teaching. Citation 14 Three such factors are the recipient, provision of feedback itself, and the impact of feedback on the individual. Citation 15 First, however, consideration needs to be given to why learners seek feedback. Teunissen, et al. identified that not all learners actively seek feedback on their performance. Citation 16 Factors influencing feedback seeking behavior include goal orientation, personal factors, interpersonal factors, and perceived costs and benefits. Citation 16 , Citation 17 In the existing literature the goal orientations of student peer teachers seeking feedback are currently undescribed.

In addition to the above, for recipients to perceive feedback as credible it should also be timely, specific, constructive, and ‘actionable’. Citation 18 Others support this and highlight the need to provide recipients with support and information to address the gap between current and desired performance. Citation 19 This support can avoid critical feedback being perceived as burdensome and paralyzing which may lead to non-engagement with the feedback process. Citation 20

There have been no identified reports in the existing medical education literature of students’ experiences of peer observation of teaching or, indeed, how they respond to and act upon feedback on their teaching practice. This study aimed to explore students’ experiences of peer observation of teaching and how they intend to use feedback provided on their teaching.

Ethical approval was granted from Keele University School of Medicine Ethics Committee. This manuscript is reported in accordance with the Consolidated criteria for reporting qualitative research (COREQ). Citation 21

We previously reported full details of the peer observation of teaching scheme we developed for medical student peer teachers. Citation 7 At our institution there is a strong culture of extra-curricular near-peer teaching as part of a student society. Medical students deliver near-peer teaching to more junior students on a fortnightly basis covering a wide range of clinical and non-clinical topics. Sessions usually last one to two hours in the evening and are classroom based for small groups of approximately 12 students. As part of our tutor development programme, student tutors have the opportunity of attending a half day training workshop on session design and small group teaching, and are offered the opportunity to have a senior medical student trained in peer observation and feedback observe one of their teaching sessions. We adopted a model of POT, incorporating elements of the developmental and collaborative models aiming to develop both the tutor’s and observer’s teaching through feedback, discussion, and reflection. Citation 7 Tutors were allocated a near-peer observer based on availability. Tutors and observers met to establish observation goals and the tutor’s desired focus for feedback. Peer observers completed a peer observation form to structure their feedback. Observers and tutors met immediately after the observation to have a feedback conversation and to provide the tutor with the written feedback for future reference. Tutors were encouraged to reflect on the feedback they received but this was not mandated.

We emphasized to all tutors that the purpose was purely to develop their teaching rather than to evaluate or assess. Citation 8 The peer observers are senior medical students trained in peer observation through a half day workshop.

We conducted a qualitative interview study of tutors who had participated in peer observation at the School of Medicine, Keele University. We adopted a constructivist perspective, recognizing that meaning is constructed through dialogue between the researcher and the researched. Citation 22

Sampling and recruitment

We used a criterion sampling approach. Citation 23 All students who had delivered near-peer-teaching and received feedback after peer observation of teaching (n = 16 during the period of data collection) were invited to participate via an email from the lead researcher (ME). Interviews were arranged in the same academic year as the peer observation and were a maximum of three months after the POT encounter. Written consent was obtained at the time of interviews.

Data collection

We conducted individual semi structured interviews using an interview schedule to guide our questioning (Appendix 1, Supplementary material ). We piloted the schedule with the first two participants and made minor revisions before proceeding with data collection.

The interviews were held at a mutually convenient time in a university building. Students were encouraged to bring copies of any feedback on their teaching to help inform discussion. All interviews were conducted by one researcher (ME) who was not involved in the peer observation process with the intention to allow open and candid discussion of students’ experiences of the feedback that they received. We also anticipated that the interviewer’s role as a fellow medical student would minimize any power dynamic. All interviews were audio recorded and then professionally transcribed. The transcripts were pseudonymised and then imported in to NVivo version 12 to facilitate analysis.

Data analysis

We analyzed the transcripts using thematic analysis. Citation 24 All three researchers read through all the transcripts to familiarize themselves with the data. We then each independently analyzed two selected transcripts and coded them inductively. We then met to discuss any discrepancies in the codes and to agree on an initial coding framework. ME and ELR then coded the remaining transcripts. We met periodically to review and discuss our coding and interpretations. Once all of the transcripts were coded, we met as a research team to construct themes. We then reviewed the content of the coding for each theme to ensure internal homogeneity and external heterogeneity. ME and ELR then reviewed all the transcripts to ensure our thematic framework appropriately reflected the entirety of our data and to ensure all data relevant to each theme had been coded. We then named our final themes to reflect the messages conveyed within them.

Reflexivity

Given our epistemological perspective, it was important to recognize the potential influence of our research teams’ backgrounds and our interaction with the participants and our interpretation of their accounts. At the time of data collection, we were all senior medical students. We have since graduated and were early postgraduate trainees during the analysis phase. ELR also holds an academic appointment in faculty development. We were all involved in establishing and co-ordinating the POT scheme. We were cognizant, therefore, that we may have a propensity to seek the positive elements of the data. In the interviews, ME encouraged participants to express both their positive and negative perceptions they held. During analysis, we consciously sought divergent opinions within our data and discussed how our individual assumptions may influence our interpretation of the data during our regular meetings. Citation 25

Nine students (six males, three females) participated in individual interviews lasting a mean of 42 minutes each. The participants ranged from years 2 to 5 of a five-year degree programme.

We constructed three main themes: motivations for observation, experience of observation, and responses to feedback. Within these results we will refer to medical students engaged in near-peer teaching as ‘tutors’, other medical students observing this teaching as ‘observers’, the students being taught as ‘students’, and academic staff employed at the medical school as ‘faculty’.

Motivations for observation

Tutors described several different motivations for participating in POT. These included: to provide evidence for their involvement in teaching, to develop teaching skills, and to reassure themselves of the quality of their teaching.

Some tutors were predominantly extrinsically motivated, describing wanting to be observed in order to evidence their involvement in near-peer teaching. They reported expecting the written feedback they received would be more useful in their learning portfolios (reflective portfolios that are maintained by students and reviewed by a member of faculty who was their personal development tutor during an annual appraisal) than a certificate of appreciation. They described this as being valuable, enabling them to reflect on and demonstrate their development to their personal tutors.

‘Pad out my Portfolio!… This teaching thing wasn’t a completely selfless act, there is some personal gain and that was one of the things.

Student 4, Male, Year 4.

I know we get the certificates for saying we’ve done it but actually having something like this is, good to have in your portfolio even just for your own reference to look back at but certainly if you’re reviewing it with your PDT [Personal Development Tutor] then perhaps allows a bit more discussion

Student 8, Female, Year 2.

Others described a predominant intrinsic motivation to develop as a teacher. They recognized that teaching will form a crucial part of their future career in medicine and sought to develop these skills early. They recognized that POT could give them a different perspective on areas to improve that they may not have considered through self-reflection alone. Most tutors had limited formal training in teaching so were unsure of the quality of their teaching and as a result obtaining reassurance was a strong motivation for feedback.

Obviously we’re doing this to sort of improve our teaching, erm, further ourselves so feedback is, it’s like a crucial part of that […] I really just wanted feedback on what I was doing right and what I was doing wrong

Student 7, Male, Year 2

Medicine is a profession where you’re constantly teaching your juniors and receive teaching from your seniors. So, as I know I’ll be teaching in the future, I wanted to get quite good at it early

Student 1, Male, Year 3

I’m very interested in teaching, and I see it as part of my future career. It’s important to me that I develop myself as a teacher. And peer observation, having a peer observe my teaching allows me to do that

Student 3, Male, Year 4

You’ll get something insightful from the person giving you feedback. Something that either you’ve thought went wrong or went well, that they disagree with, or just something that you haven’t thought about completely, that they can enlighten you on

Student 6, Male, Year 5

I maybe thought that the stuff I’d been doing so far was possibly wrong, I just tried what I thought worked for me. So yeah, it was just basically to get some assurance that the teaching that I was doing was useful

Student 2, Male, Year 3

Experience of observation

Students’ experiences of observation were variable. They were generally anxious before the observation and described three reasons for this. Firstly, they were concerned regarding repercussions if their teaching was perceived to be poor, such as being withdrawn from the near-peer-teaching programme. Secondly, they feared looking “stupid” or being judged by their peers if the session went badly, an anxiety which may be exacerbated by the close knit nature of the medical school. Thirdly, they worried about their content knowledge being insufficient and there being a more knowledgeable peer in the room. Conversely, this last point acted as a source of reassurance for some students that any factual inaccuracies could be corrected.

I was a bit apprehensive about it at first, because, obviously, there’s someone else in the session, and there’s someone there just to watch you, rather than, someone who’s appreciating the teaching. So it is a bit intimidating.

I was pretty nervous because my performance was being assessed and umm, I wasn’t the most knowledgeable person in the room, because usually when you teach you should be, so I was conscious of making sure I didn’t say anything inaccurate.

Student 4, Male, Year 4

In order to overcome anxiety regarding content knowledge, tutors reported enhanced preparation as a coping strategy in sessions when they knew they were going to be observed. This may reinforce the educational benefits to the tutor of peer teaching.

Initially I think I best put more work in to it potentially because if I am going to be being watched I don’t want it to be terrible

It made me reflect on past teaching. It made me think about my preparation for the teaching session at hand, and I think I did prepare a bit more because I thought to myself ‘right, what do I want feedback on?’ or ‘How can I make sure this is as good as possible?’

Despite the initial anxiety described, students universally reported feeling comfortable being observed by near peers. This was also evident in the post-observation feedback meeting with tutors where the social congruence inherent in the peer relationship allowed for perceived empathy and understanding, creating a more informal discussion. This informal relationship led to honest discussion and constructive feedback.

I was nervous at the beginning […] knowing that he was in my eyeline and thinking ‘what is he going to be thinking?’ But then that faded after about 5 or 10 minutes and I just got on with it and focused on the students

(Student 5, Female, Year 2)

They’ve come from a similar stage from you, only a couple of years ago, erm, they seem a lot more understanding. You feel like more, it feels like more informal, more like a general conversation rather than a formal affair where they’re telling you how you did and start criticising you.

Student 8, Female, Year 2

If it’s someone you know, then the informality is really there, and they can just say to you, ‘Look. This wasn’t very good… they can be a bit blunt with you and not have to worry about, you know, professional courtesy and not offending you, because, you know, your mates can offend you.

I can’t say I felt any worry or anxiety about it, erm more a sense of…er, reassurance, I guess, there was, there was a more senior student there. His, er, his obviously not my knowledge but I guess that’s a useful thing as well because if you, if you’re unsure of anything when you explain stuff to junior students, they’re, they, they’re there to help as well, I think.

Responses to feedback

Tutors reported valuing the feedback they received after peer observation. They described the verbal feedback as the most useful element, allowing clarification of learning points. However, they also recognized the utility of written feedback for future reference and reflection. The value of the feedback was also influenced by timing. Tutors noted that the immediacy of verbal feedback made it more useful as the delay with written feedback gave time to forget key points. Tutors highlighted that fatigue after the teaching session may limit the efficacy of the post-observation feedback.

I think the contact with the observer afterwards is quite important to clarify any issues and just gives you a better understanding of what has been written down, but its good to have the hard copy as well so both forms I think are good.

It gives you that immediacy [verbal feedback]. You can bounce things off them and say, ‘Do you think that was a good idea or should I not have done that?’ It gives you that immediate, ‘Well, this was all right or not’

We were emailed it probably about a week after the session. So yes, like, interval time you tend to forget about all the little things you did. Erm, so it’s probably less useful in that case

The feedback from the peer observer was considered to be more useful than other sources of feedback, for example student evaluation questionnaires. This was felt to be because the observers were more specific and detailed with their feedback. They were also considered more likely to offer a balance of confirmatory and constructive feedback. They described the narrative feedback as more useful than the Likert type questions as the latter were perceived to lack detail.

Yeah, it was more detailed the observational feedback, the students just had the questionnaires and they have about two minutes, and they just want to go home I guess and they just tick the boxes, and put maybe one comment at the bottom, and you never really know if they are being honest or if they are just being nice because they don’t want to offend you

Student 5, Female, Year 2

The positive is good for the reassurance and the negatives is good for moving forward and knowing what to do next time to change it. I think if you did it all either way then you lose out on the benefits of the other

Tutors reported that peer observation and feedback influenced their future teaching. They described the process encouraged them to reflect on their teaching and helped consideration of how they may improve future sessions. They were able to identify specific changes that were utilized in their future teaching sessions.

I had a read through it, […] I focused more on the negatives and just had basically a little think about how I could improve that the next time I did it.”

I think its sort of evidence of my reflection, the fact that I’ve changed my teaching style slightly, and also producing lesson plans to improve the teaching to the students

Some participants described reflecting for action in advance of their next teaching sessions, whereby they would review the feedback they received after their peer observation and consider how they would approach the session differently this time in order to improve.

I also used it and took it out when I was planning my next session and wrote down a few things… like just making sure that I introduce myself, and also we implemented name badges for the next session as well, which was useful

Summary of results

This study sought to explore students’ experiences of POT and how they utilize the feedback received. We have identified that students were motivated to have their teaching observed by a mix of extrinsic and intrinsic factors. While many were anxious prior to the observations, they describe feeling comfortable during the experience which they attribute to social congruence between observer and tutor. Students use the feedback they receive both for reflection and to inform future teaching.

Comparison with existing literature

Previous studies have identified that students are motivated to develop their teaching skills.

For example, an evaluation of a programme to develop student teaching, identified through questionnaire and focus groups, that students were motivated to develop their teaching skills as they realized that being an educator would form a key role in their medical careers. Citation 26 Another important motivator was use of the written feedback as evidence of teaching and development. Whilst several programmes to develop students’ teaching utilize certificates for portfolios as an incentive Citation 27 , Citation 28 written evidence for portfolios has not been previously reported as a motivating factor for seeking feedback. The present study has highlighted that written feedback is a useful way to evidence student teaching and provides an opportunity to demonstrate development over time. As a result, having this documentation as part of the process may be an important factor for students to receive feedback on their teaching.

Overall, student tutors found POT to be an acceptable way of receiving feedback on their teaching. However, despite this, pre-observation anxiety was widely reported amongst tutors. This anxiety was reportedly due to fear of assessment and reprisals for poor performance, as well as fear of embarrassment if criticized by colleagues. This is in keeping with reports of POT in other populations. Others have found anxiety reported as a potential barrier to observation of teaching in GP tutors especially when observed by a non-peer. Citation 8 Similarly, foundation doctors undergoing POT almost universally reported apprehension before observation. Citation 29 Interestingly, in keeping with our study, they also reported a case of a tutor feeling reassured by having the observer to help if needed. This anxiety may be heightened if there is a power differential between observer and tutor or that there are perceived consequences based on performance as in the evaluative model. Citation 9 Use of peer observers at a similar stage of training and repeat observations may help to minimize this power differential, and improve familiarity and trust with the process therefore helping to reduce this anxiety. Citation 29 , Citation 30 One of the unique findings of our study is the importance attributed to the social congruence between tutors and observers in establishing a psychologically safe learning environment and the fact participants report observation by faculty would be undesirable. This is similar to the cognitive and social congruence in peer teaching. Citation 31 Ultimately, after an initial period of anxiety, all tutors reported feeling comfortable with being observed by peers. This corroborates the findings of another study which interviewed senior dental tutors involved in POT and identified initial anxiety followed by comfort, which persisted into the post-observation feedback meeting with tutors reporting they could have more open and honest discussions with their peers. Citation 32

All student tutors were able to identify areas for development and specific changes in their teaching following their feedback using the proforma as a tool for reflection on and for action, reviewing this prior to future teaching. This process of reflection forms a key part of the POT process as observation alone does not equate to improved teaching. Citation 10 A study of POT with foundation doctors as peer tutors identified that the process stimulated reflection and specific changes in future teaching. Citation 29 These findings suggest that POT is an effective method of developing novice tutors’ teaching skills.

In concordance with existing literature, student tutors found the verbal aspect of the feedback most useful, possibly due to the immediacy and opportunity to explore feedback in depth. Citation 33 However, tutors also recognized the value of written feedback as a tool for future reflection for action and that immediate feedback may be limited by fatigue at the end of teaching sessions often after a full day of learning activities. Similar issues are raised as a barrier for clinicians participating in POT around clinical commitments. Citation 8 , Citation 33 It is recognized that effective POT is time consuming and provides a major challenge for making the process useful and sustainable. Citation 34 Consequently, consideration should be given to allow appropriate time for feedback when delivering POT.

Strengths and limitations

This is the first report of medical students’ experiences of peer observation of teaching as a tutor development approach. We have provided important and novel insights into the phenomenon that can help inform the design of student tutor training. We used a student peer to conduct the interviews which we believe will have fostered a more candid discussion due to social congruence and lack of power dynamics. While the interviewer was not involved in the peer observation scheme during or prior to the interviews, he was a member of the committee of the near-peer teaching society (Keele Medical Education Society) at the time of the interviews. He endeavored to encourage honest discussion from the participants, but his role on the committee may have influenced their responses through social desirability bias.

A further limitation of this study is the relatively small sample size. While there are no absolute numbers required for qualitative studies, authors generally recommend between 12 and 60, Citation 35 and empiric work suggests saturation at 12 interviews. Citation 36 Due to the small sampling frame of students that had participated in the POT scheme at the time of data collection we were not able to recruit any further participants. While we do not purport to have reached saturation, we believe our data is sufficient to answer our research questions given the narrow focus and sample specificity. Citation 37

Recommendations for future research and practice

We have found that POT is an acceptable and useful method of receiving feedback. We recommend that educators consider incorporating observed authentic teaching practice into peer tutor development programmes. These observations should be conducted by peers or near peers and be followed by a feedback conversation, the main points of which should be documented in writing to enable future reflection.

Given the reported impact that this feedback has on students’ teaching, future work should look to examine the content of peer feedback to ensure that it is of sufficient quality to optimize the development of student tutors teaching.

This study has identified several different motivating factors for undergraduates to participate in the process of peer observation and feedback. These include reassurance about their teaching skills, evidence for portfolios, and importantly, to aid their development as a teacher. Student responses demonstrate that the majority found the process useful and that despite some initial anxiety, POT is a valuable and acceptable way of receiving feedback on their teaching. Separation of ‘evaluation’ from the process may reduce the barriers to acceptance and reduce anxiety, aiding a positive developmental learning process. Interestingly, all student tutors reported using the feedback to improve and develop their future teaching performance. Overall, it appears that peer observation of student teaching should be encouraged and may be a useful tool in developing the teaching skills of student tutors.

Acknowledgments

We would like to thank the students who participated in this study.

No conflict of interest to declare.

Eliot L Rees is funded by a National Institute for Health Research Academic Clinical Fellowship: ACF-2020-18-021. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

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Observational Studies: Cohort and Case-Control Studies

Jae w. song.

1 Research Fellow, Section of Plastic Surgery, Department of Surgery The University of Michigan Health System; Ann Arbor, MI

Kevin C. Chung

2 Professor of Surgery, Section of Plastic Surgery, Department of Surgery The University of Michigan Health System; Ann Arbor, MI

Observational studies are an important category of study designs. To address some investigative questions in plastic surgery, randomized controlled trials are not always indicated or ethical to conduct. Instead, observational studies may be the next best method to address these types of questions. Well-designed observational studies have been shown to provide results similar to randomized controlled trials, challenging the belief that observational studies are second-rate. Cohort studies and case-control studies are two primary types of observational studies that aid in evaluating associations between diseases and exposures. In this review article, we describe these study designs, methodological issues, and provide examples from the plastic surgery literature.

Because of the innovative nature of the specialty, plastic surgeons are frequently confronted with a spectrum of clinical questions by patients who inquire about “best practices.” It is thus essential that plastic surgeons know how to critically appraise the literature to understand and practice evidence-based medicine (EBM) and also contribute to the effort by carrying out high-quality investigations. 1 Well-designed randomized controlled trials (RCTs) have held the pre-eminent position in the hierarchy of EBM as level I evidence ( Table 1 ). However, RCT methodology, which was first developed for drug trials, can be difficult to conduct for surgical investigations. 3 Instead, well-designed observational studies, recognized as level II or III evidence, can play an important role in deriving evidence for plastic surgery. Results from observational studies are often criticized for being vulnerable to influences by unpredictable confounding factors. However, recent work has challenged this notion, showing comparable results between observational studies and RCTs. 4 , 5 Observational studies can also complement RCTs in hypothesis generation, establishing questions for future RCTs, and defining clinical conditions.

Levels of Evidence Based Medicine

From REF 1 .

Observational studies fall under the category of analytic study designs and are further sub-classified as observational or experimental study designs ( Figure 1 ). The goal of analytic studies is to identify and evaluate causes or risk factors of diseases or health-related events. The differentiating characteristic between observational and experimental study designs is that in the latter, the presence or absence of undergoing an intervention defines the groups. By contrast, in an observational study, the investigator does not intervene and rather simply “observes” and assesses the strength of the relationship between an exposure and disease variable. 6 Three types of observational studies include cohort studies, case-control studies, and cross-sectional studies ( Figure 1 ). Case-control and cohort studies offer specific advantages by measuring disease occurrence and its association with an exposure by offering a temporal dimension (i.e. prospective or retrospective study design). Cross-sectional studies, also known as prevalence studies, examine the data on disease and exposure at one particular time point ( Figure 2 ). 6 Because the temporal relationship between disease occurrence and exposure cannot be established, cross-sectional studies cannot assess the cause and effect relationship. In this review, we will primarily discuss cohort and case-control study designs and related methodologic issues.

Analytic Study Designs. Adapted with permission from Joseph Eisenberg, Ph.D.

Temporal Design of Observational Studies: Cross-sectional studies are known as prevalence studies and do not have an inherent temporal dimension. These studies evaluate subjects at one point in time, the present time. By contrast, cohort studies can be either retrospective (latin derived prefix, “retro” meaning “back, behind”) or prospective (greek derived prefix, “pro” meaning “before, in front of”). Retrospective studies “look back” in time contrasting with prospective studies, which “look ahead” to examine causal associations. Case-control study designs are also retrospective and assess the history of the subject for the presence or absence of an exposure.

COHORT STUDY

The term “cohort” is derived from the Latin word cohors . Roman legions were composed of ten cohorts. During battle each cohort, or military unit, consisting of a specific number of warriors and commanding centurions, were traceable. The word “cohort” has been adopted into epidemiology to define a set of people followed over a period of time. W.H. Frost, an epidemiologist from the early 1900s, was the first to use the word “cohort” in his 1935 publication assessing age-specific mortality rates and tuberculosis. 7 The modern epidemiological definition of the word now means a “group of people with defined characteristics who are followed up to determine incidence of, or mortality from, some specific disease, all causes of death, or some other outcome.” 7

Study Design

A well-designed cohort study can provide powerful results. In a cohort study, an outcome or disease-free study population is first identified by the exposure or event of interest and followed in time until the disease or outcome of interest occurs ( Figure 3A ). Because exposure is identified before the outcome, cohort studies have a temporal framework to assess causality and thus have the potential to provide the strongest scientific evidence. 8 Advantages and disadvantages of a cohort study are listed in Table 2 . 2 , 9 Cohort studies are particularly advantageous for examining rare exposures because subjects are selected by their exposure status. Additionally, the investigator can examine multiple outcomes simultaneously. Disadvantages include the need for a large sample size and the potentially long follow-up duration of the study design resulting in a costly endeavor.

Cohort and Case-Control Study Designs

Advantages and Disadvantages of the Cohort Study

Cohort studies can be prospective or retrospective ( Figure 2 ). Prospective studies are carried out from the present time into the future. Because prospective studies are designed with specific data collection methods, it has the advantage of being tailored to collect specific exposure data and may be more complete. The disadvantage of a prospective cohort study may be the long follow-up period while waiting for events or diseases to occur. Thus, this study design is inefficient for investigating diseases with long latency periods and is vulnerable to a high loss to follow-up rate. Although prospective cohort studies are invaluable as exemplified by the landmark Framingham Heart Study, started in 1948 and still ongoing, 10 in the plastic surgery literature this study design is generally seen to be inefficient and impractical. Instead, retrospective cohort studies are better indicated given the timeliness and inexpensive nature of the study design.

Retrospective cohort studies, also known as historical cohort studies, are carried out at the present time and look to the past to examine medical events or outcomes. In other words, a cohort of subjects selected based on exposure status is chosen at the present time, and outcome data (i.e. disease status, event status), which was measured in the past, are reconstructed for analysis. The primary disadvantage of this study design is the limited control the investigator has over data collection. The existing data may be incomplete, inaccurate, or inconsistently measured between subjects. 2 However, because of the immediate availability of the data, this study design is comparatively less costly and shorter than prospective cohort studies. For example, Spear and colleagues examined the effect of obesity and complication rates after undergoing the pedicled TRAM flap reconstruction by retrospectively reviewing 224 pedicled TRAM flaps in 200 patients over a 10-year period. 11 In this example, subjects who underwent the pedicled TRAM flap reconstruction were selected and categorized into cohorts by their exposure status: normal/underweight, overweight, or obese. The outcomes of interest were various flap and donor site complications. The findings revealed that obese patients had a significantly higher incidence of donor site complications, multiple flap complications, and partial flap necrosis than normal or overweight patients. An advantage of the retrospective study design analysis is the immediate access to the data. A disadvantage is the limited control over the data collection because data was gathered retrospectively over 10-years; for example, a limitation reported by the authors is that mastectomy flap necrosis was not uniformly recorded for all subjects. 11

An important distinction lies between cohort studies and case-series. The distinguishing feature between these two types of studies is the presence of a control, or unexposed, group. Contrasting with epidemiological cohort studies, case-series are descriptive studies following one small group of subjects. In essence, they are extensions of case reports. Usually the cases are obtained from the authors' experiences, generally involve a small number of patients, and more importantly, lack a control group. 12 There is often confusion in designating studies as “cohort studies” when only one group of subjects is examined. Yet, unless a second comparative group serving as a control is present, these studies are defined as case-series. The next step in strengthening an observation from a case-series is selecting appropriate control groups to conduct a cohort or case-control study, the latter which is discussed in the following section about case-control studies. 9

Methodological Issues

Selection of subjects in cohort studies.

The hallmark of a cohort study is defining the selected group of subjects by exposure status at the start of the investigation. A critical characteristic of subject selection is to have both the exposed and unexposed groups be selected from the same source population ( Figure 4 ). 9 Subjects who are not at risk for developing the outcome should be excluded from the study. The source population is determined by practical considerations, such as sampling. Subjects may be effectively sampled from the hospital, be members of a community, or from a doctor's individual practice. A subset of these subjects will be eligible for the study.

Levels of Subject Selection. Adapted from Ref 9 .

Attrition Bias (Loss to follow-up)

Because prospective cohort studies may require long follow-up periods, it is important to minimize loss to follow-up. Loss to follow-up is a situation in which the investigator loses contact with the subject, resulting in missing data. If too many subjects are loss to follow-up, the internal validity of the study is reduced. A general rule of thumb requires that the loss to follow-up rate not exceed 20% of the sample. 6 Any systematic differences related to the outcome or exposure of risk factors between those who drop out and those who stay in the study must be examined, if possible, by comparing individuals who remain in the study and those who were loss to follow-up or dropped out. It is therefore important to select subjects who can be followed for the entire duration of the cohort study. Methods to minimize loss to follow-up are listed in Table 3 .

Methods to Minimize Loss to Follow-Up

Adapted from REF 2 .

CASE-CONTROL STUDIES

Case-control studies were historically borne out of interest in disease etiology. The conceptual basis of the case-control study is similar to taking a history and physical; the diseased patient is questioned and examined, and elements from this history taking are knitted together to reveal characteristics or factors that predisposed the patient to the disease. In fact, the practice of interviewing patients about behaviors and conditions preceding illness dates back to the Hippocratic writings of the 4 th century B.C. 7

Reasons of practicality and feasibility inherent in the study design typically dictate whether a cohort study or case-control study is appropriate. This study design was first recognized in Janet Lane-Claypon's study of breast cancer in 1926, revealing the finding that low fertility rate raises the risk of breast cancer. 13 , 14 In the ensuing decades, case-control study methodology crystallized with the landmark publication linking smoking and lung cancer in the 1950s. 15 Since that time, retrospective case-control studies have become more prominent in the biomedical literature with more rigorous methodological advances in design, execution, and analysis.

Case-control studies identify subjects by outcome status at the outset of the investigation. Outcomes of interest may be whether the subject has undergone a specific type of surgery, experienced a complication, or is diagnosed with a disease ( Figure 3B ). Once outcome status is identified and subjects are categorized as cases, controls (subjects without the outcome but from the same source population) are selected. Data about exposure to a risk factor or several risk factors are then collected retrospectively, typically by interview, abstraction from records, or survey. Case-control studies are well suited to investigate rare outcomes or outcomes with a long latency period because subjects are selected from the outset by their outcome status. Thus in comparison to cohort studies, case-control studies are quick, relatively inexpensive to implement, require comparatively fewer subjects, and allow for multiple exposures or risk factors to be assessed for one outcome ( Table 4 ). 2 , 9

Advantages and Disadvantages of the Case-Control Study

An example of a case-control investigation is by Zhang and colleagues who examined the association of environmental and genetic factors associated with rare congenital microtia, 16 which has an estimated prevalence of 0.83 to 17.4 in 10,000. 17 They selected 121 congenital microtia cases based on clinical phenotype, and 152 unaffected controls, matched by age and sex in the same hospital and same period. Controls were of Hans Chinese origin from Jiangsu, China, the same area from where the cases were selected. This allowed both the controls and cases to have the same genetic background, important to note given the investigated association between genetic factors and congenital microtia. To examine environmental factors, a questionnaire was administered to the mothers of both cases and controls. The authors concluded that adverse maternal health was among the main risk factors for congenital microtia, specifically maternal disease during pregnancy (OR 5.89, 95% CI 2.36-14.72), maternal toxicity exposure during pregnancy (OR 4.76, 95% CI 1.66-13.68), and resident area, such as living near industries associated with air pollution (OR 7.00, 95% CI 2.09-23.47). 16 A case-control study design is most efficient for this investigation, given the rarity of the disease outcome. Because congenital microtia is thought to have multifactorial causes, an additional advantage of the case-control study design in this example is the ability to examine multiple exposures and risk factors.

Selection of Cases

Sampling in a case-control study design begins with selecting the cases. In a case-control study, it is imperative that the investigator has explicitly defined inclusion and exclusion criteria prior to the selection of cases. For example, if the outcome is having a disease, specific diagnostic criteria, disease subtype, stage of disease, or degree of severity should be defined. Such criteria ensure that all the cases are homogenous. Second, cases may be selected from a variety of sources, including hospital patients, clinic patients, or community subjects. Many communities maintain registries of patients with certain diseases and can serve as a valuable source of cases. However, despite the methodologic convenience of this method, validity issues may arise. For example, if cases are selected from one hospital, identified risk factors may be unique to that single hospital. This methodological choice may weaken the generalizability of the study findings. Another example is choosing cases from the hospital versus the community; most likely cases from the hospital sample will represent a more severe form of the disease than those in the community. 2 Finally, it is also important to select cases that are representative of cases in the target population to strengthen the study's external validity ( Figure 4 ). Potential reasons why cases from the original target population eventually filter through and are available as cases (study participants) for a case-control study are illustrated in Figure 5 .

Levels of Case Selection. Adapted from Ref 2 .

Selection of Controls

Selecting the appropriate group of controls can be one of the most demanding aspects of a case-control study. An important principle is that the distribution of exposure should be the same among cases and controls; in other words, both cases and controls should stem from the same source population. The investigator may also consider the control group to be an at-risk population, with the potential to develop the outcome. Because the validity of the study depends upon the comparability of these two groups, cases and controls should otherwise meet the same inclusion criteria in the study.

A case-control study design that exemplifies this methodological feature is by Chung and colleagues, who examined maternal cigarette smoking during pregnancy and the risk of newborns developing cleft lip/palate. 18 A salient feature of this study is the use of the 1996 U.S. Natality database, a population database, from which both cases and controls were selected. This database provides a large sample size to assess newborn development of cleft lip/palate (outcome), which has a reported incidence of 1 in 1000 live births, 19 and also enabled the investigators to choose controls (i.e., healthy newborns) that were generalizable to the general population to strengthen the study's external validity. A significant relationship with maternal cigarette smoking and cleft lip/palate in the newborn was reported in this study (adjusted OR 1.34, 95% CI 1.36-1.76). 18

Matching is a method used in an attempt to ensure comparability between cases and controls and reduces variability and systematic differences due to background variables that are not of interest to the investigator. 8 Each case is typically individually paired with a control subject with respect to the background variables. The exposure to the risk factor of interest is then compared between the cases and the controls. This matching strategy is called individual matching. Age, sex, and race are often used to match cases and controls because they are typically strong confounders of disease. 20 Confounders are variables associated with the risk factor and may potentially be a cause of the outcome. 8 Table 5 lists several advantages and disadvantages with a matching design.

Advantages and Disadvantages for Using a Matching Strategy

Multiple Controls

Investigations examining rare outcomes may have a limited number of cases to select from, whereas the source population from which controls can be selected is much larger. In such scenarios, the study may be able to provide more information if multiple controls per case are selected. This method increases the “statistical power” of the investigation by increasing the sample size. The precision of the findings may improve by having up to about three or four controls per case. 21 - 23

Bias in Case-Control Studies

Evaluating exposure status can be the Achilles heel of case-control studies. Because information about exposure is typically collected by self-report, interview, or from recorded information, it is susceptible to recall bias, interviewer bias, or will rely on the completeness or accuracy of recorded information, respectively. These biases decrease the internal validity of the investigation and should be carefully addressed and reduced in the study design. Recall bias occurs when a differential response between cases and controls occurs. The common scenario is when a subject with disease (case) will unconsciously recall and report an exposure with better clarity due to the disease experience. Interviewer bias occurs when the interviewer asks leading questions or has an inconsistent interview approach between cases and controls. A good study design will implement a standardized interview in a non-judgemental atmosphere with well-trained interviewers to reduce interviewer bias. 9

The STROBE Statement: The Strengthening the Reporting of Observational Studies in Epidemiology Statement

In 2004, the first meeting of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) group took place in Bristol, UK. 24 The aim of the group was to establish guidelines on reporting observational research to improve the transparency of the methods, thereby facilitating the critical appraisal of a study's findings. A well-designed but poorly reported study is disadvantaged in contributing to the literature because the results and generalizability of the findings may be difficult to assess. Thus a 22-item checklist was generated to enhance the reporting of observational studies across disciplines. 25 , 26 This checklist is also located at the following website: www.strobe-statement.org . This statement is applicable to cohort studies, case-control studies, and cross-sectional studies. In fact, 18 of the checklist items are common to all three types of observational studies, and 4 items are specific to each of the 3 specific study designs. In an effort to provide specific guidance to go along with this checklist, an “explanation and elaboration” article was published for users to better appreciate each item on the checklist. 27 Plastic surgery investigators should peruse this checklist prior to designing their study and when they are writing up the report for publication. In fact, some journals now require authors to follow the STROBE Statement. A list of participating journals can be found on this website: http://www.strobe-statement.org./index.php?id=strobe-endorsement .

Due to the limitations in carrying out RCTs in surgical investigations, observational studies are becoming more popular to investigate the relationship between exposures, such as risk factors or surgical interventions, and outcomes, such as disease states or complications. Recognizing that well-designed observational studies can provide valid results is important among the plastic surgery community, so that investigators can both critically appraise and appropriately design observational studies to address important clinical research questions. The investigator planning an observational study can certainly use the STROBE statement as a tool to outline key features of a study as well as coming back to it again at the end to enhance transparency in methodology reporting.

Acknowledgments

Supported in part by a Midcareer Investigator Award in Patient-Oriented Research (K24 AR053120) from the National Institute of Arthritis and Musculoskeletal and Skin Diseases (to Dr. Kevin C. Chung).

None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript.

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