title: Staging a performance: learners' perceptions about direct observation during residency.
abstract: BACKGROUND
  Evidence strongly supports that direct observation is a valid and reliable assessment tool; support for its impact on learning is less compelling, and we know that some learners are ambivalent about being observed. However, learners' perceptions about the impact of direct observation on their learning and professional development remain underexplored. To promote learning, we need to understand what makes direct observation valuable for learners.
  
  
  METHODS
  Informed by constructivist grounded theory, we interviewed 22 learners about their observation experiences. Data collection and analysis occurred iteratively; themes were identified using constant comparative analysis.
  
  
  RESULTS
  Direct observation was widely endorsed as an important educational strategy, albeit one that created significant anxiety. Opaque expectations exacerbated participants' discomfort, and participants described that being observed felt like being assessed. Consequently, participants exchanged their 'usual' practice for a 'textbook' approach; alterations to performance generated uncertainty about their role, and raised questions about whether observers saw an authentic portrayal of their knowledge and skill.
  
  
  CONCLUSIONS
  An 'observer effect' may partly explain learners' ambivalence about direct observation; being observed seemed to magnify learners' role ambiguity, intensify their tensions around professional development and raise questions about the credibility of feedback. In turn, an observer effect may impact learners' receptivity to feedback and may explain, in part, learners' perceptions that useful feedback is scant. For direct observation to be valuable, educators must be explicit about expectations, and they must be aware that how learners perform in the presence of an observer may not reflect what they do as independent practitioners. To nurture learners' professional development, educators must create a culture of observation-based coaching that is divorced from assessment and is tailored to developing learners' identities as practitioners of both the art and the science of medicine.
authors.affiliation: Centre for Education Research & Innovation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
authors.forename: Kori A
authors.initials: KA
authors.lastname: LaDonna
authors.affiliation: Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: Rose
authors.initials: R
authors.lastname: Hatala
authors.affiliation: Department of Medicine and Centre for Education Research & Innovation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
authors.forename: Lorelei
authors.initials: L
authors.lastname: Lingard
authors.affiliation: Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: Stephane
authors.initials: S
authors.lastname: Voyer
authors.affiliation: Department of Clinical Neurological Sciences and Centre for Education Research & Innovation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
authors.forename: Christopher
authors.initials: C
authors.lastname: Watling
mesh_terms: D002983:Clinical Competence; D004521:Educational Measurement / Q000379:methods*; D005246:Feedback; D066296:Grounded Theory; D006801:Humans; D007396:Internship and Residency / Q000379:methods*; D007407:Interviews as Topic; D007858:Learning; D010465:Perception; D036301:Qualitative Research