Feedback
last authored: Feb 2012, David LaPierre
last reviewed:
This page is largely based on a document written and graciously shared by Dr Wayne Weston.
Introduction
Feedback is “information communicated to the learner that is intended to modify his or her thinking or behavior to improve learning” (Shute, 2008). In health care, this usually relates to various aspects of clinical care, but is also relevant for other roles.
It is designed to improve a learner's awareness of positive and negative aspects of performance. Feedback should build the learner up and provide motivation to continually strengthen their practice. It should be oriented to accomplish these goals, and it's purpose should be clearly communicated to the learner.
Feedback is one of the most powerful influences on learning (Norcini, 2010). However, some research has shown that students and residents are not observed frequently enough and the feedback they do receive is often vague and unhelpful (Bing and Trowbridge). Also, many people's opinions of feedback can be quite negative. In the not too distant past, when teacher-centred approaches dominated thinking about medical education, feedback consisted of the authoritative pronouncements by teachers about their students’ performance – what they did right and what they did wrong. It was often an unpleasant and sometimes humiliating experience. The learners’ role in receiving feedback was passive – they were expected to accept their teachers’ opinions without question and change their behaviour accordingly.
More recently, learner-centered approaches to medical education have become prominent. "Giving feedback is not just to provide a judgement or evaluation. It is to provide insight. Without insight into their own strengths and limitations (trainees) cannot progress or resolve difficulties.” (King, 2004). For example, a deeper understanding of what went well enables the learner to achieve the same ends at will in future occasions. Feedback, in this approach, is a collaborative enterprise in which teachers and learners together explore a student’s performance seeking to understand better how it went – what went well and what could be done even better; “in an educational context, it is now argued that learning is the key purpose of assessment" (Norcini and Burch, 2007).
When to Give Feedback
Feedback should be offered regularly - at least daily. Ensure you establish a trusting environment early on in the relationship, with feedback being an integral, regular part of the learner's education.
As feedback becomes part of the educational routine, choose an appropriate time and place to establish a pattern. Many times this is at the end of the day, but critical feedback - positive or negative - is best given right away after the event.
When medical education is structured so that feedback is provided by a series of supervisors, often from different clinical rotations, it is ineffective. It is important for learners to have an ongoing relationship with a small number of supervisors who they respect and trust.
How to Give Feedback
Feedback can come from observing the consequences of one's actions, from personal reflection, from peers, patients and teachers.
- overview
- Pendleton
- ALOBA
Overview
Feedback quick notes
- Continue to...
- Start, or do more of...
- Consider...
- Stop, or do less of...
An effective feedback conversation answers three questions (Shute, 2008):
- Where am I going (what are the goals)?
- How am I doing (what progress is being made towards the goal)?
- Where to next (what activities need to be undertaken to make better progress)?
Choose specific, observable behaviour, and focus on the 1-2 most important points. Give feedback primarily on aspects of behavour that can be changed.
Start with learner's self-assessment: "how do you think you did?"
Share information, rather than giving advice. "I've found it helpful to routinely ask about end-of-life decisions".
Relate feedback back to pre-determined objectives, and develop an action plan together to address gaps in knowledge, skill, or behaviour that have been identified.
Assess the learner's response and interpretations of feedback.
Document feedback, ideally in the learner's portfolio or educational tracking tool. Regular feedback, stemming from observation should form the basis of workplace-based assessment.
Pendleton
Pendleton’s framework for feedback: Having a framework for providing feedback is helpful. The following two frameworks are used for teaching communication skills. One common framework was developed by Pendleton and his colleagues. Prior to or at the beginning of a feedback session, teacher and learner should clarify the process: the timeframe for the discussion, the learner’s agenda, the teacher’s agenda, the roles and responsibilities of each. It is important to have a clearly established focus for the feedback conversation. It is not fair to raise concerns about an issue that had not been on the agenda unless there is mutual agreement to add it. The feedback session itself is framed by four rules or principles that should be applied flexibly depending on the circumstances:
- 1. “Briefly clarify any matters of fact (but no rhetorical questions please!)
- 2. Encourage the learner to go first
- 3. Consider what has been done well first
- 4. Make recommendations rather than state weaknesses.”
Positive feedback preserves or enhances the learner’s self-respect whereas negative feedback may damage self-respect and provoke defensiveness or resistance to change. The following is an example of positive feedback about good performance:
- “When you explained that the stomach pain could not have been caused by indigestion, you incorporated her ideas and used her own words effectively. You made a real contribution to her understanding of her health.”
Positive feedback can also be given about behaviour that needs to improve. It is better to provide recommendations rather than a list of deficiencies. Even more effective is soliciting recommendations for change from the learner.
- “Instead of explaining so much all at once, I think it would have been better to cover only the first two point you made. I think you may have needed to find out more about her ideas. You may have asked her to tell you how she thought the pain began. This would have let you go on to explore her concerns more fully.”
By contrast, here is an example of negative feedback about good behaviour. It comes across as a backhanded compliment.
- “You normally overcomplicate your explanations. This time you didn’t do that. Why can’t you always explain like this, so your patient stand a chance of remembering some of what you told them? Once you started to concentrate and got yourself organized, the consultation went quite well.”
Finally, here is an example of negative feedback about what needs to be improved. This form of feedback is humiliating and often results in anger, discouragement and deterioration of performance.
- “If I’ve told you once, I’ve told you a thousand times, don’t just tell your patients what to do – discuss the options and make a choice together. You didn’t do that here and you don’t usually. Are you sure you’re really cut out for general practice?”
ALOBA
The ALOBA (Agenda-Led Outcome-Based Analysis)i shares many similarities with the Pendleton approach but is more elaborate (Kurtz, Silverman, and Draper, 2004). It is often used with a small group of learners. The first step is to organize the feedback process:
- Start with the learner’s agenda – the problem(s) they would like help with
- Look at the outcomes the learner and patient are trying to achieve – this encourages a problem-solving approach
- Encourage self assessment and self problem solving first
- Involve the whole group in problem solving – to help the learner and also to help themselves in similar situations.
Then give feedback to each other:
- Use descriptive language to encourage a non-judgmental approach – be as specific as possible to avoid vague generalizations
- Provide balanced feedback – learning from what went well and what didn’t work so well
- Make offers and suggestions; generate alternatives rather than making prescriptive comments – they should be offered in the spirit of ideas for consideration
- Show respect and be sensitive to each other
Then consolidate the learning:
- Rehearse suggestions – all members of the group try out alternative phrasing by roleplaying
- Value the interview as a gift of raw material for the group to learn from
- Introduce theory, research evidence and wider discussion as appropriate and if time permits
- Structure and summarise learning so that a constructive end point is reached
Feedback and Emotions
Providing feedback is challenging because of the multiple needs it must satisfy – the fundamental need to protect patient safety, the need to assure that feedback is honest and accurate, and the need to protect the self-esteem of the learner. “Students’ emotions greatly influence the way in which they are able to receive and process feedback, and sometimes the value of such feedback may be ‘eclipsed by learners reactions’ to it" (Varlander, 2008).
When feedback, critical of a performance, is experienced as a judgement about the person, the remarks may be magnified with damage to self-esteem and confidence. It is more helpful to offer feedback about deficiencies as suggestions for improvement rather than as a list of weaknesses. Positive feedback tends to produce feelings of well-being and energy in students. But negative feedback arouses feelings of anxiety and depression. Students receiving negative feedback may discount it as useless, burdensome, critical or controlling (Baron, 1988).
Providing positive feedback first makes negative feedback more tolerable and believable. Involving students in discussion about the feedback makes it less threatening and more effective. Peer feedback is also less intimidating because it is reassuring to learn that others share the same difficulties. When students feel a lack of power and recognition from their teacher they may experience fear, anxiety and low self-esteem.
Mann, van der Vleuten, Eva, et al (2011) describe some of the tensions that interfere with the feedback process. For example, students may want feedback yet fear disconfirming information. They may want to be able to question others and learn from feedback, yet not want to look incompetent or share areas of deficiency. The studies of feedback highlight the importance of developing a relationship between teacher and learner that is supportive and in which they feel safe to disclose their struggles. If learners do not trust the positive intent of their teachers they are likely to discount any negative feedback their supervisor provides and will not learn from it.
The “culture of assessment” needs to change from one in which any learning need is seen as a deficiency to be criticized to one in which feedback is experienced as a gift to enhance learning. Reframing the supervisor as a coach rather than a judge might be a step in the right direction. A coach’s role is to pinpoint areas that the learner performed well and identify approaches they could use to perform even better. And then, together with the learner, develop a plan to acquire and practice the new skills.
Giving Difficult (Very Critical) Feedback
It can be hard to receive negative criticism, but is important to give it, to ensure growth of the student and the protection of those they will be caring for.
Focus on your own perspective. For example, say "I observed Mrs Jones being distressed during your conversation" vs "Your questions hurt Mrs Jones when you talked to her".
Some language is usually viewed as confrontational:
- "Why" is a potentially accusatory question, and is best avoided
- "You should" is a potentially blaming statement, and may create resistance in the learner
Feedback from the Learner's Perspective
Eliciting feedback can be effectively taught, and medical students report that learning how to ask for feedback leads to improvements in their clinical skills (Milan, Dyche, and Fletcher, 2011).
Ask your supervisor to observe you performing a particular task (e.g., examination of the knee, breaking bad news, or explaining a management plan to a patient) and ask for feedback on particular aspects of your performance. It helps if you can provide specific comments on how you thought you did to begin a dialogue about your strengths and areas to work on. At its best, feedback is a conversation with your teacher focused on trying to understand at a deep level what went well, what you did to make it go well, and what you might do to make it even better.
If the feedback is vague or general, even if it is positive, ask for suggestions on how to improve, e.g., “I’m wondering if you can help me think of ways I could have done that even better.” Or you can ask for comments about specific aspects of an interaction with a patient, e.g., “I thought the history was going well until I started asking about his relationship with his wife. At that point he started giving me one-word answers and seemed to not want to talk about it. I couldn’t think of a way to get back on track. What do you do in those situations?”
If you receive negative feedback, pause and think before responding. The initial pain of negative feedback will fade. Resist the powerful urge to explain yourself. “Well the reason that I did that was because. . .,” “That was because I . . ..” Explanations cut-off further feedback, they are interpreted as statements that you are not ready to hear more. Students with a learning orientation use feedback as a tool to help them improve; students with a performance orientation are more focused on demonstrating competence to others. Research shows that those with a learning orientation are less likely to give up and are more willing to tackle difficult or challenging tasks where success is less likely (Archer, 2010).
Indicate verbally and nonverbally that you value the feedback even if you disagree with it. Remember that teachers usually feel uncomfortable providing negative feedback and that it takes courage to tell you about their concerns. Use facial gestures and nodding of your head to acknowledge the feedback. Ask questions for understanding. Summarize and reflect what you hear to show that you are really listening. Ask for it to be repeated if you did not fully understand it.
Try to suspend judgment; work to accept the feedback as possibly correct. But don’t take negative feedback personally or blow it out of proportion and assume everything you do is bad. Use the 1% rule (assume that all of the feedback is at least partially true – at least 1%). Assume it is constructive until proven otherwise. Often others can see us better than we can see ourselves. Accept it positively (for consideration) rather than dismissively (for self protection).
Show appreciation to the person providing the feedback.
Take time after the feedback to reflect on the information and consider specific areas for improvement. Use feedback to clarify your goals and to track progress on your goals.
Resources and References
PracticalProf - Alberta Rural Physician Action Plan
Archer JC: State of the science in health professional education: effective feedback. Medical Education. 2010;44:101-108.
Baron RA: Negative effects of destructive criticism: impact on conflict, self-efficacy, and task performance. Journal of Applied Psychology. 1988;73:199-207.
Bing-You RG, Trowbridge RL: Why medical educators may be failing at feedback. JAMA. 302 (112):1330-1331.
Cantillon P, Sargeant J: Giving feedback in clinical settings. British Medical Journal. 2008;337:1292-1294.
King J: Giving feedback. British Medical Journal. 1999;318:2.
Kurtz SM, Silverman JD, Draper J: Teaching and Learning Communication Skills in Medicine. 2nd edition. Oxford: Radcliffe, 2004.
Mann K, van der Vleuten C, Eva K, et al: Tensions in informed self-assessment: how the desire for feedback and reticence to collect and use it can conflict. Academic Medicine. 2011;86(9):1120-1127.
Milan FB, Dyche L, Fletcher J: “How am I doing?” Teaching medical students to elicit feedback during their clerkships. Medical Teacher. 2011;33:904-910.
Norcini J: The power of feedback. Medical Education. 2010;44:16-17.
Norcini J, Burch V: Workplace-based assessment as an educational tool: AMEE Guide No. 31. Medical Teacher. 2007;29:855-871.
Pendleton D, Schofield T, Tate P, Havelock P: The New Consultation. Oxford: Oxford University Press, 2003.
Shute VJ: Focus on formative feedback. Review of Educational Research. 20089;78(1):153-189.
Värlander S: The role of students’ emotions in formal feedback situations. Teaching in Higher Education. 2008;13(2):145-156.
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