Twelve Tips For Giving Feedback Effectively in The Clinical Environment
Twelve Tips For Giving Feedback Effectively in The Clinical Environment
Twelve Tips For Giving Feedback Effectively in The Clinical Environment
To cite this article: Subha Ramani & Sharon K. Krackov (2012) Twelve tips for giving
feedback effectively in the clinical environment, Medical Teacher, 34:10, 787-791, DOI:
10.3109/0142159X.2012.684916
Download by: [Oregon Health & Science University] Date: 23 September 2016, At: 17:33
2012; 34: 787–791
TWELVE TIPS
Abstract
Background: Feedback is an essential element of the educational process for clinical trainees. Performance-based feedback
enables good habits to be reinforced and faulty ones to be corrected. Despite its importance, most trainees feel that they do not
receive adequate feedback and if they do, the process is not effective.
Aims and methods: The authors reviewed the literature on feedback and present the following 12 tips for clinical teachers to
provide effective feedback to undergraduate and graduate medical trainees. In most of the tips, the focus is the individual teacher
in clinical settings, although some of the suggestions are best adopted at the institutional level.
Results: Clinical educators will find the tips practical and easy to implement in their day-to-day interactions with learners. The
techniques can be applied in settings whether the time for feedback is 5 minutes or 30 minutes.
Conclusions: Clinical teachers can improve their skills for giving feedback to learners by using the straightforward and practical
tools described in the subsequent sections. Institutions should emphasise the importance of feedback to their clinical educators,
provide staff development and implement a mechanism by which the quantity and quality of feedback is monitored.
Correspondence: S. Ramani, Division of General Internal Medicine and Primary Care, Harvard Medical School, 1180 Beacon Street, Suite 1A-B,
Brookline, MA 02446, USA. Tel: 1-617-278-1700; fax: 1-617-232-2196; e-mail: sramani@partners.org
ISSN 0142–159X print/ISSN 1466–187X online/12/100787–5 ß 2012 Informa UK Ltd. 787
DOI: 10.3109/0142159X.2012.684916
S. Ramani & S. K. Krackov
Barriers to effective feedback environment, the goals and objectives of the learning expe-
rience and the expectations for what the learner is expected to
Hesketh and Laidlaw (2002) state that there are several barriers
achieve during the experience.
that prevent effective feedback from taking place. The purpose
The teacher should inform the learner in advance about the
of feedback may not be clear to the teacher or learner. There
feedback session, schedule the meeting at a mutually conve-
may be no appropriate time or place for a feedback session.
nient time and private location and get agreement on the
The teacher may have minimal or no formal training in giving
session goals, agenda and expected outcomes (Hewson &
effective feedback, may lack confidence about his/her obser-
Little 1998). This preliminary orientation and discussion of
vations, or may not know how to translate observations into
responsibilities and goals sets the stage, makes the learner
specific, nonjudgemental and constructive feedback (Brukner
more comfortable and responsible and engages the learner as
et al. 1999; Cantillon & Sargeant 2008). Consequently, feed-
a moving force for learning (Wood 2000).
back may be very general and not helpful to a learner seeking
to improve performance (Brukner et al. 1999). The hierarchical
culture of medicine promotes a one-way flow of information
from teacher to learner instead of a two-way conversation
Tip 3
(Krackov 2011). As a result, the learner may view feedback as
a negative experience in which performance will be criticised.
Base feedback on direct observation
A major responsibility of faculty is to ensure that trainees are
competent to move on to the next level and ultimately to
Objectives
independent practice as a physician (Hauer et al. 2011).
In this article, we provide 12 key strategies that will help Trainees in medicine learn key clinical skills such as history-
clinical teachers give effective feedback to learners, increase taking, physical examination, communication and patient
acceptance of feedback and enable the improvement of counselling skills through patient care and in simulated
performance based on the feedback. experiences. As the learner progresses from a novice to a
competent practitioner and beyond, more experienced physi-
cians should observe the performance and note important
Tip 1 areas of success or remediation. This direct observation forms
the basis for the feedback session.
Establish a respectful learning environment Feedback on behaviours based on direct observation by the
A positive learning climate is essential in order for feedback to teacher has been reported to be more acceptable and
be maximally effective (Hewson & Little 1998). The learning instructive to trainees than feedback based on second-hand
climate should promote the concept that the teacher and reporting (Ende 1983; Van Hell et al. 2009). When Bing-You
learner are working together to help the learner achieve the et al. (1997) surveyed medicine residents, they found that
expected outcomes, with an expectation that teachers will trainees tended to discount feedback if they did not believe
observe performance and give feedback regularly in an that the statements arose out of first-hand observation.
atmosphere of mutual trust and respect. Teachers and learners
should be partners in the process of feedback. A feedback
session should be viewed as a two-way conversation in which Tip 4
the learner plays an important role in assessing his/her own
performance (Krackov 2011). The teacher should be genuinely Make feedback timely and a regular occurrence
receptive to feedback from trainees. An important purpose of feedback is formative, to enable the
When medical residents were surveyed, they stated that learner to make needed changes before the end of the course/
trust and respect for the teacher are factors that would make rotation. If a behaviour needs correction, the teacher should
them more receptive to feedback (Bing-You et al. 1997; provide feedback as soon as possible after the encounter so
Hesketh & Laidlaw 2002). Feedback that was termed effective the learner has sufficient time to act. If feedback is not given
was given in a private setting and featured a considerate tone until the very end of the experience, the learner will not have
and good interpersonal skills on the part of the teacher (Bing- an opportunity to remediate the behaviour during the course/
You et al. 1997). Learners also found it helpful if feedback was rotation.
even-handed (addressed both strengths and mistakes) and was Formative feedback can take place in several ways. A brief,
given gently, supportively, caringly and with concern for their informal formative feedback session takes place immediately
situation (Hewson & Little 1998). or as soon as possible after the observation of a behaviour,
when both teacher and learner recall the events accurately and
the learner can make adjustments in performance before the
Tip 2 final evaluation (Perera et al. 2008). This session can be related
to correcting a specific skill, for example, cardiac auscultation
Communicate goals and objectives for feedback
technique (Branch & Paranjape 2002). A longer formative
Wood (2000) stated that the teachers and learners should work feedback session should be scheduled at the mid-point of the
together to create a learning model in which feedback will be course/rotation. This meeting can address a range of skills and
effective. The first step is to orient the learner to the work behaviours, but still have the purpose of enabling mid-course
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Feedback in clinical environment
as necessary. Inviting the learner to generate a plan for feedback from learners, peers and their superiors on their
improvement as opposed to the teacher giving him/her a list of performance as teachers. The institution should develop a
items to accomplish will help develop the trainee’s skills of process for monitoring the feedback process in individual
reflection, summarise the meeting by repeating the learner’s courses/rotations. Videotaping feedback sessions and/or peer
areas of strength and the agreed-upon plan to address observation with debriefing can be very useful techniques that
deficiencies. Then, set a time for a follow-up meeting where should be implemented at an institutional level. Trainees
you can review progress and continue to work together to should be oriented to the expectations of regular feedback at
achieve the desired outcomes. the institution and strongly encouraged to be proactive in
asking for feedback (Milan et al. 2011).
The institution can promote the importance of feedback by
Tip 10 organising a variety of staff development opportunities for
teachers as described earlier and by supporting faculty’s
Reflect on your feedback skills attendance at sessions offered at other institutions and
Reflection by the teacher should follow every feedback session educational conferences.
After the session ends, the teacher should reflect on what went
well, what to change the next time and what new strategies
he/she will adapt for future sessions (Krackov 2009). It is also
Conclusion
useful to discuss challenges and acquire new tricks from peers Even the most experienced teachers find it challenging to
and senior educators. provide feedback to learners. Frequently, there is a mismatch
Despite the best preparation and use of recommended between teachers’ and learners’ perceptions of the adequacy
strategies, all feedback sessions do not go perfectly. The and effectiveness of feedback. Staff development is key in
learner may be defensive and may not accept corrective increasing teachers’ comfort and skills in this area. Moreover,
feedback (Ende 1983; Krackov 2009). He/she may try to assign the institution should make the soliciting and giving of
blame elsewhere to account for the performance. Even feedback an expectation of teachers and learners alike. The
successful feedback sessions will benefit from the process of tips described in this article will provide clinical teachers with a
reflection to help assure that future meetings also turn out well. framework of strategies to provide brief, or more detailed
Making reflection a part of every feedback encounter will formative and summative feedback to learners.
improve the teacher’s skills at giving feedback.
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