How To Give Feedback
How To Give Feedback
How To Give Feedback
What is feedback?
Feedback is an essential part of education and training programmes. It helps learners to maximise their potential at different stages of training, raise their awareness of strengths and areas for improvement, and identify actions to be taken to improve performance. Feedback can be seen as informal (for example in daytoday encounters between teachers and students or trainees, between peers or between colleagues) or formal (for example as part of written or clinical assessment). However, ‘there is no sharp dividing line between assessment and teaching in the area of giving feedback on learning’ (Ramsden, 1992, p. 193). Feedback is part of the overall dialogue or interaction between teacher and learner, not a oneway communication. If we don't give feedback what is the learner gaining, or indeed, assuming? They may think that everything is OK and that there are no areas for improvement. Learners value feedback, especially when it is given by someone credible who they respect as a role model or for their knowledge, attitudes or clinical competence. Failing to give feedback sends a nonverbal communication in itself and can lead to mixed messages and false assessment by the learner of their own abilities, as well as a lack of trust in the teacher or clinician. Most clinicians already give feedback to students or trainees. This module offers some suggestions on how you can improve the feedback you give so that you are better able to help motivate and develop learners’ knowledge, skills and behaviours.
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Thinking point Are there any issues for learners in receiving feedback from the groups/individuals above?
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Emphasising that responding to the senders’ communication is vital and that feedback is fundamental to effective communication, Parsloe (1995) suggests that: ‘Communication is a twoway process that leads to appropriate action… in the context of developing 4/19
competence, it is not an exaggeration to describe feedback as “the fuel that drives improved performance”.’
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This cycle is similar to the ‘plan – do – reflect – act’ cycle which is often used in appraisals. Hill (2007) identifies that ‘feedback plays an important role in helping learners move round the cycle. For example, feedback supports the process of reflection and the consideration of new or more indepth theory. Through a process of negotiation, feedback can also help the learner plan productively for the next learning experience.’
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If we consider that one of the tasks of those giving feedback is to help the learner achieve their learning goals, then Hill (2007) suggests that we need to start with an understanding of: (a) where the learner is in terms of their learning, the level they have reached, past experience, and understanding of learning needs and goals (b) the learning goals in terms of knowledge, technical skills and attitudes. You may be observing more than one of these learning domains at the same time. During the observation, our task is to identify where and how far the learner has travelled towards the learning goals, where they may have gone off track and what further learning or practice may be required.
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Pendleton’s rules
1. Check the learner wants and is ready for feedback. 2. Let the learner give comments/background to the material that is being assessed. 3. The learner states what was done well. 4. The observer(s) state what was done well. 5. The learner states what could be improved. 6. The observer(s) state how it could be improved. 7. An action plan for improvement is made. Although this model provides a useful framework, there have been some criticisms of its rigid and formulaic nature and a number of different models have been developed for giving feedback in a structured and positive way. These include reflecting observations in a chronological fashion, replaying the events that occurred during the session back to the learner. This can be helpful for short feedback sessions, but you can become bogged down in detail during long sessions. Another model is the ‘feedback sandwich’, which starts and ends with positive feedback. When giving feedback to individuals or groups, an interactive approach is deemed to be most helpful. This helps to develop a dialogue between the learner and the person giving feedback and builds on the learners’ own selfassessment, it is collaborative and helps learners take responsibility for their own learning. A structured approach ensures that both trainees and trainers know what is expected of them during the feedback sessions. Walsh (2005) and Vassilas and Ho (2000) describe a model adapted from Kurtz et al. (1998), summarising the key points for problembased analysis in giving feedback to groups as follows. Start with the trainee’s agenda. Look at the outcomes that the interview is trying to achieve. Encourage selfassessment and selfproblem solving first. Involve the whole group in problem solving. Use descriptive feedback. Feedback should be balanced (what worked and what could be done differently). 8/19
Suggest alternatives. Rehearse suggestions through roleplay. Be supportive. The interview is a valuable tool for the whole group. Introduce concepts, principles and research evidence as opportunities arise. At the end, structure and summarise what has been learnt. Vassilas and Ho (2000) identify that medical educationalists claim that using this method for groups and individuals is more likely to motivate adults, in particular, to learn. Initially, grasping this different way of working can be more difficult for trainers than using the traditional didactic approach, but research into using this method supports its effectiveness in clinical settings. The widely used CalgaryCambridge approach to communication skills teaching (Silverman et al., 1996) is referred to by Walsh (2005) in his summary of ‘agendaled, outcomesbased analysis’: ‘Teachers start with the learners’ agenda and ask them what problems they experienced and what help they would like. Then you look at the outcomes that they are trying to achieve. Next you encourage them to solve the problems and then you get the trainer and eventually the whole group involved. Feedback should be descriptive rather than judgmental and should also be balanced and objective.’ See also the Teachers’ toolbox for a summary of Giving and receiving feedback.
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Concious incompetence Low level of competence. Aware of failings but not having full skills to correct them
Conscious competence Demonstrates competence but skills not fully internalised or integrated. Has to think about activities
Unconscious competence Carries out tasks with conscious thought. Skills internalised and routine. Little or no conscious awareness of detailed processes involved in activities Raises awareness of detail and unpacks processes for more advanced learning, notes any areas of weakness/bad habit
Feedback giver
Helps learner to recognise weaknesses, identify areas for development and become conscious of incompetence
Helps learner to develop and refine skills, reinforces good practice and competence, demonstrates skills
Helps learner to develop and refine skills, reinforces good practice and competence through positive regular feedback
Hesketh and Laidlaw (2003) note that providing informal onthejob feedback can take only a few minutes of the clinician’s time. To be the most effective, feedback should take place at the time of the 11/19
activity or as soon as possible after so that the learner (and teacher) can remember the events accurately. The feedback should be positive and specific, focusing on the trainee’s strengths and helping to reinforce desirable behaviour: ‘You maintained eye contact with Mrs X during the consultation, I feel this helped to reassure her…’. Negative feedback should also be specific and nonjudgemental, possibly offering a suggestion: ‘Have you thought of approaching the patient in such a way…’. Focus on some of the positive aspects before the areas for improvement: ‘You picked up most of the key points in the history, including X and Y, but you did not ask about Z…’. Avoid giving negative feedback in front of other people, especially patients. Keep the dialogue moving with openended questions: ‘How do you think that went?’, which can be followed up with more probing questions. Hesketh and Laidlaw (2003) also suggest that learners should be encouraged to ‘seek feedback themselves from others… feedback actually works best when it is sought’.
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After the session, you should: complete any outstanding documentation and ensure the learner has copies carry out any agreed followup activities or actions make sure that opportunities for remedial work or additional learning are arranged set a date for the next feedback session, if required.
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Receiving feedback
Sometimes feedback is not received positively by learners, and fear of this can inhibit teachers giving regular facetoface feedback. People’s responses to criticism, however constructively it is framed, can vary. Learners often discount their ability to take responsibility for their learning, and their responses may present in negative ways, including anger, denial, blaming or rationalisation (King, 1999). When giving feedback, it is helpful to maintain an empathic yet consistent approach with a view to helping the learner take responsibility for development and improvement. The focus in this module has mainly been about giving effective feedback to learners, but it is also helpful to think in a structured way about how feedback might be received. You can help to prepare learners (and yourself) for receiving feedback by providing opportunities for them to practise the guidelines listed below. The aim of developing an open dialogue between the person giving feedback and the recipient is so that both parties are relaxed and able to focus on actively listening, engaging with the learning points and messages, and developing these into action points for future development.
Congratulations
You have now reached the end of the module. Provided you have entered something into your log you can now print your certificate. To generate your certificate please go to ‘my area’ and click on ‘complete’ in the course status column. Please note, you will not be able to print your certificate unless you have entered something in your ‘reflections area’. Please now take a moment to evaluate the course and enter your comments below.
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Further Information
This module was written by Judy Mckimm, Visiting Professor of Healthcare Education and Leadership, Bedfordshire & Hertfordshire Postgraduate Medical School. The module relates to areas 1, 2, 3, 4 and 5 of the Professional Development Framework for Supervisors in the London Deanery.
Teachers’ toolkit
Download guidelines for giving and receiving feedback in pdf format.
References
Department of Health. Modernising Medical Careers (MMC) website www.mmc.nhs.uk (accessed 24 July 2007). Gordon J (2003) BMJ ABC of Learning and Teaching in Medicine: one to one teaching and feedback. British Medical Journal. 326: 543–5 (accessed 23 July 2007). Hill F (2007) Feedback to enhance student learning: Facilitating interactive feedback on clinical skills. International Journal of Clinical Skills. 1: 21–4. Hesketh EA and Laidlaw JM (2002) Developing the teaching instinct: feedback. Medical Teacher. 24: 245–8. King J (1999) Giving feedback. British Medical Journal. 318: 2. Kolb DA (1984) Experiential Learning: experience as the source of learning and development. Prentice Hall, EnglewoodCliffs, NJ. Kurtz S, Silverman J and Draper J (1998) Teaching and Learning Communication Skills in Medicine. Radcliffe Medical Press, Oxford. Pendleton D, Scofield T, Tate P and Havelock P (1984) The Consultation: an approach to learning and teaching. Oxford University Press, Oxford. Proctor B (2001) Training for supervision attitude, skills and intention. In: Cutcliffe J, Butterworth T and Proctor B (eds) Fundamental Themes in Clinical Supervision. Routledge, London. Ramsden P (1992) Learning to Teach in Higher Education. Routledge, London. Silverman JD, Kurtz SM and Draper J (1996) The CalgaryCambridge approach to communication skills teaching. Agendaled, outcomebased analysis of the consultation. Journal of Education in General Practice. 7: 288–99.
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Spencer J (2003) BMJ ABC of Learning and Teaching in Medicine: learning and teaching in the clinical environment. British Medical Journal. 326; 591–4 (accessed 23 July 2007). Vassilas C and Ho L (2000) Video for teaching purposes. Advances in Psychiatric Treatment. 6: 304–11. The Royal College of Psychiatrists (accessed 23 July 2007) Walsh K (2005) The rules. British Medical Journal. 331: 574 (accessed 22 July 2007).
Further reading
ASME Understanding Medical Education Guides: Boursicot KAM, Roberts,TE and Burdick WP (2007) Structured Assessments of Clinical Competence. Association for the Study of Medical Education, Edinburgh. Launer J (2006) Supervision, Mentoring and Coaching: onetoone learning encounters in medical education. Association for the Study of Medical Education, Edinburgh. Norcini JJ (2007) Workplacebased Assessment in Clinical Training. Association for the Study of Medical Education, Edinburgh. Pitts J (2007) Portfolios, Personal Development and Reflective Practice. Association for the Study of Medical Education, Edinburgh. Schuwirth LWT and van der Vleuten CPM (2006) How to Design a Useful Test: the principles of assessment. Association for the Study of Medical Education, Edinburgh. Wood D (2006) Formative Assessment. Association for the Study of Medical Education, Edinburgh. BMJ ABC of Learning and Teaching in Medicine: learning and teaching in the clinical environment, at www.bmj.com
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Course Glossary
Aim An aim in educational terms, is a brief statement of intent, indicating the scope and range of intended learning outcomes that the educational episode has been structured to address. Appraisal A positive and ongoing process to provide feedback on performance, review progress and plan action. The appraisal interview or discussion is a key part of the process where strengths and areas for improvement are summarized and agreed and a formal development plan is made. Assessment Assessment is the term used to indicate an appraisal of students' performance. Typical formal assessments in medicine include written examinations, Multiple choice questionnaires (MCQ), observations of clinical or communication skills, Objective Structured Clinical Examinations (OSCEs) and MultiSource Feedback (MSF). Assessments may be summative (where the marks gained contribute to a formal grade or award) or formative (where the focus is on providing feedback for ongoing development). Class Class refers to hierarchical differences between individuals or groups in societies or cultures . Factors that determine class may vary widely from one society to another. However, economic disadvantage and barriers to access servces are major issues within class discrimination. Learning Outcomes Learning outcomes are similar to learning objectives in that they specify the intended outcomes of the programme of study. These should be stated in clear and specific terms and should be developed along with a specification of the learning experiences that will allow the outcomes to be achieved. Learning outcomes Learning outcomes are similar to learning objectives in that they specify the intended outcomes of the programme of study. These should be stated in clear and specific terms and should be developed along with a specification of the learning experiences that will allow the outcomes to be achieved. Supervision Usually a formal onetoone relationship, focussed around professional conversations to help the supervisee develop reflective professional practice, learning and skills with the aim of improving patient care.
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Learning Activities
Select one or more of the activities below to focus your attention on developing your feedback skills and putting into practice some of the learning from the module.
3 Multisource feedback
Find out what training opportunities have been (or could be) put in place for trainees and those giving feedback in your trust.
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