Reflection on feedback in clinical education
Feedback in clinical education is described as “Specific information about the comparison between a trainee’s observed performance and a standard, given with the intent to improve the trainee’s performance” (Van den Berg et al, 2006). For feedback to be of value, some observation, or assessment, is a prerequisite. Assessment and feedback can either be formative or summative.
Formative assessment has the specific purpose of improving the learner’s knowledge, skills, or behaviour whereas summative assessment’s goals is to evaluate learners learning against some standard or benchmark usually at the end of the year to allow progression.
Although giving feedback is an essential component of a lifelong career in medicine, nursing, and many other health professions, it is a skill seldom taught in university or at the workplace (Gordon, 2003, Pencheon, 1998, Vickery et al, 2005). Most of the feedback I have received in my training have not been constructive and did not improve learning or performance. Poor feedback can often be destructive and damage self-confidence (Hamid and Mahmood, 2010), so I aim to provide feedback to my trainees that is meaningful which may help them to become better learners.
In my clinical practice, medical students are attached to a hospital ward or medical team, usually for a period of four to six weeks. Receipt of accurate feedback can help to narrow the gap between actual and desired performance (Taras, 2005). I also teach, and asses junior doctors placed in the surgical department. Most of the feedback is formal, through Work Based Assessments (WBAs). It has been suggested (Reddy et al, 2005) that trainees prefer face to face feedback rather than online assessment tools since trainees consider them barrier to effective feedback. However, providing feedback has been a box ticking exercise for me. I have received and given generic feedbacks in the past, which I now realise can be confusing and completely unhelpful. The person receiving feedback remains unclear about the actual purpose of the session and usually starts exploring hidden agendas that might have triggered the feedback. After attending Advance Certificate of Clinical Education course, I have started evaluating my methods of delivering feedback and aim to use some of the techniques learned in the course.
I had some experience with the Sandwich method of delivering feedback. The feedback sandwich starts and concludes with positive feedback, and what can be considered as the more critical feedback is “sandwiched” between the positive aspects (Johnson and Philips, 2003). This model is used regularly in clinical practice. However, if this method is used continuously, it might lose its effectiveness. The person receiving feedback will only wait for the “but” in the middle of the sentence. This model is very prescriptive and does not invite the trainee to reflect on their performance and discourages two-way communication between trainee and trainer (Hamid and Mahmood, 2010). I aim to use other forms of feedback and stay away from sandwich method to encourage reflective practice in my learners.
Pendleton Rules (PR) are most commonly used methods of feedback delivery in medical practice. They help trainers give balanced feedback to trainees (Pendleton, 1984). The idea is that, when giving feedback, learners and teachers should concentrate on the positive first and then say what they thought could have been done better. These rules were brought in the time when many trainers were too destructive in their criticisms, and PRs are an attempt to correct this. It offers the learner the opportunity to reflect on their own practice and allows even critical points to be matters of agreement (Archer, 2009). Although this model provides a useful framework, there have been some criticisms of its rigid and formulaic nature (Chowdhury and Kalu, 2004) and several different models have been developed for giving feedback in a structured and positive way. It can also be difficult to think of positive things to say to trainees who are still in the early stages of the learning curve or who, worse still, have turned up to teaching sessions without having done any preparatory work. Nonetheless, I have since used PRs in my clinical practice with good engagement with my trainees. I find PRs easy to use and it also creates a base which could be used in a busy hospital environment but still provide meaning effective feedback.
Other feedback models 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. Silverman et al (1996) have described a new way of giving feedback—called agenda-led, outcomes based analysis (ALOBA). In this method you 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. You encourage problem solving and self reflection first. Feedback given in be descriptive rather than judgmental and should also be balanced and objective. Other methods include reflective feedback conversion (Sergeant et al, 2007), SETGO (Chowdhury and Kalu, 2004) and the Chicago model (Chambers et al., 2004). These models are similar to ALOBA as they focus on learners specific aims and goals.
I have been providing feedback for few years to my trainees. But after attending this course, I realised that I have been providing similar feedback as I had received in my training, which was ineffective. I am now aware of various effective model of providing feedback which I aim to use in my clinical practice. I have been using PRs in the last few weeks and have been told by my trainees that they found it least intimidating. It also allows them to reflect on the session without being defensive. So far, I have not been able to use other feedback methods, such as ALOBA, but certainly aim to add it in my delivery methods. I have also learned that timing and frequency are equally important in providing quality feedback. Feedback closer to the assessment, done in a private setting is more effective than “on the run” feedback. Self reflection is an important exercise in improving the quality of feedback, which I aim to continue.
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