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Tools & Strategies for Providing Effective Feedback

Facilitators: Kristin Vaga, Eric Tseng, Ian Porter

Conflicts of Interest

— The presenters have no conflicts of interest to

declare.

Mitigating Potential Bias

— Discussion of any issues is encouraged during this

workshop.

Agenda

Time Activities 8:00 – 8:30 Introductions 8:30 – 8:40 Pre-Test 8:40 – 9:00 Presentation: The Importance of Feedback 9:00 – 9:30 Activity # 1: Effective & Non- effective Feedback 9:30 – 10:00 Break 10:00 – 10:20 Presentation: Tools, Strategies & Frameworks 10:20 – 11:00 Activity # 2: Practice Giving & Receiving Feedback 11:00 – 11:20 Activity # 3: Case Studies 11:20 – 11:30 Post Test & Wrap-Up

Facilitators

Ian Porter Eric Tseng

Facilitators

— Kristin Vaga

Assessment

— Course Evaluation — FEEDBACK

— Assessment FOR

Learning

— Assessment OF

Learning

— OSCE — Mini-Cex — MCQ — Validity — Reliability — Formative — Summative — Self Assessment — Portfolio

“Lets Do Feedback”

• Ian, Eric & Kristin

FOCUS

Feedback

— “An essential element of the educational process…

enables learners to achieve program goals by reinforcing good performance and providing the basis for remediation when needed.”

— “Feedback is often very general and not helpful to

• students. Even when faculty think they have given

detailed feedback, students often consider the process to be inadequate.”

Brukner, H. (1999). Giving effective feedback to medical students: A workshop for faculty and house staff. Medical Teacher, 21(2), 161-165. Ramani, S., & Krackov, S. K. (2012). Twelve tips for giving feedback effectively in the clinical environment. Medical Teacher, 34(10), 787-791.

Feedback

— “Giving effective feedback is a skill that can be

learned through practice”.

Brukner, H. (1999). Giving effective feedback to medical students: A workshop for faculty and house staff. Medical Teacher, 21(2), 161-165.

Goal

— To improve the learner’s ability to give effective

feedback in a clinical setting

Objectives

— Knowledge: List 5 characteristics of effective

feedback

— Skill: Distinguish between cases involving effective

and non-effective feedback techniques

— Attitude: Recognize the importance of providing

effective feedback

2 Truths & A Lie

— Think of two truths and a lie about yourself to

share with the class (1 sentence or less)

— Write your name at the top of the paper followed by

— 1 — 2 — 3

— Beside each # write 1 word that describes each

sentence.

Learner Profiles (What We Learned)

Instructional Setting?

• Clinic
• Small Group
• Lecture
• Ward / Bedside

Types of Learners?

• Medical trainees
• Health professions
• Colleagues

Comfort Providing Feedback?

• Not at all à

somewhat comfortable Prior instruction in Providing Feedback?

• Yes
• No

Pre-Test

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The Importance of Providing Effective Feedback

What is "Feedback"?

— "Feedback"

— Ende (1983): "information that a system uses to make

adjustments in reaching a goal"

— Swanwick (2014): "a way in which learners become

aware of the gap between their current level of knowledge or skill and the desired goal"

— Critical component of formative assessment

— Ende (1983): "Feedback provides information, not

judgment"

What is "effective feedback"?

— "Effective Feedback"

— Archer (2013): "Feedback in which information about

previous performance is used to promote positive and desirable development" — Swanwick (2014): "Effective feedback is achieved only when the student takes action to narrow the gap... [the students] are empowered to take the necessary action to achieve"

Effective feedback is a collaboration

Learners Teachers — Tensions of providing feedback (Archer):

— Acknowledging psychosocial needs of recipient — Ensuring feedback is honest and accurate

Why do we need to provide effective feedback?

• 1. Increasing the insight of learners into their own

skills, capabilities, and areas for improvement

• 2. Facilitating the achievement of physician

competencies and improvement

• 3. Accommodating the recipient emotional response

to feedback

• 1. Increasing learner self-

awareness

— Self-assessment by

learners is poor in the absence of external input

— Feedback can reinforce

good performance while prompting remedial action when necessary

— A culture of regular

feedback encourages awareness of performance, guides future actions (Krackov & Pohl 2011)

• 2. Facilitating achievement

and improvement

— Feedback empowers

learner to self-regulate his own learning (Nicol & MarFarlane 2006)

— Pairing detailed,

specific feedback with

• pportunities to

improve (Ramani 2012): achieving milestones

— Helps learners gauge

their own progress

• 3. Watching the emotional

response to feedback

— Disconfirming feedback

can "threaten self- perceptions" (Sargeant 2011)

— Defensiveness can prevent

incorporation of helpful feedback

— Anxiety from faculty about

causing emotional distress, especially when not formally trained (Brukner 1999)

Barriers

— Purpose of feedback unclear — Setting an appropriate time or place — Lack of training

— How to observe — How to give constructive feedback

— Expectation of one-way communication

Ramani (2012) Med Teach

Summary: Importance of Effective Feedback

— Effective feedback provides learners with knowledge

about own performance to drive improvement

— Provision of effective feedback enables:

— Improved self-insight of learners — Achievement of competencies — Respect for emotional response of the learner

Activity #1

— Effective vs. Non-Effective

Feedback Characteristics

Effective Feedback

— “Think Pair Share” — Reflect on personal experience receiving feedback — Should be an actual event/teacher — Identify 2 characteristics — Share with a partner

Non-Effective Feedback

— Repeat same activity focusing on a negative

feedback experience.

— Identify 1 characteristic.

Share

— Partners share effective & non-effective

characteristics!

Tools, Strategies & Frameworks

• 1. Specific features of effective feedback
• 2. Practical models for providing effective feedback

— Pendleton’s rules — One-minute preceptor — The Chicago model — ECO model

Constructive feedback

— Importance of constructive feedback — Balance between comments on strengths, and

comments on areas to improve

— Ideally both High Support and High Challenge

High challenge High support Low challenge Low support Adapted from: Mohanna et al (2011)

Constructive feedback

High support Low challenge High challenge Low support Adapted from: Mohanna et al (2011)

Safe, general, potentially patronizing Focused, attentive, potentially threatening In passing, nothing specific, dismissive Critical - induces defensiveness, potentially paralyzing

Effective Feedback Strategies

— Positive learning environment — Clear goals and objectives — Timely — Learner self-assessment — Based on direct observation — Focus on specific behaviours — Action plan

Effective Feedback Strategies

— Two-way: teachers and

learners as partners, working together

— Common goals — Trust and respect — Private environment,

gentle, supportive, caring Positive learning environment

Effective Feedback Strategies

— Clear objectives and

expectations for the learning activity Clear goals and objectives

Effective Feedback - Strategies

— Opportunity for learner to work on improvement

immediately

— Teacher and learner are able to remember the

learning event and specific behaviours Timely

Effective Feedback Strategies

— Start feedback with self-assessment — Learner may raise topics that teacher was planning

to discuss — Initiates dialogue — Feedback may be more acceptable to learner

— Learner may be more critical of themselves — Controversial? - self-assessment possibly flawed

Learner self-assessment

Effective Feedback – Strategies

— Direct observation from

the teacher providing the feedback, rather than from second-hand information — Feedback more

acceptable to learner

— Be wary of subjective

comments — Identify them as such if

they are used

Based on direct observation

Effective Feedback Strategies

— Reinforce positive behaviours, correct behaviours

needing improvement

— Specific examples

— NOT vague generalizations

— Behaviors, actions, and decisions

— NOT personality — NOT inferring intention, NOT interpreting thought process — NON-judgmental

Focus on Specific Behaviors

Effective Feedback Strategies

— Plan to result in improvement — Learner generated, modified by teacher — Time for next follow-up

Action Plan

Practical models/ frameworks

Pendleton’s Rules

1)

Learner performs activity

2)

Questions to clarify fact only

3)

Learner says what they thought was done well

4)

Teacher says what they thought was done well

5)

Learner says what could be improved

6)

Teacher says what could be improved and discussion about how to improve Strengths? Weaknesses?

Practical models/ frameworks

One-Minute Preceptor (“Microskills”)

• 1. Obtain a commitment
• 2. Probe for evidence
• 3. Teach general rules
• 4. Reinforce what was done well (specific behaviours)
• 5. Correct mistakes (specific behaviors, learner self-

assessment)

Practical models/ frameworks

The Chicago Model (Brukner 1999)

• 1. Review goals and objectives
• 2. Give positive feedback
• 3. Ask for learner self-assessment
• 4. Give behaviour-focused feedback
• 5. Give specific examples to support feedback
• 6. Suggest specific strategies for improvement

Practical models/ frameworks

ECO Model (Emotion, Content, Outcomes)

• 1. Explore Emotional reaction to feedback
• 2. Clarify Content of feedback
• 3. Develop Outcomes plan to improve performance

— Goal: to engage learner

— Allowed learner to reflect on their emotions

— Teacher as feedback facilitator rather than provider — Beneficial if feedback unexpected to learner (positive or

negative)

Sargeant et al. (2011)

Summary: Tools, Strategies, & Frameworks

Effective Feedback

— Positive learning

environment

— Clear goals and objectives — Timely — Learner self-assessment — Based on direct observation — Focus on specific behaviors — Action plan

Practical Models

— Pendleton’s rules — One-minute preceptor — The Chicago model — ECO model

Activity #2

— Practicing Giving & Receiving

Feedback

Activity #2: Task

— Break into groups of 3 — Each group member select a role (learner, teacher,

• bserver) and the corresponding handout.

— Examine handouts independently — Clarify concerns/questions with facilitator

Roles

— Learner — Teacher — Observer

Scenario: Task

— Learner takes part in scenario while teacher and

• bserver watch

Feedback: Task

— Teachers provide feedback to learners (using

handout as a guide)

— Observers provide feedback to teachers (using

handout as a guide)

Debrief

— Break up into groups based on roles — Debrief (using handout as a guide)

Debrief

— Learners — What was the most effective aspect of the teacher’s

feedback?

— Were there any components that you had difficulty

understanding?

— What did you learn?

Debrief

— Teachers — What was the most difficult part about giving

feedback?

— Were you more comfortable giving or receiving

feedback?

— After receiving your feedback, how well do you think

you did?

Debrief

— Observers — Were there any barriers to you giving feedback? — What question about feedback would you like to ask

the group?

Activity #3:

— Case Studies

Activity #3: Task

— Break into groups of 3 — Read through each case study and highlight

— Effective Characteristics in YELLOW — Non-effective characteristics in BLUE — Barriers in PINK DEBRIEF

— Discuss one case study with the class

Post Test

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Objectives (revisited)

— Knowledge: List 5 characteristics of effective

feedback

— Skill: Distinguish between cases involving effective

and non-effective feedback techniques

— Attitude: Recognize the importance of providing

effective feedback

Wrap Up

— Effective Feedback

— Increases insight — Facilitates achievement — Accommodates emotional response

Wrap Up

— Effective Feedback:

— Lack of clarity — Lack of time & location — Lack of training — Lack of two way communication

Barriers

Wrap Up

— Effective Feedback:

— Positive Learning

Environment

— Clear Goals &

Objectives

— Timely — Involves Learner Self

Assessment

Characteristics

— Based on Direct

Observation

— Focuses on Specific

Behaviors

— Involves an Action

Plan

Wrap Up

— Effective Feedback:

— Pendleton’s Rules — The One Minute Preceptor — The Chicago Model — The ECO Model

Frameworks

References

1.

Archer, J.C. (2010). State of the science in health professional education: effective feedback. Medical Education, 44, 101-108.

2.

Brukner, H. (1999). Giving effective feedback to medical students: a workshop for faculty and house staff. Medical Teacher, 21(2), 161-165.

3.

Ende, J. (1983). Feedback in clinical medical education. JAMA, 250(6), 777-781.

4.

Eppich, W., Cheng, A. (2015). Promoting Excellence and Reflective Learning in Simulation (PEARLS): development and rationale for a blended approach to health care simulation debriefing. Sim Healthcare (00)0, 1-10.

5.

Krackov SK, Pohl H. 2011. Building expertise using the deliberate-practice curriculum-planning model. Medical Teacher, 33(7):570–575.

6.

Mohanna, K., Cottrell, E., Wall, D., and Chambers, R. (2011). Teaching made easy: a manual for health professionals (3rd ed). Abingdon, UK: Radcliffe Publishing.

7.

Neher, J.O., Gordon, K.C., Meyer, B., and Stevens, N. (1992). A five-step "microskills" model of clinical teaching. J Am Board Fam Pract, 5, 419-424.

8.

Nicol, D.J., and Macfarlane-Dick, D. (2006). Formative assessment and self-regulated learning: a model and seven principles of good feedback practice. Studies in Higher Education, 31(2), 199-218.

9.

Ramani, S., and Krakov, S.K. (2012). Twelve tips for giving feedback effectively in the clinical environment. Medical Teacher, 34(10), 787-791.

10.

Ramani, S., & Leinster, S. (2008). AMEE guide no. 34: Teaching in the clinical environment. Medical Teacher, 30(4), 347-364.

11.

Sargeant, J., et al (2011). Providing feedback: Exploring a model (emotion, content, outcomes) for facilitating multisource feedback. Medical Teacher, 33(9), 744-749.

12.

Wood, D. (2014). Formative assessment. In: T . Swanwick (Eds.),Understanding medical education: Evidence, theory, and practice (2nd ed., pp. 317-328). Oxford: John Wiley & Sons, Ltd.