giving effective feedback: a teacher’s toolkit

INTAPTAPRIL 8, 2011

GIVING EFFECTIVE FEEDBACK: A TEACHER’S TOOLKIT

FACILITATORS

• Glenda Bendiak• Annie Cloutier• Kathleen Doukas• Paula Shing• Donna Spaner

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FORMING, STORMING, NORMING, PERFORMING!

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HOW DID I GET HERE?

How did YOU come to be here, on this day, in this workshop,

as this person?

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RESULTS OF NEEDS ASSESSMENT

• Short needs assessment conducted October 24, 2010 after workshop outline presentation

• Purpose: guide our group in developing a workshop that met needs of other learners

• 7 people completed needs assessment• Response rate = 70%

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•Question 1. How important is feedback in teaching situations?

• All respondents indicated feedback was either important or very important

• Question 2. How comfortable are you giving feedback to learners?

• All respondents were either very uncomfortable or somewhat uncomfortable giving feedback

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• Question 3 – “What would you like to learn about giving feedback?” How to give negative feedback/difficult learners(3) Strategies for providing constructive feedback(1) How to give meaningful, concise and useful

feedback(3)

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• Question 4 -“What are the biggest barriers you face in giving feedback?” The problem learner/resistant learner(4) Lack of time(2) Concern about upsetting the learner(1)

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LEARNING OBJECTIVES

•To describe qualities of effective feedback•To appreciate common barriers to giving feedback and giving feedback in difficult situations•To incorporate a feedback model in the form of a toolkit framework with concise and meaningful take home messages•To develop an increased comfort level with giving feedback•To demonstrate increased ability to integrate newly used feedback skills through role play

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THE TOOLKIT

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What is Feedback?

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FEEDBACK: THE NEED FOR A DEFINITION

• Although feedback is viewed as important, there is little consensus on its definition

• The agreement on the meaning of feedback between the instructor and student is not always evident

• Instructors frequently believe they are giving feedback, whereas trainees report feedback is rare

• Research on effective feedback cannot be performed without a clear operational definition of feedback

Van de Ridder JMM, Stokking KM, McGaghie WC, ten Cate OTJ. What is feedback in clinical education? Med.Educ. 2008 February;42(2):189-

197

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PROPOSED DEFINITION

• Feedback is:

• “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 de Ridder et al

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Why do you think feedback is important?

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FEEDBACK – WHY IS IT IMPORTANT?

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FEEDBACK: WHY IS IT IMPORTANT?

• Helps learner achieve their learning goals• enforces engagement with learner’s training

• Without feedback, mistakes can go uncorrected and bad habits can develop• the learner may also drop positive behaviours or make

inaccurate assumptions

Piccinin, Crisiti & McCoy, 1999

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FEEDBACK: WHY IS IT IMPORTANT?

• Needed for the development of competency and expertise

• Clinical reasoning• Critical thinking• Judgment

• Facilitates learning process and teaching performance

• Improves teaching skills• University teachers receiving feedback aimed at improving

teaching showed improvement immediately post consultation and this continued to be observable 3 y later

Piccinin, Crisiti & McCoy, 1999 Côté et Bélanger, 2006

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THE EVIDENCE FOR FEEDBACK

• 1912 – Thorndike’s study• providing simple feedback about line length allowed

students to draw lines of specified length faster vs. those who received no feedback

• OSCE (1992)• Students who performed OSCE with 2min of feedback

significantly improved performance on identical stations vs. controls

• Improvement is maintained up to 3 mo later

Shannon & Norman, 1995

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THE EVIDENCE FOR FEEDBACK

• Feedback in medical interviewing skills (1986)• Improved interviewing performance immediately and 5y later vs

controls

• Feedback delivered in the sandwich manner (positive-negative-positive) is rated most desirable, acceptable and accurate by students

• Feedback from a group leader or preceptor is valued more than feedback from peers or patients

• Feedback including objective evidence of performance may be more effective than specific comments from an observer

Shannon & Norman, 1995

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Setting the Tone

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HOW TO PREPARE TO GIVE FEEDBACK: SETTING THE TONE

• Create a positive relationship, a climate of trust and safety (non-threatening)

• Choose appropriate physical location/ environment as able

• Collect descriptive data while observing actual performance (write it down!)• You should target specific performance and changeable

behaviours

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QUESTIONS TO ASK YOURSELF…

• What was performed well and what could be performed differently?

• What specific behaviours do I want to comment on?

• Can this behaviour be modified and if so, what behaviour would I like to see in its place?

• What is the priority for improvement?

• How can I express respect and support for the learner as I provide feedback?

• Is it the right time and place?

Dent & Harden, 2009 Mckinley, Williams & Stephenson, 2010

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• “Students will forget what you said and they will forget what you did BUT they will never forget how you made them feel”.

Piccinin, 2003

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WATCH, CONSIDER, DISCUSS!

What do you think of the feedback given in the following

video clips?

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Principles & Qualities of Effective Feedback

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PRINCIPLES & QUALITIES OF EFFECTIVE FEEDBACK

• Feedback is effective if it:

• promotes learning • increases motivation • enhances self esteem • leads to deepening of relationship between the

giver and receiver

Piccinin, 2003

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•Solicited• a person requesting feedback is more likely to accept

feedback and respond to it

•Attentive, caring and respectful in delivery• more fruitful to emphasize positive consequence of their

amended performance than to use threats

•Collaborative• reduces power distance in the relationship, more

egalitarian, less threatening, more encouraging

Côté et Bélanger, 2006

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• Well-timed• as soon as possible after the event keeping it concrete and relatively free of distortion from lapse of time

• Expected

• Clear and Direct / Specific• focus specifically on behaviour, not general performance• give feedback on decisions and actions, not on an interpretation of the student’s motive or personality traits

• Rounded or balanced• giving positive and negative• Use descriptive terms

• Provides direction for improvement


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• When feedback is subjective, label it as such• Using“I” statements expresses feedback in terms of personal

opinions, feelings and your assessment of the situation• Using evaluative statements beginning with“you” tends to

sound accusatory

• Make Eye contact

• Control emotions, try to keep cool

• Try not to overload the learner, be selective and limit to 1 or 2 items only• Too much constructive or negative feedback can demoralize

the learner


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• Encourage reflection; ask for self-assessment• this can create insight into their behaviour, move the

discussion to a more complex level and form a basis for improvement

• Label clearly as feedback

• Check for understanding• Ask for a summary of what the student has retained

• Propose pedagogic follow-up


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SUMMARY: EFFECTIVE FEEDBACK

•Relevant•Factual and Descriptive•Timely, Frequent and Expected•Specific and Focused on behaviour/performance

• Target an alterable behaviour; must be able to “prove”•Helpful with direction for improvement•Balanced•Collaborative

Dent & Harden, 2009

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Types of Feedback

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TYPES OF FEEDBACK

• Verbal

• Non-verbal• we continuously send and receive non verbal messages• via tone of voice, raised eyebrow, smile, frown, hand

gesture or body movement simultaneously

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TYPES OF FEEDBACK

• Formative Feedback

• Interactive activity between teacher and learner

• Purpose is to improve or modify the learner’s knowledge, skills or attitudes

• useful in promoting learning

• should be provided on a frequent basis to a learner for most effect

Bienstock, Katz, Cox et. al., 2007

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TYPES OF FEEDBACK

• Summative Feedback

• Judgment is made about the learner’s performance for the purpose of assigning grades, assessing competence, or comparing performance to standards

• Thought of as a type of final assessment

• Not as likely to change learner’s behavior

Bienstock, Katz, Cox et. al., 2007

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TYPES OF FEEDBACK

• Brief Feedback• given often and is short, focused on a skill

• Formal Feedback• provided when one sets aside time for feedback for 5-20

minutes- may be feedback about a case presentation

• Major Feedback• scheduled feedback lasting 15-30 minutes often to address

major issues or midpoint review

Branch & Paranjape, 2002

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Models of Feedback

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THE SANDWICH TECHNIQUE

• Reinforcing Statement: positive remark or observation to learner

• Constructive Comment: constructive observations , examples that need change

• Reinforcing Statement: positive remark or direction for future growth

Cantillon & Sargeant , 2008

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Google images

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A REAL-LIFE EXAMPLE

• Mr. X is a 73 year old man with metastatic lung cancer. He is on a Palliative Care Unit and his condition is deteriorating. A family meeting is held to clarify advance directives, as well as discuss the extent of illness and prognosis with patient and his family.

• The Learner chairs the family conference while the teacher observes.

• The Learner and teacher meet after the conference to discuss how things went.

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Role Play!

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Cantillon & Sargeant, 2008

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SANDWICH MODEL - STRENGTHS

• Good way of giving specific feedback to support learning in a way that promotes respect, understanding and corrective action

• Can be done quickly

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SANDWICH MODEL - CHALLENGES

• Praise may obscure the corrective comment or serve no function

• Learner may get tuned in to the “praise -criticism-praise pattern” and come to be expecting criticism• Subsequently, student learns to discount the praise

• Mostly a one-way transmission of information from the teacher to the learner

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THE PENDLETON MODEL

• Structured approach for talking about a learner’s performance after an educational encounter• such as a case presentation, consultation or a practical

skill

• Pendleton’s rules build on the Feedback Sandwich to promote a two- way process • allows the learner to make observations about his or her

own performance.


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PENDLETON’S RULES

• Briefly clarify matters of fact

• Learner states what was good about his/her performance

• Teacher states areas of agreement and elaborates on good performance

• Learner then states what was poor or could have been improved

• Teacher then states what he or she thinks could have been improved

Cantillon &Sargeant, 2008

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A REAL-LIFE EXAMPLE




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Role Play!

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PENDLETON’S RULES






Cantillon &Sargeant, 2008

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PENDLETON’S RULES - STRENGTHS

• Like the Sandwich model, a good way to give specific feedback in a supportive manner

• Easy to use

• Integrates the learner’s own self assessment and allows for two way dialogue

Kurtz, Silverman & Draper, 1998

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PENDLETON’S RULES - CHALLENGES

• Rules impose a strict order of feedback with good points having be made before difficulties are discussed and the learner having to make comments before the teacher

• Evaluative phrasing of feedback

• Learner’s agenda may not be discovered till late in the feedback process when he/she will have an opportunity to mention areas of concern

• May be an inefficient use of time

Kurtz, Silverman & Draper, 1998

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REFLECTIVE FEEDBACK CONVERSATION

• A modified interactive feedback approach which builds on the Pendleton model

• Emphasizes learner’s ability to recognize his or her own performance deficits • includes a discussion about how the learner plans to

improve

• Encourages development of reflective practice


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• Teacher asks learner to share any concerns about a recently completed performance

• Learner describes what they would have liked to have done better

• Teacher provides views on performance and offers support• Teacher asks learner to reflect on what might improve

situation• Student responds• Teacher elaborates on response, correcting if necessary• Feedback ends with a clear and agreed plan for change


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A REAL-LIFE EXAMPLE




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Role Play!

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REFLECTIVE FEEDBACK CONVERSATION - STRENGTHS

• Collaborative approach: interactive and engages the learner

• Encourages self-reflection with emphasis on learner’s ability to recognize performance deficits

• Discussion flow is natural with the goal of assisting the learner in achieving their own critical analysis

• Motivates subsequent improvement in performance

• With practice, this model can be routinely incorporated into clinical teaching and learning


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REFLECTIVE CONVERSATION MODEL - CHALLENGES

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SIX STEP FEEDBACK MODEL

• Based on elements necessary to improve clinical performance:

• An observed event (learner behavior)• An appraisal of that event( teacher’s assessment)• A recommendation for improvement

Brown, Hodges & Wakefield, 1995


• The impact of Feedback is increased when the learner compares his/her self assessment with feedback provided about his or her performance

Brown, Hodges & Wakefield, 1995


• Make sure the student understands the difference between current behaviour & desired behaviour

• Ask learner to paraphrase

• Elaborate a plan to close the gap• Elicit ideas from learner to increase motivation• Share information rather than giving advice

• Follow-up on improvement• Ensure that recommendations for improvement are carried out• Assess that performance has improved and give feedback

Brown, Hodges & Wakefield, 1995 Hodges, 2003

A REAL-LIFE EXAMPLE




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Role Play!

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• Observe student behaviour/work• Invite the learner’s self assessment of a clinical

encounter• Describe the desired behaviour• Make sure the student understands the difference

between current behaviour & desired behaviour• Elaborate a plan to close the gap• Follow-up on improvement

Brown, Hodges & Wakefield, 1995Hodges, 2003

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SIX STEP FEEDBACK MODEL- STRENGTHS

• Encourages self-assessment, a necessary skill for life long learning

• Encourages delivery of feedback in a positive and respectful manner

• Provides direction for improvement• Provides follow-up to ensure that performance

has improved

SIX STEP FEEDBACK MODEL- CHALLENGES

• May be too time consuming to use completely in some clinical environments

OTHER FEEDBACK MODELS

• The SCOPME model*• The Chicago model*• The ALOBA model*• SET- GO method of descriptive feedback• IMPROVE Model• One-minute clinical preceptor

*Mohanna, Wall & Chambers, 2004

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QUESTIONS?

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HOW ARE THINGS GOING SO FAR?

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ENJOY YOUR BREAK!

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Tips for Giving Feedback:

The “Problem” Learner

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PREVENTION: STEP 1!

• Easier to prevent a problem than manage it – set ground rules!• Primary prevention

• Know learning expectations; orient learner; learning contract; reassess halfway

• Secondary prevention• Watch for warning signs; give specific feedback as early as

possible (don’t “watch & wait”), reassess• Tertiary prevention

• Seek help early; don’t be a “martyr”; don’t give an undeserved passing grade

http://www.oucom.ohiou.edu/fd/monographs/difficult.htm, 1998

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WHAT IS A “PROBLEM LEARNER”?

• Negative connotation

• But, present in literature

• Defined as: • “learners who perform significantly below their potential

due to specific difficulties”

Lucas & Stallworth, 2003

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WHY DON’T WE HELP THE LEARNER IN DIFFICULTY MORE OFTEN?

• Numerous Barriers to feedback…

• Lack skills• Fear of exposing own inadequacies• Fear of upsetting trainee• Fear of doing “more harm than good”• Fear reprisals through legal action• Lack of time

McKimm & Swanwick, 2010Lake & Ryan, 2005

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SOAP APPROACH

• Subjective

• What made you consider there may be a problem with the student’s performance?

• What do others think?• Pattern of behaviour?• What does the learner think – “how are things going with the

rotation”?


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SOAP APPROACH

• Objective

• Need to document specific examples of the problem behaviour/interactions

• Write these down – student needs to know what exactly to improve on


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SOAP APPROACH

• Assessment

• Analyze subjective and objective components and formulate hypotheses for why the student is in difficulty

• Several “differential diagnoses” to consider


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SUPERVISOR & SYSTEM FACTORS

• Previous examples were “personal factors”

• There are also supervisor or system factors:• Receiving no feedback/support• Being given responsibilities beyond level of competence• Interpersonal problems• Overwork• Exposure to patients with serious illness/death


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SOAP APPROACH

• Plan

• Gather more data (if current situation is mild)• Discuss problem with learner• Contact school/training program• Detailed, specific feedback – then, set plan for tackling

the issues and a time to re-evaluate performance


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TIPS MODEL

• Categorizes problem learners as having affective, cognitive, structural and/or interpersonal difficulties


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TIPS MODEL

• T: type and specify the ineffective behaviours• Redirect these• Provide detailed description about ineffective behaviours

• I: identify the category of difficulty experienced by the learner


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TIPS MODEL

• P: perception vs. reality• Describe the perception you have of the learner’s

behaviour, but acknowledge the learner may have a different view

• S: strategy for treatment/follow-up• Discuss concerns with director/experts, as well as the

learner • Include consequences if student does not follow steps for

improvement


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GIVING THE FEEDBACK

• The critical intervention of having a private discussion with the trainee requires:

• Setting aside time in a confidential setting;

• Getting student to speak first (positive critique);

Lake & Ryan, 2005

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GIVING THE FEEDBACK

• Defining the issues involved (important, measurable, reproducible?);

• Determining the remediable cause(s);

• Agreeing on an action plan; and

• Monitoring outcomes and following up • with frequent feedback

Lake & Ryan, 2005

Gordon, 2003

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CALL FOR HELP!

**Remember! If you have major concerns about a learner, you have an obligation as a teacher and professional to discuss these with both the learner and the appropriate program contact(dean, program director, etc.)

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How to Role Play:Ground Rules

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GOALS OF ROLE PLAY

• Opportunity to practice giving feedback

• Obtain feedback on your feedback

• Identify difficulties encountered while giving feedback

• Determine strategies to overcome these

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GROUPS OF THREE

• Student• Trainee in an ambulatory clinic• Receiving end-of-rotation feedback

• Preceptor• Supervising preceptor in an ambulatory clinic

• Observer• Extra eyes and ears, keeper of field notes

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FORMAT

• 10 minutes: Review and prepare for role

• 20 minutes: Give feedback!!

• 15 minutes: Discuss within large group– What worked well?– What could be improved and how?

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GROUND RULES

• Time-outs are encouraged!– Rewind/fast-forward to repeat scenarios– Rerun scenario with different feedback method

• Sharing /trading roles is encouraged!– Rerun scenario with different roles

• Respect for each other is essential!– Privacy must be respected

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Feedback Away!

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DEBRIEFING

• Preceptors … – What was most difficult to discuss with the student?– What was the easiest?

• Students …– How did you feel when receiving feedback?– What was your reaction?

• Observers …– What went well?– What problems did you notice?

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Receiving Feedback

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RECEIVING FEEDBACK

•Receiving feedback involves thinking of it as new information, focusing on trying to understand it and clarifying the meaning of the feedback.

Piccinin, 2003

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FACTORS THAT AFFECT HOW FEEDBACK IS RECEIVED

• Receiver’s Self Confidence • the greater the receiver’s level of self confidence, the easier

it is for that person to respond to feedback

• Type of Feedback being Given• major difficulty is receiving negative feedback

• Relationship between Giver and Receiver • feedback from a trusted source is better received

Piccinin, 2003

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STRATEGIES FOR RECEIVING FEEDBACK EFFECTIVELY

• Preparatory Phase• Keep in mind that feedback is valuable to all of us

• Receiving Phase• Listen carefully to the entire feedback• Try not to be defensive or to argue• Paraphrase the content of the feedback• Recognize the validity of the feedback• Provide information to correct misinformation• Say what you intend to do about the feedback received

Piccinin, 2003

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STRATEGIES FOR RECEIVING FEEDBACK EFFECTIVELY

• Follow up Phase• collaboratively set definite dates or times to monitor progress

toward implementation of the action steps decided on.

Piccinin, 2003

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RECEIVING FEEDBACK: SUMMARY

• Listen to the feedback• Ask for it to be repeated if you did not hear• Assume it is constructive till proven otherwise• Pause and think before responding• Ask for clarification or examples if statements are

unclear or unsupported• Accept feedback positively• Ask for suggestions of ways that you might modify

behavior• Respect and thank the person giving the feedback

http://londondeanery.ac.uk, 2010

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THE FEEDBACK TOOLKIT

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QUESTIONS TO ASK YOURSELF…

• What was performed well and what could be performed differently?

• What specific behaviours do I want to comment on?

• Can this behaviour be modified and if so, what behaviour would I like to see in its place?

• What is the priority for improvement?

• How can I express respect and support for the learner as I provide feedback?

• Is it the right time and place?

Dent & Harden, 2009 Mckinley, Williams & Stephenson, 2010

103

SUMMARY: EFFECTIVE FEEDBACK

•Relevant•Factual and Descriptive•Timely, Frequent and Expected•Specific and Focused on behaviour/performance

• Target an alterable behaviour; must be able to “prove”•Helpful with direction for improvement•Balanced•Collaborative

Dent & Harden, 2009

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PENDLETON’S RULES







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• Observe student behaviour/work• Invite the learner’s self assessment of a clinical

encounter• Describe the desired behaviour• Make sure the student understands the difference

between current behaviour & desired behaviour• Elaborate a plan to close the gap• Follow-up on improvement

Brown, Hodges & Wakefield, 1995Hodges, 2003

108

TIPS MODEL

• T: type and specify the ineffective behaviours• Redirect these• Provide detailed description about ineffective behaviours

• I: identify the category of difficulty experienced by the learner• affective, cognitive, structural and/or interpersonal


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TIPS MODEL

• P: perception vs. reality• Describe the perception you have of the learner’s

behaviour, but acknowledge the learner may have a different view

• S: strategy for treatment/follow-up• Discuss concerns with director/experts, as well as the

learner • Include consequences if student does not follow steps for

improvement


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RECEIVING FEEDBACK: SUMMARY

• Listen to the feedback• Ask for it to be repeated if you did not hear• Assume it is constructive till proven otherwise• Pause and think before responding• Ask for clarification or examples if statements are

unclear or unsupported• Accept feedback positively• Ask for suggestions of ways that you might modify

behavior• Respect and thank the person giving the feedback

http://londondeanery.ac.uk, 2010

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Now, we would appreciate your

feedback!

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LEARNING OBJECTIVES

•To describe qualities of effective feedback•To appreciate common barriers to giving feedback and giving feedback in difficult situations•To incorporate a feedback model in the form of a toolkit framework with concise and meaningful take home messages•To develop an increased comfort level with giving feedback•To demonstrate increased ability to integrate newly used feedback skills through role play

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FEEDBACK WORKSHOP

• How did we feel the workshop went?

• Overall impressions • Material covered and well researched?• Clarity, organization?• Time allotment for each section?• Role play/interactive component?• Audiovisual aids and materials?

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HOW DID THINGS GO (IN GENERAL?)

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FEEDBACK WORKSHOP

• What did you feel went well?

• What could we change/improve on for next time?

• What (if anything) was missing?

• What one pearl will you take back to your clinic/hospital/teaching from this workshop?

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THANK YOU

• Thank you for attending our workshop!

• Thank you also to the INTAPT instructors for your help and guidance

• Thank you to Rob Blain• Toolkit creator!

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giving effective feedback: a teacher’s toolkit

Documents

feedback model

meaning of feedback

definitionalthough feedback

uncomfortable giving

trainees report feedback

used feedback skills

giving feedbackto

important question