Guidelines: the do’s, don’ts and don’t knows of feedback for clinical education

Perspect Med Educ (2015) 4:284–299 DOI 10.1007/s40037-015-0231-7 Guidelines Guidelines: the do’s, don’ts and don’t knows of feedback for clinical education Janet Lefroy · Chris Watling · Pim W. Teunissen · Paul Brand Published online: 30 November 2015 © The Author(s) 2015. This article is published with open access at Springerlink.com Abstract Introduction The guidelines offered in this paper aim to amalgamate the literature on formative feedback into practical Do’s, Don’ts and Don’t Knows for individual clinical supervisors and for the institutions that support clinical learning. Methods The authors built consensus by an iterative process. Do’s and Don’ts were proposed based on authors’ individual teaching experience and awareness of the literature, and the amalgamated set of guidelines were then refined by all authors and the evidence was summarized for each guideline. Don’t Knows were identified as being important questions to this international group of educators which if answered would change practice. The criteria for inclusion of evidence for these guidelines were not those of a systematic review, so indicators of strength of these recommenda- Electronic supplementary material The online version of this article (doi:10.1007/s40037-015-0231-7) contains supplementary material, which is available to authorized users. J. Lefroy () Keele University School of Medicine, Clinical Education Centre RSUH, ST4 6QG Staffordshire, UK e-mail: C. Watling Schulich School of Medicine and Dentistry, Western University, Ontario, Canada P. W. Teunissen Maastricht University and VU University Medical Center, Amsterdam, The Netherlands P. Brand Isala Klinieken, Zwolle, The Netherlands tions were developed which combine the evidence with the authors’ consensus. Results A set of 32 Do and Don’t guidelines with the important Don’t Knows was compiled along with a summary of the evidence for each. These are divided into guidelines for the individual clinical supervisor giving feedback to their trainee (recommendations about both the process and the content of feedback) and guidelines for the learning culture (what elements of learning culture support the exchange of meaningful feedback, and what elements constrain it?) Conclusion Feedback is not easy to get right, but it is essential to learning in medicine, and there is a wealth of evidence supporting the Do’s and warning against the Don’ts. Further research into the critical Don’t Knows of feedback is required. A new definition is offered: Helpful feedback is a supportive conversation that clarifies the trainee’s awareness of their developing competencies, enhances their selfefficacy for making progress, challenges them to set objectives for improvement, and facilitates their development of strategies to enable that improvement to occur. Keywords Formative assessment · Feedback · Workplace based assessment · Feedback relationship · Feedback culture Do’s—educational activity for which there is evidence of efficacy Don’ts—educational activity for which there is evidence of no efficacy or of harms (negative effects) Don’t Knows—educational activity for which there is no evidence of efficacy Guidelines: the do’s, don’ts and don’t knows of feedback for clinical education 285 Table 1 Summary of guidelines. For the individual clinical supervisor giving feedback 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. Do’s for the process of feedback Do realize that feedback is not just one person providing information to another to help them improve. Feedback is part of a social interaction influenced by culture, values, expectations, personal histories, relationships, and power. Do treat feedback as a conversation rather than as a commodity Do recognize that trainees must perceive feedback as credible in order for it to be influential. Credible feedback is well-informed, typically by direct observation of the task or event, and it comes from a trustworthy source. Make sure that you as supervisor set a good example as a credible role model Decide the timing of feedback depending on the competence level of the trainee and on the complexity of the task Do encourage trainees to look for feedback and use it to enhance their performance Do’s for the content of feedback Do tailor bespoke feedback to the individual trainee. The trainee might benefit from: –Reinforcement of key points done well –Identification of key points which might have been done better or omissions –Working out strategies for improving the quality of their work –An increased self-awareness Do give specific feedback, focused on how the task was done and how that type of task should/might be done Do make sure to indicate whether feedback is about necessary improvement for minimally acceptable performance or whether it is a reflection on possible variations to build upon adequate performance Consider offering grades as an element of formative feedback if it seems that receiving grades will enhance the seeking of strategies for improvement. Conversely, avoid giving grades to trainees who you suspect will stop trying to learn if they get a good enough grade and to those who will give up if they get a poor grade Do ensure that feedback is actionable, enabling the trainee to construct strategies for improvement. After discussing the trainee’s performance of a task, provide some guidance or ‘scaffolding’ to enable them to step beyond their current competence Do attend to trainee motivation when discussing strategies for improvement Regardless of the specific approach to feedback that is used, do engage the trainee in a reflective conversation that marries their self-assessment with your observations and elaborations Several approaches have been described in the literature (sandwich, Pendleton, reflective feedback conversation, agenda-led outcome-based analysis, feedforward), but no single approach has been established to be the most effective. Rather, the likely best approach varies according to the learner, the teacher-learner relationship, and the context Don’ts Don’t assume that a single approach to feedback will be effective with all trainees or in all circumstances. As the players and the contexts change, so too does the most useful approach to feedback. Don't assume: –You know what a trainee wants to learn –You know why a trainee is struggling –You know if or why a trainee wants feedback –You know what information a trainee takes out of a situation or feedback conversation Don’t provide feedback without follow-up. Trainees are unlikely to be influenced by feedback that is not followed by an opportunity for them to demonstrate improving performance Don’t provide feedback that is poorly informed (or is based on hearsay); doing so diminishes the value that trainees assign to feedback in general Don’t underestimate the emotional impact of feedback that is perceived as negative. Emotional distress may be a barrier to acceptance and use of feed (...truncated)