Chapter 40 • Feedback. The purpose of feedback is formative: to provide insights that help the learner make mid-course adjustments in performance and demonstrate improvement. The language of feedback is descriptive and neutral. Formative feedback should be task-orientated and given frequently and as soon as feasible after the performance so the learner has time to make changes. (Perera et al 2008). • Summative assessment. Summative assessment occurs at the conclusion of a course of study and communicates a decision about performance. This assessment should follow formative feedback and subsequent remedial actions and should express a judgement about whether the learner has achieved the expected outcomes. Summative assessment is often given as a grade or the learner’s ranking in comparison to other learners or to a standard, for example, 4.2/5 on clinical skills. • Brief ongoing feedback. Brief feedback sessions (5–10 minutes) occur frequently, in the context of regular work activities, while the learner is demonstrating findings on physical examination or during the presentation of the patient’s history. On these occasions, the teacher might say, ‘I’d like to give you some pointers about another way to examine the spleen’. • Formal mid-course feedback. A formal feedback session is scheduled in advance, and both learner and teacher plan ahead. The session may last from 10–30 minutes and addresses the teacher’s observations over a period of time. This allows for improvement prior to the summative evaluation. • End-of-course feedback. Summative assessment should be accompanied by feedback, reflection, and mentoring to help the learner improve (Krackov & Pohl 2011). Ericsson (2004) maintains that the ‘acquisition of expert performance requires engaging in deliberate practice and that “continued deliberate practice is necessary for maintenance of many types of professional performance’. Feedback is an essential component of the deliberate practice concept. In Ericsson’s framework, the following conditions lead to improvement through deliberate practice: • Well-defined tasks or objectives • Detailed and immediate feedback on performance • Opportunities to improve by performing the same or similar tasks repeatedly. Feedback plays a critical role for the learner, the teacher and the educational programme. Feedback helps the learner achieve course or programme goals. It reinforces good performance and provides a basis for correcting mistakes. Feedback serves as a reference point for summative assessment. It offers insights into actual performance and demonstrates commitment to the learner as a person (Box 40.1) Learners value teachers who facilitate their learning by giving constructive feedback that is adapted to their professional needs. King (1999) asked learners for their views on feedback. Negative feedback experiences are characterized by: • lack of personal interest in the learner • feedback that is too general • feedback that is too brief and/or too long after the event to be useful. Positive feedback experiences involve: • Time and place. The teacher and learner are ‘too busy’ for a feedback session; this can lead to an excessive delay before feedback is given or prevent it from happening at all. There may be no appropriate space for a feedback session in the area where the teacher and learner interact. • Knowledge base. Both teacher and learner may be unclear about the purpose or use of feedback. The teacher may lack first-hand data about the learner’s performance or may not be certain what feedback is appropriate in a given situation. • Ability. The teacher may not know how to give feedback or have had little practice giving feedback. • Affective factors. A variety of elements play a role: • Different perceptions about feedback. Learners and teachers differ in their perceptions about feedback. Teachers believe they provide feedback more frequently than learners say they received it. • The culture. The traditional culture of medicine requires that the learner acquire extensive knowledge and skills in a highly structured hierarchical environment. It promotes a one-way flow of information from teacher to learner and can form an experience in which the learner feels like a ‘victim’ rather than a partner in a collegial activity. In this culture, the learner may consider negative feedback as an overall assessment of worth. Attention to important principles of effective feedback will help set the stage for an effective session (Ende 1983, Hesketh & Laidlaw 2002, Pendleton et al 1984). • A culture that values constructive improvement. The educational climate should foster constructive improvement in an atmosphere of trust and concern. Both learner and teacher should expect feedback to be a regular and frequent occurrence. From the outset it should be clear that they will work together toward a common goal of improving performance. Providing feedback about the course and instructors should be an expected responsibility of learners. The learner might also be asked to provide feedback to the teacher in the context of the feedback session. All of this will foster a climate of mutual trust. • Attention to time and location. Formal feedback sessions should be scheduled so they are mutually convenient for the teacher and the learner and both should have adequate time to prepare. Either the teacher or the learner can initiate a feedback session. The session should take place in a private setting where the learner will feel more relaxed and comfortable discussing sensitive issues. • Use of standards. The learner’s performance should be measured against well-defined outcome goals and objectives. • First-hand observation. Whenever possible, the teacher should observe the behaviours first-hand and not relate feedback observed by somebody else. Passing along feedback based on data collected from another person may send mixed messages and produce defensiveness. • Use of positive communication strategies. Giving effective feedback requires attention to a range of dynamics: some observable and others unseen.
Giving feedback
Introduction and background
Formative feedback versus summative assessment
The intent of a feedback session
Why is feedback important?
For the learner
Why is giving feedback difficult to do?
Barriers
Poor rapport between the learner and teacher may affect or prevent feedback sessions.
Ende (1983) believes the concern that negative feedback can elicit an unwanted emotional reaction from the learner may lead the teacher to use unclear, indirect statements or avoid giving feedback at all.
Principles of effective feedback:
Communicating effectively. Feedback involves active listening, asking open-ended reflective, facilitative questions and responding. These key skills help the learner gain insight into strengths and weaknesses.
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Giving feedback
“Without feedback, mistakes go uncorrected, good performance is not reinforced, and clinical competence is achieved empirically or not at all. The sense of being adrift in a strange environment is amplified and learners may ‘generate their own feedback by attaching inappropriate importance to internal and external cues’.”
