Identifying educator behaviours for high quality verbal feedback in health professions education: literature review and expert refinement

Radiologist preferences for faculty development initiatives to improve resident feedback in the era of competency-based medical education

INTRODUCTION

Since 2022, all Canadian post-graduate medical programs have transitioned to a Competence by Design (CBD) model within a Competency-Based Medical Education (CBME) framework. The CBME model emphasized more frequent, formative assessment of residents to evaluate their progress towards predefined competencies in comparison to traditional medical education models. Faculty members therefore have increased responsibility for providing assessments to residents on a more regular basis, which has associated challenges. Our study explores faculty assessment behaviours within the CBD framework and assesses their openness to opportunities aimed at improving the quality of written feedback. Specifically, we explore faculty's receptiveness to routine metric performance reports that offer comprehensive feedback on their assessment patterns.

METHODS

Online surveys were distributed to all 28 radiology faculty at Queen's University. Data were collected on demographics, feedback practices, motivations for improving the teacher-learner feedback exchange, and openness to metric performance reports and quality improvement measures. Following descriptive statistics, unpaired t-tests and one-way analysis of variance were conducted to compare groups based on experience and subspecialty.

RESULTS

The response rate was 89% (25/28 faculty). 56% of faculty were likely to complete evaluations after working with a resident. Regarding the degree to which faculty felt written feedback is important, 62% found it at least moderately important. A majority (67%) believed that performance reports could influence their evaluation approach, with volume of written feedback being the most likely to change. Faculty expressed interest in feedback-focused development opportunities (67%), favouring Grand Rounds and workshops.

CONCLUSION

Assessment of preceptor perceptions reveals that faculty recognize the importance of offering high-quality written feedback to learners. Faculty openness to quality improvement interventions for curricular reform relies on having sufficient time, knowledge, and skills for effective assessments. This suggests that integrating routine performance metrics into faculty assessments could serve as a catalyst for enhancing future feedback quality.

Impact of a coaching program on resident perceptions of communication confidence and feedback quality

BACKGROUND

While communication is an essential skill for providing effective medical care, it is infrequently taught or directly assessed, limiting targeted feedback and behavior change. We sought to evaluate the impact of a multi-departmental longitudinal residency communication coaching program. We hypothesized that program implementation would result in improved confidence in residents' communication skills and higher-quality faculty feedback.

METHODS

The program was implemented over a 3-year period (2019-2022) for surgery and neurology residents at a single institution. Trained faculty coaches met with assigned residents for coaching sessions. Each session included an observed clinical encounter, self-reflection, feedback, and goal setting. Eligible residents completed baseline and follow-up surveys regarding their perceptions of feedback and communication. Quantitative responses were analyzed using paired t-tests; qualitative responses were analyzed using content analysis.

RESULTS

The baseline and follow-up survey response rates were 90.0% (126/140) and 50.5% (46/91), respectively. In a paired analysis of 40 respondents, residents reported greater confidence in their ability to communicate with patients (inpatient: 3.7 vs. 4.3, p < 0.001; outpatient: 3.5 vs. 4.2, p < 0.001), self-reflect (3.3 vs. 4.3, p < 0.001), and set goals (3.6 vs. 4.3, p < 0.001), as measured on a 5-point scale. Residents also reported greater usefulness of faculty feedback (3.3 vs. 4.2, p = 0.001). The content analysis revealed helpful elements of the program, challenges, and opportunities for improvement. Receiving mentorship, among others, was indicated as a core program strength, whereas solving session coordination and scheduling issues, as well as lowering the coach-resident ratio, were suggested as some of the improvement areas.

CONCLUSIONS

These findings suggest that direct observation of communication in clinical encounters by trained faculty coaches can facilitate long-term trainee growth across multiple core competencies. Future studies should evaluate the impact on patient outcomes and workplace-based assessments.

Clinical supervisors' experience of a first-time application of entrustable professional activities in clinical supervision of medical students: findings from a Swedish pilot study

BACKGROUND

Recently, all medical universities in Sweden jointly developed a framework for Entrustable Professional Activities (EPAs) for work-based training and assessment. This framework is now being introduced nationally in the new 6-year undergraduate medical programme that directly lead to a licence to practise. When EPAs are introduced, it is of central importance to gain clinical supervisors' acceptance to apply the framework in their supervision of students. The aim of this study was therefore to investigate how clinical supervisors, not familiar with EPAs, experience clinical supervision using the framework for EPAs.

METHODS

We used a purposive sampling to recruit clinical supervisors. They were given written information on EPAs with a selection of suitable EPAs and the Swedish observation rating scale for assessment of autonomy, and they were offered to attend a 30-minute introductory web course. The participants were informed that EPAs were to be tested, and the students were asked to participate. After the study period the clinical supervisors participated in semi-structured interviews. Inductive qualitative content analysis was used to analyse the transcribed interviews.

RESULTS

Three general themes emerged in the qualitative analysis: Promoting Feedback, Trusting Assessments and Engaging Stakeholders. The participants described benefits from using EPAs, but pointed out a need for preparation and adaptation to facilitate implementation. The structure was perceived to provide structured support for feedback, student involvement, entrustment decisions, enabling supervisors to allow the students to do more things independently, although some expressed caution to rely on others' assessments. Another concern was whether assessments of EPAs would be perceived as a form of examination, steeling focus from formative feedback. To understand the concept of EPA, the short web-based course and written information was regarded as sufficient. However, concern was expressed whether EPA could be applied by all clinical supervisors. Involvement and adaption of the workplace was pointed out as important since more frequent observation and feedback, with documentation requirements, increase the time required for supervision.

CONCLUSIONS

EPAs were accepted as beneficial, promoting structured feedback and assessments of the students' autonomy. Preparation of supervisors and students as well as involvement and adaptation of the workplace was pointed out as important.

Developing student nurses' evaluative judgement in clinical practice tertiary education: A systematic scoping review of teaching and assessment methods

OBJECTIVES

This review aimed to systematically scope undergraduate or postgraduate tertiary higher education nursing students' clinical practice teaching and assessment methods to identify features that align with promoting students' evaluative judgement.

INTRODUCTION

Evaluative judgement is a new concept to nursing tertiary education. Currently, there are no published reviews of evaluative judgement in nursing clinical practice education. This review aims to assist nursing educators to operationalise the concept of evaluative judgement in clinical practice education. As such the starting point was to determine features of evaluative judgement in current clinical teaching and assessment designs.

INCLUSION CRITERIA

Peer reviewed qualitative or quantitative studies that have evaluated teaching and/or assessment of tertiary (university/higher education) pre-registration (undergraduate) or post-registration (postgraduate) nursing students' clinical practice.

METHODS

The systematic scoping review was prospectively registered systematic review (OSF DOI 10.17605/OSF.IO/PYWZ6) reported using PRISMA guidelines. A systematic search of five databases (Medline, Scopus, Web of Science, ProQuest, CINAHL) was conducted, limited from 1989 onwards and in English. Two reviewers independently screened titles and abstracts, then full text, with disagreements resolved with a third independent author. Data were extracted, including the frequency and methods of developing students' evaluative judgement across the categories of discerning quality, judgement process, calibration and feedback. A narrative synthesis was performed.

RESULTS

Seventy-one studies were included (n=53 teaching, n=18 assessment). Most of the included studies, included some, but not all, of the features to develop nursing students' evaluative judgment. For teaching methods, the most identified evaluative judgement features in the included studies were discerning quality (n=47), feedback (n=41) and judgement process (n=21). Only three studies included a method of calibration. For the assessment methods, feedback (n=16), discerning quality (n=15), judgement process (n=9) and calibration (n=4) were included. Many clinical practice teaching and assessment methods in nursing included features that develop students' evaluative judgement, with methods relating to discerning quality and feedback well embedded. Further adjustments are required to include methods to assist students to judge and calibrate their own performance.

CONCLUSION

This systematic scoping review identified that evaluative judgement in current nursing clinical teaching and assessment is not an overt aim. With minor adjustment to teaching and assessment design, nursing students could be better supported to develop their ability to judge the value of their own work.

The integrative feedback tool: assessing a novel feedback tool among emergency medicine residents

OBJECTIVE

Feedback is critical to the growth of learners. However, feedback quality can be variable in practice. Most feedback tools are generic, with few targeting emergency medicine. We created a feedback tool designed for emergency medicine residents, and this study aimed to evaluate the effectiveness of this tool.

METHODS

This was a single-center, prospective cohort study comparing feedback quality before and after introducing a novel feedback tool. Residents and faculty completed a survey after each shift assessing feedback quality, feedback time, and the number of feedback episodes. Feedback quality was assessed using a composite score from seven questions, which were each scored 1 to 5 points (minimum total score, 7 points; maximum, 35 points). Preintervention and postintervention data were analyzed using a mixed-effects model that took into account the correlation of random effects between study participants.

RESULTS

Residents completed 182 surveys and faculty members completed 158 surveys. The use of the tool was associated with improved consistency in the summative score of effective feedback attributes as assessed by residents (P=0.040) but not by faculty (P=0.259). However, most of the individual scores for attributes of good feedback did not reach statistical significance. With the tool, residents perceived that faculty spent more time providing feedback (P=0.040) and that the delivery of feedback was more ongoing throughout the shift (P=0.020). Faculty felt that the tool allowed for more ongoing feedback (P=0.002), with no perceived increase in the time spent delivering feedback (P=0.833).

CONCLUSION

The use of a dedicated tool may help educators provide more meaningful and frequent feedback without impacting the perceived required time needed to provide feedback.

Introducing Graduate Students in Biomedical Sciences to an Institutional Animal Research Program

At the University of Oklahoma Health Sciences Center, graduate students enrolled in biomedical science programs comprise a significant portion of personnel working with research animals. Although the University requires that all personnel receive appropriate training before working with animals, veterinarians and research mentors agreed students would benefit from additional training. As a result, a course entitled "Laboratory Animal Use and Concepts" was added to the curriculum of the University's largest graduate program in biomedical sciences starting in 2017. The course introduces students to a number of topics relevant to the use of animals in biomedical research, with an emphasis on mice. Here we present a summary of the course and an assessment of its impact during the initial 5 y, from 2017-2021. Enrollment, student outcomes, and student evaluation surveys were included in this assessment. The course was offered to 6 classes totaling more than 120 students during this period. After completing the course, nearly 80% of students used animals as part of their graduate training. Among those, at least 21% sought additional training through formal workshops that offered supplemental opportunities to practice animal handling techniques. Student feedback suggested strong satisfaction with the course content and an appreciation for wet lab sessions. Providing enhanced training for incoming graduate students through this structured course appears to help students improve knowledge, skills, and attitudes that facilitate the responsible and ethical use of animals in biomedical research.

Measuring changes in nursing students' workplace performance following feedback encounters: A quasi-experimental study

BACKGROUND

Work-integrated learning and performance is intimately linked with assessment and feedback; however, empirical evidence concerning the impact of feedback on student performance in workplace settings is limited. A novel practice-based feedback intervention-the REMARK (nuRse fEedback iMplementAtion frameworRK) program-was developed and implemented. Sustainable feedback processes that involve both learners and learning partners can ultimately maximise learning outcomes, optimise self-regulation, and impact performance.

OBJECTIVES

To determine the impact of implementing an educational intervention based on best practice principles of feedback on undergraduate nursing student performance during clinical placements in acute healthcare settings.

METHODS

A non-equivalent, quasi-experimental design was used. A pre- and post-assessment strategy for both control and intervention groups was employed. The REMARK program was based on known attributes of effective feedback critiqued in the literature that foster interactions between a learner and learning partner and, hence, support dialogic feedback.

RESULTS

Clinical assessment data of 214 final-year nursing students collected at three time points were analysed. Using multivariate modelling, the results indicated that students participating in the REMARK programme (intervention group) had statistically higher performance scores than students in the control group when time and placement setting were controlled.

CONCLUSIONS

This research provides evidence that engagement with an intervention based on attributes of effective feedback improves nursing students' workplace performance during clinical placement. To achieve the greatest advantage, incorporating strategies that encourage students to adopt an active role in feedback conversations that relate to the student's learning goals are recommended.

Self-Assessment in Feedback Conversations: A Complicated Balance

PURPOSE

Learner-centered feedback models encourage educators to ask learners to self-assess at the start of feedback conversations. This study examines how learners perceive and respond to self-assessment prompts during feedback conversations and assesses medical students' perceptions of and approach to self-assessment used as the basis for these conversations.

METHOD

All rising second-, third-, and fourth-year medical students at a midwestern U.S. medical school were invited to participate in this study. Students participated in 1-on-1 interviews between June and August 2019 during which they were asked open-ended questions about their experiences with self-assessment and feedback during medical school. The interviews were audio recorded and transcribed, and comments related to self-assessment in feedback conversations were extracted. Thematic analysis was used to identify recurrent ideas and patterns within the transcripts, and all excerpts were reviewed and coded to ensure that the identified themes adequately captured the range of student responses.

RESULTS

A total of 25 students participated in the study. Although some students noted improvement in their self-assessment abilities with increasing experience, no consistent gender, race, or training-level differences were found in reported attitudes or preferences. Students identified many benefits of self-assessment and generally appreciated being asked to self-assess before receiving feedback. Students had varied responses to specific self-assessment prompts, with no clear preferences for any particular self-assessment questions. Students described weighing multiple factors, such as image concerns and worries about impact on subsequent evaluations, when deciding how to respond to self-assessment prompts.

CONCLUSIONS

The process by which learners formulate and share self-assessments in feedback conversations is not straightforward. Although educators should continue to elicit self-assessments in feedback discussions, they should recognize the limitations of these self-assessments and strive to create a safe environment in which learners feel empowered to share their true impressions.

"Maybe it's the first time somebody's been honest with you": exploring how residents reconcile feedback variability

BACKGROUND

Supervisors in postgraduate medical education may deliver different feedback for the same quality of performance. Residents may struggle to make sense of inconsistent and sometimes contradictory information. We sought to explore how residents experience feedback from different supervisors, how they process inconsistent information, and what factors influence their experiences.

METHODS

Eighteen residents participated in semi-structured interviews to explore their perspectives on feedback. Using a constructivist grounded theory approach, we engaged in iterative cycles of data collection and analysis, sampling until theoretical sufficiency was reached. Constant comparative analysis was used to identify and define themes.

RESULTS

We identified a central theme of reconciliation, which we defined as the act of processing inconsistent feedback and determining how to engage with it. This reconciliation was informed by the credibility of, and residents' relationship with, supervisors and was achieved through conversations with peers and mentors, observation of other supervisors' behavior toward their performance, and reflection on their own performance. Participants expressed a reluctance to discard feedback, even if they felt it was incongruent with previous feedback or their own self-concept and self-assessment.

CONCLUSION

The findings of this study show that while residents are regular consumers of feedback, not all feedback is used equally. Residents actively reconcile sometimes-contradictory feedback and must work to balance a general reluctance to discard feedback, while developing an understanding of its credibility. This work reinforces the importance of pedagogical relationships and identifies that facilitated reflection that explicitly acknowledges feedback inconsistencies may be important in the reconciliation process.

Residents' and supervisors' experiences when using a feedback-model in post-graduate medical education

BACKGROUND

Supervisors play a key part as role models and supporting the learning during residents' post-graduate medical education, but sometimes lack sufficient pedagogic training and are challenged by high demands in today's healthcare. The aim of this study was to describe the strengths and areas for improvement identified in the supervision process by residents and supervisors in post-graduate medical education.

METHODS

This study included supervisors and residents working at departments and health centres who have used a web-based questionnaire, as a part of the Evaluation and Feedback For Effective Clinical Teaching (EFFECT) model, during the period 2016-2019. Descriptive statistics and content analysis were used to analyse ratings and comments to describe strengths and areas for improvement in the supervision process.

RESULTS

The study included 287 resident evaluations of supervisors and 78 self-evaluations by supervisors. The supervisor as a role model, being available, and, giving personal support, were the three most important strengths identified by the residents and supervisors. Residents in primary care also identified the role modelling of general practice competence as a strength, whereas residents and supervisors in hospital departments addressed supervisors as energetic and showing work was fun. The area with the need of most improvement was, Giving and receiving feedback.

CONCLUSIONS

To be able to give feedback, residents and supervisors, needed to see each other in work, and the learning environment had to offer time and space to pedagogical processes, like feedback, to improve the learning environment.

Feedback in family medicine clerkships: a qualitative interview study of stakeholders in community-based teaching

Feedback is an important aspect of teaching and learning in medical education. Irrespective of the training environment, too little effective dialogic feedback occurs. Community-based outpatient learning environments, such as general practitioner practices, have heterogeneous framework conditions regarding feedback that decrease feedback quality. To improve feedback in this setting, characteristics of feedback in such learning environments must be considered. This study aims to reveal such characteristics from different perspectives and derive ideas for improving feedback in community-based learning environments. Three stakeholder groups in family medicine clerkships as an example of community-based learning environments (n = 15 students, n = 12 faculty and administrative staff, n = 13 general physician trainers) were interviewed for this study. Transcripts of the interviews were analysed with qualitative content analysis. All stakeholders interviewed note a lack of feedback between groups. Feedback in primary care practices takes place in specific contexts (e.g., during vs after a consultation, during vs at the end of the clerkship) and is provided in different ways (e.g., verbal vs nonverbal). Barriers of effective feedback in community-based settings are: lack of opportunity/initiation, fear of giving feedback, unawareness (of correct feedback and/or lack of prior experience with feedback), and little basis for feedback. Currently, the exchange between the university and community-based learning environments is limited to grading and report writing, with little sharing of meaningful information. The potential of a better exchange between those within community-based learning environments and the university to improve feedback processes is not reached. This exchange and the framework conditions specific for the community-based learning environment should be considered as parts of the structural dimension of feedback. Teachers and course managers of family medicine institutes are in an important position to shape these factors actively, working together with stakeholders of community-based teaching.

Does Online Professional Development for Physical Therapists Enhance Clinical Practice and Patient Outcomes? Protocol for a Mixed Methods, Randomized Controlled Trial

OBJECTIVE

Online clinical mentoring has shown potential as a flexible professional development activity that enhances physical therapist practice. Online delivery can overcome time and distance barriers to participation in professional development. The impact of this learning activity on physical therapist practice and patient outcomes has not been rigorously tested. Thus, the aim of this study is to determine whether online clinical mentoring is more effective than asynchronous online lectures at improving physical therapist practice and patient outcomes. An additional aim is to explore the lived experience of physical therapist learners who participate in online clinical mentoring.

METHODS

In this mixed methods evaluation, 24 physical therapist learners will be randomized to 1 of 2 online professional development activities. Experimental group physical therapists will complete 6 online clinical mentoring sessions. Control group physical therapists will complete 6 online lectures. The primary outcome evaluated will be the effect on the physical therapist's patients, using the Patient-Specific Functional Scale. Physical therapist learner secondary outcomes are confidence, self-reflection, and satisfaction. Accounting for possible dropouts, a sample size of 216 patients was determined using a pragmatic sample of 24 physical therapists, power of 0.80, alpha of 0.05, and between-group differences of 1.0 (SD = 2.0) on the Patient-Specific Functional Scale. Consecutive, eligible patients under the care of the physical therapist learners will complete outcome measures at initial appointment and at 4 weeks follow-up. Linear mixed model regression analysis will be used to estimate treatment effects from the posttreatment group means at 4 weeks. Participants undertaking online clinical mentoring will complete semi-structured interviews that will be thematically analyzed using a phenomenological approach.

IMPACT

This research study will establish the effectiveness of online clinical mentoring to inform future professional development. The qualitative component will identify the potential mechanisms by which online clinical mentoring might be effective, thus informing future implementation of this professional development activity.

'Everyone's nice, but …': A qualitative exploration of trainees' experiences of postgraduate geriatric medicine training in Australia

OBJECTIVE

To understand the experiences of trainees who undertake geriatric medicine advanced training in Australia.

METHODS

In this qualitative study, data were collected through semi-structured interviews with geriatric medicine advanced trainees. Data were analysed using a thematic analysis approach and data collection ceased when thematic saturation was achieved.

RESULTS

Thirteen trainees participated. Trainees enjoyed the training program, supported each other and felt prepared for independent practice as a geriatrician. However, they noted the variability of supervision and feedback practices, and educational opportunities afforded to them across different clinical learning environments. They felt unable to give feedback on their training. The research project and concerns about employment after training were also substantial sources of stress.

CONCLUSION

While geriatric medicine advanced trainees reported positively on much of their training, areas for improvement could include improved training for supervisors, improved support for research projects and more robust mechanisms for providing feedback.

Speech and Language Therapists' Perspectives of an E-Learning Course on Providing Feedback in the Clinical Learning Environment

BACKGROUND

A fundamental component of supervising a student speech and language therapist (SLT) on placement is the provision of feedback. There are numerous identified challenges to ensure the delivery of high-quality feedback to optimise student learning and student success. Supervisors can help overcome these challenges and engage in evidence-based feedback processes if they are supported to develop the necessary knowledge and skills. E-learning is one possible means to provide this professional development to a large number of practising SLTs who are geographically dispersed and have conflicting schedules.

AIMS

This study aimed to capture and evaluate the perspectives of SLTs who completed an e-learning course on providing feedback in the clinical learning environment, including the suitability and effectiveness of the e-learning tool used.

METHODS AND PROCEDURES

An innovative e-learning course was designed to provide asynchronous video and interactive content on evidence-based theories and practices for effective feedback processes. Clinical scenarios relevant to the discipline of speech and language therapy were included. Participants were invited to complete optional, anonymous pre- and post-evaluation surveys. Data were analysed quantitively (descriptive and inferential statistics) and qualitatively (thematic analysis).

OUTCOMES AND RESULTS

Participants indicated that the e-learning course supported them to enhance their feedback processes in the clinical learning environment through identified changes to their practices. The increases in confidence providing feedback they reported were statistically significant. In addition, the e-learning course was rated highly on numerous variables related to quality. Recommendations for adaptations and additions were also highlighted.

CONCLUSIONS AND IMPLICATIONS

An e-learning course on effective and evidence-based feedback processes provides an opportunity to provide professional development to a large number of geographically dispersed practitioners in a cost-effective and flexible way. This could ensure more SLTs are confident and competent in their role as supervisor of students, which requires distinct knowledge and skills from that of a practitioner. Ultimately, this will help maximise educator and student success in the feedback process and consequently improve clinical performance and healthcare delivery.

Twelve tips for developing feedback literacy in health professions learners

Despite feedback being widely-used by health professions educators as a tool to develop clinical competencies, strategies to guide its successful implementation remain limited. In addition, health professions learners are often dissatisfied with the quality and/or volume of feedback they receive. Efforts to better engage learners in feedback processes have resulted in the development of a number of theoretical frameworks to guide educators, one being feedback literacy. Feedback literacy can be conceptualised as a learner's ability to recognise, comprehend, generate, and take action on feedback they encounter during their learning to aid health professions learners' clinical competency development. Here, we draw on both a conceptual framework of feedback literacy and other contemporary feedback literature to provide 12 practical tips by which feedback literacy can be developed in health professions learners.

Development of the Feedback Quality Instrument: a guide for health professional educators in fostering learner-centred discussions

BACKGROUND

Face-to-face feedback plays an important role in health professionals' workplace learning. The literature describes guiding principles regarding effective feedback but it is not clear how to enact these. We aimed to create a Feedback Quality Instrument (FQI), underpinned by a social constructivist perspective, to assist educators in collaborating with learners to support learner-centred feedback interactions. In earlier research, we developed a set of observable educator behaviours designed to promote beneficial learner outcomes, supported by published research and expert consensus. This research focused on analysing and refining this provisional instrument, to create the FQI ready-to-use.

METHODS

We collected videos of authentic face-to-face feedback discussions, involving educators (senior clinicians) and learners (clinicians or students), during routine clinical practice across a major metropolitan hospital network. Quantitative and qualitative analyses of the video data were used to refine the provisional instrument. Raters administered the provisional instrument to systematically analyse educators' feedback practice seen in the videos. This enabled usability testing and resulted in ratings data for psychometric analysis involving multifaceted Rasch model analysis and exploratory factor analysis. Parallel qualitative research of the video transcripts focused on two under-researched areas, psychological safety and evaluative judgement, to provide practical insights for item refinement. The provisional instrument was revised, using an iterative process, incorporating findings from usability testing, psychometric testing and parallel qualitative research and foundational research.

RESULTS

Thirty-six videos involved diverse health professionals across medicine, nursing and physiotherapy. Administering the provisional instrument generated 174 data sets. Following refinements, the FQI contained 25 items, clustered into five domains characterising core concepts underpinning quality feedback: set the scene, analyse performance, plan improvements, foster learner agency, and foster psychological safety.

CONCLUSIONS

The FQI describes practical, empirically-informed ways for educators to foster quality, learner-centred feedback discussions. The explicit descriptions offer guidance for educators and provide a foundation for the systematic analysis of the influence of specific educator behaviours on learner outcomes.

Hierarchy, "Kreng Jai" and Feedback: A Grounded Theory Study Exploring Perspectives of Clinical Faculty and Medical Students in Thailand

Phenomenon: Institutional learning culture influences how feedback is provided, accepted, and acted upon. The Thai societal culture, characterized by strict hierarchy and collectivism, may have a significant impact on the learning culture and, therefore, feedback conversations between teachers and learners. This study explored: common approaches used by faculty to provide feedback to students; and faculty and student perspectives regarding sociocultural factors that impact feedback seeking, provision, and acceptance. Approach: Using a constructivist paradigm, we explored perspectives of clinical faculty and medical students at an academic medical center in Thailand using focus groups (students) and a focus group and individual interviews (faculty). Sessions were audiotaped, transcribed, and de-identified prior to analysis. Constant comparative analysis was performed on transcripts, focusing on perceived cultural factors that impacted feedback conversations. Findings: Thirty faculty participated in the study, four participated in a focus group, and 27 participated in individual interviews. Twenty-two medical students participated in four focus groups. We identified the following key themes, which could be grouped under three categories: (1) Faculty approaches to providing feedback (1.1) Feedback should be initiated by faculty. (1.2) Feedback is initiated primarily for deficit identification and correction. (2) Factors impacting students' feedback seeking and acceptance. (2.1) Students are willing to accept harsh feedback when it provides suggestions for improvement. (2.2) Feedback is most credible when faculty have direct knowledge of the student's effort. (2.3) Feedback seeking is considered a burden on teachers. (3) Cultural factors that influence feedback (3.1) Societal hierarchy perpetuates unidirectional top-down feedback. (3.2) Kreng jai (the balance between consideration for others and self-interests) affects feedback seeking and provision. Insights: Though the value of feedback on learning was emphasized by all participants, the hierarchical culture of Thai society was perceived to have a significant influence on feedback seeking, provision, and acceptance. Identifying and addressing societal as well as institutional cultural factors would be key in designing growth-enhancing feedback initiatives relevant to the local context. One size feedback training does not fit all.

Driving lesson or driving test? : A metaphor to help faculty separate feedback from assessment

Although there is consensus in the medical education world that feedback is an important and effective tool to support experiential workplace-based learning, learners tend to avoid the feedback associated with direct observation because they perceive it as a high-stakes evaluation with significant consequences for their future. The perceived dominance of the summative assessment paradigm throughout medical education reduces learners' willingness to seek feedback, and encourages supervisors to mix up feedback with provision of 'objective' grades or pass/fail marks. This eye-opener article argues that the provision and reception of effective feedback by clinical supervisors and their learners is dependent on both parties' awareness of the important distinction between feedback used in coaching towards growth and development (assessment for learning) and reaching a high-stakes judgement on the learner's competence and fitness for practice (assessment of learning). Using driving lessons and the driving test as a metaphor for feedback and assessment helps supervisors and learners to understand this crucial difference and to act upon it. It is the supervisor's responsibility to ensure that supervisor and learner achieve a clear mutual understanding of the purpose of each interaction (i.e. feedback or assessment). To allow supervisors to use the driving lesson-driving test metaphor for this purpose in their interactions with learners, it should be included in faculty development initiatives, along with a discussion of the key importance of separating feedback from assessment, to promote a feedback culture of growth and support programmatic assessment of competence.

A self-determination theory analysis of reflective debrief themes about dietetic student placement experiences in hospital: implications for education

BACKGROUND

Healthcare placements in dietetics education contribute significantly to student learning. Exploring students' self-conceptualisation of placement experiences may provide insights to better support learning. Self-determination theory (SDT) has been used to seek insight into clinical and educational settings but has not yet been applied to dietetic placement learning. The present study investigated dietetics students' reflections of key influences on placement learning experiences and their alignment with an SDT framework.

METHODS

A post-placement two-stage critical incident debrief was conducted with seven successive cohorts (168 students) of dietetic undergraduate students on final placement. In debriefs, students' anonymous themes were collected and discussed, inductively analysed, and then mapped against an SDT framework of psychological and motivational constructs.

RESULTS

Nine key themes were identified that impacted upon placement experiences. Four themes related to framework constructs: (1) Supervisor (and Peer) Autonomy Support; (2) Perceived Competence; (3) Relatedness; and (4) Autonomy and Intrinsic Motivation. Non-SDT themes were also present, including: (5) Learning Environment and Experience; as well as themes about professional behaviours and identity: (6) Teamwork and Interactions; (7) Managing Emotions and Self-Care; (8) Dietetic Communications and Behaviours; and (9) Developing a Professional Identity.

CONCLUSIONS

Embedding a structured debrief in the curriculum and using a psychological motivational SDT framework to analyse themes arising can provide valuable information about the learning needs of students on placement with potential for wider application in dietetic learning and teaching and workforce employability. The current findings may have application in university curricula before and after professional placement.

Which Learning Activities Enhance Physical Therapist Practice? Part 2: Systematic Review of Qualitative Studies and Thematic Synthesis

OBJECTIVE

Post-professional physical therapy expertise requires career-long participation in learning activities. Understanding physical therapists' lived experience of learning activities provides novel insight into how best to enhance physical therapist practice from the perspective of the learner. The purpose of this study was to explore qualified physical therapists' experiences, beliefs, and perspectives with regard to learning activities and professional development.

METHODS

Eight databases were searched for studies published from inception through December 2018. Study selection included mixed-methods and qualitative studies exploring physical therapists' experiences, perspectives, beliefs, and attitudes. Thematic synthesis was performed, and the GRADE-Confidence in the Evidence from Reviews of Qualitative research was used to assess the level of confidence in the findings. A total 41 studies with 719 participants were included.

RESULTS

The key findings include physical therapists' perceptions that worthwhile post-professional learning requires more than attendance at professional development courses. Physical therapists perceived that worthwhile learning requires connection with others and being "taken out of one's comfort zone." Sufficient time and accessible, trustworthy resources were also valued.

CONCLUSIONS

Moderate- to low-level evidence suggests that the choice of professional development activities and education design for qualified physical therapists should consider the inclusion of connected activities, activities that take participants out of comfort zones, time to practice, and trustworthy resources that are easily accessible. Future research should evaluate the effectiveness of learning activities encompassing these factors, prioritizing those that minimize the barriers of time and distance.

IMPACT

This study adds to the profession's understanding of physical therapists' lived experience of learning activities, providing novel insight into how best to enhance physical therapist practice from the perspective of the learner.

Which Learning Activities Enhance Physical Therapist Practice? Part 1: Systematic Review and Meta-analysis of Quantitative Studies

OBJECTIVE

Following graduation from professional education, the development of clinical expertise requires career-long participation in learning activities. The purpose of this study was to evaluate which learning activities enhanced physical therapist practice.

METHODS

Eight databases were searched for studies published from inception through December 2018. Articles reporting quantitative data evaluating the effectiveness of learning activities completed by qualified physical therapists were included. Study characteristics and results were extracted from the 26 randomized controlled trials that met the inclusion criteria. Clinician (knowledge, affective attributes, and behavior) and patient-related outcomes were extracted.

RESULTS

There was limited evidence that professional development courses improved physical therapist knowledge. There was low-level evidence that peer assessment and feedback were more effective than case discussion at improving knowledge (standardized mean difference = 0.35, 95% CI = 0.09-0.62). Results were inconsistent for the effect of learning activities on affective attributes. Courses with active learning components appeared more effective at changing physical therapist behavior. The completion of courses by physical therapists did not improve patient outcomes; however, the addition of a mentored patient interaction appeared impactful.

CONCLUSION

Current evidence suggests active approaches, such as peer assessment and mentored patient interactions, should be used when designing learning activities for physical therapists. Further high-quality research focused on evaluating the impact of active learning interventions on physical therapist practice and patient outcomes is now needed.

IMPACT

This study is a first step in determining which learning activities enhance clinical expertise and practice would enable the physical therapy profession to make informed decisions about the allocation of professional development resources.

An optimal environment for placement learning: listening to the voices of speech and language therapy students

BACKGROUND

Placements are a core component of learning within speech and language therapy (SLT) undergraduate and postgraduate university programmes. They facilitate the development of students' professional and clinical competencies and socialization into the profession. It is indicated that an optimal environment for placement learning often pivots on the mentoring, supervision and feedback the student receives.

AIMS

To explore the perspectives of student SLTs in the Republic of Ireland in relation to factors that would best support their learning and competency development on placement.

METHODS & PROCEDURES

Qualitative data were collected from an anonymous online student survey that consisted of eight open-ended questions. Thematic analysis was applied to the data. Excerpts from the data were selected to illustrate the themes constructed.

OUTCOMES & RESULTS

A total of 117 students responded. Four salient themes were generated that capture the students' perspectives of an optimal environment for placement learning and competency development.

CONCLUSIONS & IMPLICATIONS

This study supports quality assurance within the practice education of student SLTs and highlights aspects of an optimal learning environment that practice educators can strive to develop. In parallel, this study points to the need for improved supports from university personnel and placement site managers, and an increased need for student preparedness and self-reflection. Implications for continuing professional development specific to the role of a practice educator is described, in addition to the recommendation of an expanded perspective of supervision within SLT. What this paper adds What is already known on the subject Placements are an integral component of SLT undergraduate and postgraduate university programmes that enable students to translate theory to practice. Placement involves a transition from structured and predictable learning of the classroom to more dynamic learning environment within the placement site. Assessment of placement is carried out by practice educators using competency assessment tools. An optimal environment for placement learning often pivots on the mentoring, supervision and feedback that the student receives from their practice educator. What this paper adds to existing knowledge This study explores student SLTs' voices in relation to what they consider an optimal environment for placement learning should be and what they believe may best support them in their journey to develop their clinical competencies. It supports quality assurance of the practice education of our future colleagues. What are the potential or actual clinical implications of this work? The findings of this enquiry emphasize the distinction between competence as a SLT and competence as a practice educator and have subsequent implications for the content of continuing professional development for practice educators. In particular, an expanded perspective of the models and frameworks of supervision to promote and implement within the practice education of SLT students is presented.

Fostering a Feedback Mindset: A Qualitative Exploration of Medical Students' Feedback Experiences With Longitudinal Coaches

PURPOSE

Feedback is important for medical students' development. Recent conceptualizations of feedback as a dialogue between feedback provider and recipient point to longitudinal relationships as a facilitator of effective feedback discussions. This study illuminates how medical students experience feedback within a longitudinal relationship with a physician coach.

METHOD

In this qualitative study, second-year medical students from the University of California, San Francisco, School of Medicine participated in semistructured interviews that explored their experiences discussing feedback within longitudinal, nonevaluative coaching relationships. Interviews occurred between May and October 2018. Interview questions addressed students' experiences receiving feedback from their coach, how and when they used this feedback, and how their relationship with their coach influenced engagement in feedback discussions. Interviews were analyzed using constructivist grounded theory.

RESULTS

Seventeen students participated. The authors identified 3 major themes. First, students' development of a feedback mindset: Over time, students came to view feedback as an invaluable component of their training. Second, setting the stage for feedback: Establishing feedback routines and a low-stakes environment for developing clinical skills were important facilitators of effective feedback discussions. Third, interpreting and acting upon feedback: Students described identifying, receiving, and implementing tailored and individualized feedback in an iterative fashion. As students gained comfort and trust in their coaches' feedback, they reported increasingly engaging in feedback conversations for learning.

CONCLUSIONS

Through recurring feedback opportunities and iterative feedback discussions with coaches, students came to view feedback as essential for growth and learning. Longitudinal coaching relationships can positively influence how students conceptualize and engage in feedback discussions.

What students and new graduates perceive supports them to think, feel and act as a health professional in a rural setting

OBJECTIVE

Clinical placements in rural locations are perceived by students to provide positive learning experiences to support their transition to practice. This study explores how clinical placements in a rural health setting might influence students and new graduates to think, feel and act as a health professional.

DESIGN

A qualitative study comprising focus group discussions was conducted.

SETTING

The study was conducted in a rural health service in Queensland, Australia.

PARTICIPANTS

Allied health students (n = 12) on placement and new graduates (n = 11) working in a regional health service.

MAIN OUTCOME MEASURES

This study identified allied health student and new graduate perspectives on clinical placement factors which support them to think, feel and act as a health professional.

RESULTS

Thematic analysis was used to understand student and new graduate perceptions of how rural placements support thinking, feeling and acting as a health professional. Suggestions for supporting learning included the following: Development of learning partnerships between students and clinical educators with inbuilt expectations and opportunities for reflection and supervision. Creating a culture where students are welcomed, valued and encouraged to take meal breaks with the team supported connectedness. The importance of balancing student autonomy with educating and grading support to increase independence.

CONCLUSIONS

Findings show clinical placement experiences identified by allied health students and new graduates which support them to begin to think, feel and act as a health professional. Suggestions provided by students and new graduates can be used to inform implementation of clinical placement experiences.

Psychological safety in feedback: What does it look like and how can educators work with learners to foster it?

CONTEXT

Feedback conversations play a central role in health professions workplace learning. However, learners face a dilemma: if they engage in productive learning behaviours (such as asking questions, raising difficulties, offering opinions or contesting ideas), they risk exposing their limitations or offending the educator. This highlights the importance of psychological safety in encouraging learners to candidly engage in interactive dialogue and the co-construction of knowledge. Previous research has recommended that building safety, trust or an educational alliance is key to productive feedback encounters. Yet it is unclear how to translate this into practice. Hence our research question was: What does psychological safety look like in workplace feedback and how can educators work with learners to foster it?

METHODS

We analysed 36 videos of routine formal feedback episodes in clinical practice involving diverse health professionals. A psychologically safe learning environment was inferred when learners progressively disclosed information and engaged in productive learning behaviours during the conversation. We used thematic analysis to identify associated educator strategies, which seemed to promote psychological safety.

RESULTS

Four themes were identified: (a) setting the scene for dialogue and candour; (b) educator as ally; (c) a continuing improvement orientation, and (d) encouraging interactive dialogue. Educators approaches captured within these themes, seemed to foster a psychologically safe environment by conveying a focus on learning, and demonstrating respect and support to learners.

CONCLUSIONS

This study builds on claims regarding the importance of psychological safety in feedback by clarifying what psychological safety in workplace feedback conversations might look like and identifying associated educator approaches. The results may offer educators practical ways they could work with learners to encourage candid dialogue focused on improving performance.

Effect of face-to-face verbal feedback compared with no or alternative feedback on the objective workplace task performance of health professionals: a systematic review and meta-analysis

OBJECTIVE

Verbal face-to-face feedback on clinical task performance is a fundamental component of health professions education. Experts argue that feedback is critical for performance improvement, but the evidence is limited. The aim of this systematic review was to investigate the effect of face-to-face verbal feedback from a health professional, compared with alternative or no feedback, on the objective workplace task performance of another health professional.

DESIGN

Systematic review and meta-analysis.

METHODS

We searched the full holdings of Ovid MEDLINE, CENTRAL, Embase, CINAHL and PsycINFO up to 1 February 2019 and searched references of included studies. Two authors independently undertook study selection, data extraction and quality appraisal. Studies were included if they were randomised controlled trials investigating the effect of feedback, in which health professionals were randomised to individual verbal face-to-face feedback compared with no feedback or alternative feedback and available as full-text publications in English. The certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations approach. For feedback compared with no feedback, outcome data from included studies were pooled using a random effects model.

RESULTS

In total, 26 trials met the inclusion criteria, involving 2307 participants. For the effect of verbal face-to-face feedback on performance compared with no feedback, when studies at high risk of bias were excluded, eight studies involving 392 health professionals were included in a meta-analysis: the standardised mean difference (SMD) was 0.7 (95% CI 0.37 to 1.03; p<0.001) in favour of feedback. The calculated SMD prediction interval was -0.06 to 1.46. For feedback compared with alternative feedback, studies could not be pooled due to substantial design and intervention heterogeneity. All included studies were summarised, and key factors likely to influence performance were identified including components within feedback interventions, instruction and practice opportunities.

CONCLUSIONS

Verbal face-to-face feedback in the health professions may result in a moderate to large improvement in workplace task performance, compared with no feedback. However, the quality of evidence was low, primarily due to risk of bias and publication bias. Further research is needed. In particular, we found a lack of high-quality trials that clearly reported key components likely to influence performance.

TRIAL REGISTRATION NUMBER

CRD42017081796.

Finding common ground: meta-synthesis of communication frameworks found in patient communication, supervision and simulation literature

BACKGROUND

Effective communication between patients-clinicians, supervisors-learners and facilitators-participants within a simulation is a key priority in health profession education. There is a plethora of frameworks and recommendations to guide communication in each of these contexts, and they represent separate discourses with separate communities of practice and literature. Finding common ground within these frameworks has the potential to minimise cognitive load and maximise efficiency, which presents an opportunity to consolidate messages, strategies and skills throughout a communication curriculum and the possibility of expanding the research agenda regarding communication, feedback and debriefing in productive ways.

METHODS

A meta-synthesis of the feedback, debriefing and clinical communication literature was conducted to achieve these objectives.

RESULTS

Our analysis revealed that the concepts underlying the framework can be usefully categorised as stages, goals, strategies, micro-skills and meta-skills. Guidelines for conversations typically shared a common structure, and strategies aligned with a stage. Core transferrable communication skills (i.e., micro-skills) were identified across various types of conversation, and the major differences between frameworks were related to the way that power was distributed in the conversation and the evolution of conversations along the along the path of redistributing power. As part of the synthesis, an overarching framework "prepare-EMPOWER enact" was developed to capture these shared principles across discourses.

CONCLUSIONS

Adopting frameworks for work-based communication that promote dialogue and empower individuals to contribute may represent an important step towards learner-centred education and person-centred care for patients.

Challenging feedback myths: Values, learner involvement and promoting effects beyond the immediate task

CONTEXT

Research suggests that feedback in the health professions is less useful than we would like. In this paper, we argue that feedback has become reliant on myths that perpetuate unproductive rituals. Feedback often resembles a discrete episode of an educator "telling," rather than an active and iterative involvement of the learner in a future-facing process. With this orientation towards past events, it is not surprising that learners become defensive or disengaged when they are reminded of their deficits.

METHODS

We tackle three myths of feedback: (a) feedback needs praise-criticism balancing rules; (b) feedback is a skill residing within the teacher; and (c) feedback is an input only. For each myth we provide a reframing with supporting examples from the literature.

CONCLUSIONS

Equipping learners to engage in feedback processes may reduce the emotional burden on both parties, rendering techniques such as the feedback sandwich redundant. We also highlight the benefits for learners and teachers of conceptualising feedback as a relational activity, and of tracing the effects of information exchanges. These effects may be immediate or latent, and may manifest in different forms such as changes in learner evaluative judgement or professional identity.

A Focus on Feedback: Improving Learner Engagement and Faculty Delivery of Feedback in Hospital Medicine

Feedback is an integral part of medical education. However, there is great variation of training and effectiveness of feedback delivery, especially in the inpatient setting. The unique learning environment provided in hospital medicine allows teachers the opportunity to provide feedback on learner performance under several longitudinal observations in areas such as direct patient care, procedural tasks, and interdisciplinary team leadership skills. Most important, feedback should occur on more than one occasion to truly empower change in knowledge, attitude, and skills. This article aims to provide the reader with foundational theories on feedback and strategies to use best practices for delivery.

Educators' behaviours during feedback in authentic clinical practice settings: an observational study and systematic analysis

BACKGROUND

Verbal feedback plays a critical role in health professions education but it is not clear which components of effective feedback have been successfully translated from the literature into supervisory practice in the workplace, and which have not. The purpose of this study was to observe and systematically analyse educators' behaviours during authentic feedback episodes in contemporary clinical practice.

METHODS

Educators and learners videoed themselves during formal feedback sessions in routine hospital training. Researchers compared educators' practice to a published set of 25 educator behaviours recommended for quality feedback. Individual educator behaviours were rated 0 = not seen, 1 = done somewhat, 2 = consistently done. To characterise individual educator's practice, their behaviour scores were summed. To describe how commonly each behaviour was observed across all the videos, mean scores were calculated.

RESULTS

Researchers analysed 36 videos involving 34 educators (26 medical, 4 nursing, 4 physiotherapy professionals) and 35 learners across different health professions, specialties, levels of experience and gender. There was considerable variation in both educators' feedback practices, indicated by total scores for individual educators ranging from 5.7 to 34.2 (maximum possible 48), and how frequently specific feedback behaviours were seen across all the videos, indicated by mean scores for each behaviour ranging from 0.1 to 1.75 (maximum possible 2). Educators commonly provided performance analysis, described how the task should be performed, and were respectful and supportive. However a number of recommended feedback behaviours were rarely seen, such as clarifying the session purpose and expectations, promoting learner involvement, creating an action plan or arranging a subsequent review.

CONCLUSIONS

These findings clarify contemporary feedback practice and inform the design of educational initiatives to help health professional educators and learners to better realise the potential of feedback.

Examining the Impact of Using the SIMPL Application on Feedback in Surgical Education

OBJECTIVE

The System for Improving and Measuring Procedural Learning (SIMPL) smartphone application allows physicians to provide dictated feedback to surgical residents. The impact of this novel feedback medium on the quality of feedback is unknown. Our objective was to compare the delivery and quality of best-case operative performance feedback given via SIMPL to feedback given in-person.

DESIGN

We collected operative performance feedback given both in-person and via SIMPL from surgeons to residents over 6 weeks. Feedback transcripts were coded using Verbal Response Modes speech acts taxonomy to compare the delivery of feedback. We evaluated quality of feedback using a validated resident survey and third-party assessment form.

SETTING

University of Wisconsin School of Medicine and Public Health, a large academic medical institution.

PARTICIPANTS

Four surgical attendings and 9 general surgery residents.

RESULTS

Nineteen SIMPL and 18 in-person feedback encounters were evaluated. Feedback via SIMPL was more directive (containing thoughts, perceptions, evaluations of resident behavior, or advice) and contained more presumptuous utterances (in which the physician reflected on and assessed resident performance or offered suggestions for improvement) than in-person feedback (p = 0.01). The resident survey showed no significant difference between the quality of feedback given via SIMPL and in-person (p = 0.07). The mean score was 47.74 (SD = 3.00) for SIMPL feedback and 45.33 (SD = 4.77) for in-person feedback, with a total possible score of 50. Third-party assessment showed no significant difference between the quality of feedback given via SIMPL and in-person (p = 0.486). The mean score was 23.40 (SD = 3.75) for SIMPL feedback and 22.25 (SD = 5.94) for in-person feedback, with a total possible score of 30.

CONCLUSIONS

Although feedback given via SIMPL was more direct and based on the attendings' perspectives, the quality of the feedback did not differ significantly. Use of the dictation feature of SIMPL to deliver resident operative performance feedback is a reasonable alternative to in-person feedback.

The role of feedback in ameliorating burnout

PURPOSE OF REVIEW

Assessment of the current literature surrounding interventions directed toward the prevention of burnout in the field of medicine and particularly in anesthesiology.

RECENT FINDINGS

Recently, burnout has been noted to lead to medication errors and subsequently increased harm to our patients. On a personal level, burnout can lead to depression and even suicide amongst physicians. Strategies to prevent burnout amongst anesthesiologists that have been studied in the literature include multisource feedback, mentorship and early recognition.

SUMMARY

There remains no clear or definitive intervention to prevent burnout for physicians. However, changing our environment to embrace mentorship, the continual exchange of feedback and the fostering self-care could startlingly improve our work environment.

Effect of individual structured and qualified feedback on improving clinical performance of dental students in clinical courses-randomised controlled study

AIM

Analysis of the effect of individual structured and qualified feedback (FB) on practical skills development of dental students during clinical courses.

METHODS

Fifty-three final-year dental students at Jena University Hospital participated in this prospective randomised controlled interventional study. Two calibrated assessors evaluated 128 pre- and post-assessments of 4 different dental treatment steps performed by dental students during the integrated clinical course in restorative dentistry and prosthodontics and the clinical course paediatric dentistry. The assessment included direct observation, graded and non-grading evaluation and was documented with a specific FB assessment tool. Dental students in the intervention group (IG) received an elaborated, structured and qualified FB after the pre-assessment that focussed on individual strengths and weaknesses, providing specific suggestions for improvement and establishing a personal learning goal. Participants were randomly allocated to the IG and the control group (CG).

RESULTS

In both groups, dental students significantly enhanced their performance, but the difference was higher in the IG than in the CG. Large effect sizes (ES) were observed in all observed items, but FB had largest effect size in improving technical skills (ES = 1.6), followed by management (ES = 1.3) and communication skills (ES = 0.8). Factors with the highest influence on FB in enhancing dental students' clinical performance were their insight into their own mistakes or omissions, the observed dental treatment step and the duration of FB.

CONCLUSION

Individual structured and qualified FB is an effective method to enhance dental students' professional performances and to individually guide the learning process.

The Art (and Artifice) of Seeking Feedback: Clerkship Students' Approaches to Asking for Feedback

PURPOSE

As attention has shifted to learners as significant partners in feedback interactions, it is important to explore what feedback-seeking behaviors medical students use and how the faculty-student relationship affects feedback-seeking behaviors.

METHOD

This qualitative study was inspired by the organizational psychology literature. Third-year medical students were interviewed at Maine Medical Center in April-May 2017 after completing a traditional block rotation clerkship or a nine-month longitudinal integrated clerkship (LIC). A constructivist grounded theory approach was used to analyze transcripts and develop themes.

RESULTS

Fourteen students participated (eight LIC, six block rotation). Themes associated with why students sought feedback included goal orientations, perceived benefits and costs, and student and feedback provider characteristics. Factors influencing the way students sought feedback included busy environments, timing, and cues students were attuned to. Students described more inquiry than monitoring approaches and used various indirect and noninquiry techniques (artifice) in asking for feedback. Students did not find summative feedback as helpful as seeking feedback themselves, and they suggested training in seeking feedback would be beneficial. Faculty-student relationship dynamics included several aspects affecting feedback-seeking behaviors, and relationship differences in the LIC and block models affected feedback-seeking behaviors.

CONCLUSIONS

Medical students have many motives to seek feedback and adapt their feedback-seeking behaviors to actively participate in an intricate dialogic interaction with feedback providers. Students gradually refine the art (and artifice) of obtaining the specific feedback information that meets their needs. The authors offer a prototype curriculum that may facilitate students' development of feedback-seeking skills.

Top Medical Education Studies of 2016: A Narrative Review

Education, like clinical medicine, should be based on the most current evidence in the field. Unfortunately, medical educators can be overwhelmed by the sheer volume and range of resources for this literature. This article provides an overview of 15 articles from 2016 that the authors consider the top articles in the field of pediatric medical education. The 7 authors, all medical educators with combined leadership and expertise across the continuum of pediatric medical education, used an iterative 3-stage process to review more than 6339 abstracts published in 2016. This process was designed to identify a small subset of articles that were most relevant to educational practices and most applicable to pediatric medical education. In the first 2 stages, pairs of authors independently reviewed and scored abstracts in 13 medical education-related journals and reached consensus to identify the articles that best met these criteria. In the final stage, all articles were discussed using a group consensus model to select the final articles included in this review. This article presents summaries of the 15 articles that were selected. The results revealed a cluster of studies related to observed standardized clinical encounters, self-assessment, professionalism, clinical teaching, competencies/milestones, and graduate medical education management strategies. We provide suggestions on how medical educators can apply the findings to their own practice and educational settings. This narrative review offers a useful tool for educators interested in keeping informed about the most relevant and valuable information in the field.

Coaching the Debriefer: Peer Coaching to Improve Debriefing Quality in Simulation Programs

STATEMENT

Formal faculty development programs for simulation educators are costly and time-consuming. Peer coaching integrated into the teaching flow can enhance an educator's debriefing skills. We provide a practical guide for the who, what, when, where, why, and how of peer coaching for debriefing in simulation-based education. Peer coaching offers advantages such as psychological safety and team building, and it can benefit both the educator who is receiving feedback and the coach who is providing it. A feedback form for effective peer coaching includes the following: (1) psychological safety, (2) framework, (3) method/strategy, (4) content, (5) learner centeredness, (6) co-facilitation, (7) time management, (8) difficult situations, (9) debriefing adjuncts, and (10) individual style and experience. Institutional backing of peer coaching programs can facilitate implementation and sustainability. Program leaders should communicate the need and benefits, establish program goals, and provide assessment tools, training, structure, and evaluation to optimize chances of success.

An Evaluation of the Use of Student Response Systems in Teaching Diagnostic Reasoning for Physicians

Background

Feedback is an aspect of teaching strategy that facilitates the learners to achieve expertise in the necessary skills for effective diagnostic reasoning. Several studies have demonstrated that student response systems (SRSs) are useful for enhancing learner engagement and obtaining immediate feedback. We aimed to examine the experiences of learners who used SRSs in a diagnostic reasoning class.

Methods

In 2016, an observational study was conducted on a 4-hour training course on "improving physicians' diagnostic process" that included 34 physicians. The Zuvio multimedia online interactive system was used. The learners could use smartphones to respond to the questions. A 5-point Likerttype scale quantitative questionnaire was designed to explore the viewpoints of the learners regarding the students' engagement, feedback, and outcomes. The learners were requested to complete a brief qualitative feedback form that included the following two sections: (1) the benefi ts and (2) the challenges of using SRSs. Qualitative and quantitative methods were used for data analyses.

Results

Total 32 participants (response rate: 94%) completed the questionnaire. Most respondents reported that using the SRSs enabled them to concentrate more effectively, express themselves in a stressfree environment, strengthen their interactions with peers and teachers, improve their participation in discussions, and obtain useful feedback. Three themes were identified from the qualitative results: (1) facilitating learning, (2) hardware limitations, and (3) question-development skills.

Conclusion

The SRSs can be easily implemented and positively affect the teaching of diagnostic reasoning. However, teachers should develop question-development skills so that the systems function more effectively in the instruction of diagnostic reasoning.

Faculty feedback that begins with resident self-assessment: motivation is the key to success

CONTEXT

The seeking and incorporating of feedback are necessary for continuous performance improvement in medicine. We know that beginning feedback conversations with resident self-assessment may reduce some of the tensions experienced by faculty staff. However, we do not fully understand how residents experience feedback that begins with self-assessment, and whether any existing theoretical frameworks can explain their experiences.

METHODS

We conducted a constructivist grounded theory study exploring physical medicine and rehabilitation residents' experiences as they engaged in a structured self-assessment and faculty staff feedback programme. Utilising purposive sampling, we conducted 15 individual interviews and analysed verbatim transcripts iteratively. We implemented several procedures to enhance the credibility of the findings and the protection of participants during recruitment, data collection and data analysis. After defining the themes, we reviewed a variety of existing frameworks to determine if any fitted the data.

RESULTS

Residents valued self-assessment followed by feedback (SAFF) and had clear ideas of what makes the process useful. Time pressures and poor feedback quality could lead to a process of 'just going through the motions'. Motivation coloured residents' experiences, with more internalised motivation related to a more positive experience. There were no gender- or year of training-related patterns.

CONCLUSIONS

Self-determination theory provided the clearest lens for framing our findings and fitted into a conceptual model linking the quality of the SAFF experience and residents' motivational loci. We identified several study limitations including time in the field, evolving characteristics of the SAFF programme and the absence of faculty voices. We believe that by better understanding residents' experiences of SAFF, educators may be able to tailor the feedback process, enhance clinical performance and ultimately improve patient care.

Positive Change in Feedback Perceptions and Behavior: A 10-Year Follow-up Study

BACKGROUND

Providing and learning from feedback are essential components of medical education, and typically described as resistant to change. But given a decade of change in the clinical context in which feedback occurs, the authors asked if, and how, perceptions of feedback and feedback behaviors might have changed in response to contextual affordances.

METHODS

In 2017, the authors conducted a follow-up, ethnographic study on 2 general pediatric floors at the same children's hospital where another ethnographic study on a general pediatric floor was conducted in 2007. Data sources included (1) 21 and 34 hours of observation in 2007 and 2017, respectively, (2) 35 and 25 interviews with general pediatric attending physicians and residents in 2007 and 2017, respectively, and (3) a review of 120 program documents spanning 2007 to 2017. Data were coded and organized around 3 recommendations for feedback that were derived from 2007 data and served as standards for assessing change in 2017.

RESULTS

Data revealed progress in achieving each recommendation. Compared with 2007, participants in 2017 more clearly distinguished between feedback and evaluation; residents were more aware of in-the-moment feedback, and they had shifted their orientation from evaluation and grades to feedback and learning. Explanations for progress in achieving recommendations, which were derived from the data, pointed to institutional and national influences, namely, the pediatric milestones.

CONCLUSIONS

On the basis of follow-up, ethnographic data, changes in the clinical context of pediatric education may afford positive change in perceptions of feedback and feedback behavior and point to influences within and beyond the institution.

Feedback Quality Using an Observation Form

BACKGROUND

Direct observations with focused feedback are critical components for medical student education. Numerous challenges exist in providing useful comments to students during their clerkships. Students' evaluations of the clerkship indicated they were not receiving feedback from preceptors or house officers.

OBJECTIVE

To encourage direct observation with feedback, Structured Patient Care Observation (SPCO) forms were used to evaluate third-year medical students during patient encounters.

DESIGN

In 2014-2015, third-year medical students at a Midwestern medical school completing an 8-week pediatrics clerkship provided experiences on inpatient wards and in ambulatory clinics. Students were expected to solicit feedback using the SPCO form.

RESULTS/FINDINGS

A total of 121 third-year medical students completed the pediatrics clerkship. All of the students completed at least one SPCO form. Several students had more than one observation documented, resulting in 161 SPCOs submitted. Eight were excluded for missing data, leaving 153 observations for analysis. Encounter settings included hospital (70), well-child visits (34), sick visits (41), not identified (8). Observers included attending physicians (88) and residents (65). The SPCOs generated 769 points of feedback, comments coalesced into themes of patient interviews, physical examination, or communication with patients and family. Once themes were identified, comments within each theme were further categorized as either actionable or reinforcing feedback.

DISCUSSION

SPCOs provided a structure to receive formative feedback from clinical supervisors. Within each theme, reinforcing feedback and actionable comments specific enough to be useful in shaping future encounters were identified.

Impact of Performance Feedback in Family-Centered and Culturally Responsive Interview Instruction

PURPOSE

Conducting culturally responsive and family-centered diagnostic interviews is an important part of speech and language services. However, there is limited information on the effective ways to teach speech-language pathology graduate students to acquire these skills. The purpose of this study was to examine the effect of performance feedback on graduate students' use of ethnographic principles, open-ended questions, and restating and summarizing comments in caregiver interviews.

METHOD

A randomized controlled crossover design (n = 26) was used to examine the differential effects of students receiving performance feedback or general feedback on role-play interviews. Ethnographic principles, open-ended questions, and restating and summarizing comments were measured at 3 time points: after class instruction (Groups 1 and 2), after the first feedback type allocation (Group 1: performance feedback; Group 2: general feedback), and after the second feedback type allocation (Group 1: general feedback; Group 2: performance feedback).

RESULTS

Statistically significant increases, with large effect sizes, were found in students' use of ethnographic principles, open-ended questions, and restating and summarizing comments following the performance feedback conditions.

CONCLUSION

These findings suggest that performance feedback is an effective and efficient instructional procedure to increase culturally responsive and family-centered interview skills through an ethnographic interview approach in preservice speech-language pathology students.