HOW TO GIVE FEEDBACK TO LEARNERS
The goal of this chapter is to provide instructors with the knowledge and skills necessary for giving effective feedback to participants in an ALSO® Provider Course.
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By the end of this chapter, instructors will be able to: Discuss the importance of feedback in the learning process. List characteristics of effective feedback. Demonstrate how to give feedback appropriately to different types of learners at an ALSO® Provider Course.
The term feedback originated in the 1940s in the rocketry industry, where it referred to data being fed back to a rocket in flight to ensure that the rocket stayed on target. In educational terms, feedback from a teacher to a learner provides information that enables the learner to stay on target to reach a pre-stated goal; in other words, this chapter really is rocket science! Feedback is not an emotionally neutral term. It can be difficult to provide in a comfortable and positive manner. Often, both instructor and student will have had only unpleasant experiences in the past (including medical school where some teaching is done by humiliating the learner in front of their peers) and because feedback may have been mixed with evaluation. Feedback is simply the providing of information (not judgement) to enable the learner to stay on target, with the aim being to help the learner. Evaluation, in contrast, is a more summative and judgmental report based on observations of how a learner performs in relation to other peers. By separating these activities, instructors can become more comfortable and willing to provide feedback knowing that it should help the learner achieve competency in a particular area. Given the same instructional time, learners who receive feedback will show greater gains than those without feedback. Learning something new is like walking over uncharted ground, and feedback can inform the learner where they are going astray, or even confirm that they are going in the right direction.
Without feedback even a confident learner has no way of knowing that they are performing a new task well. Good performance needs reinforcing in just the same way that mistakes need correcting. Any learner will search for clues as to how they are doing. Without formal feedback the learner is left relying on cues from the instructor - looks of boredom, irritation, or amusement - which may have nothing to do with what the learner is doing. By comparison, research has demonstrated that giving feedback to learners increases their rate of improvement of new tasks, encourages higher levels of performance in tasks already practiced, makes tasks more interesting and less fatiguing, and helps learner motivation.
Why Give Feedback?
Instructors should see feedback as being provided at different levels. Each level of feedback is important and should be used at different times with participants in an ALSO® Provider Course. 1. Level One Feedback This is simply a sharing of observations, much like watching a videotape recording. It is factual information. For example, an instructor may tell a learner: “When I watched you applying the forceps, I noticed that you held the blades upside down.” This type of observational feedback is often the easiest for the learner to hear and accept. 2. Level Two Feedback This level of feedback includes the personal reactions of the instructor in the process. For example, an instructor may say: “When I see you struggling to remember the mnemonic for shoulder dystocia, it makes me feel that you did not read and prepare in advance for this course,” or “When I see you yelling at the nurse to get help, it makes me uncomfortable. I believe you panicked in this situation, rather than staying calm and in control.” This type of feedback provides the learner with information that they would not otherwise have. It can be provided in a constructive manner that helps to build the relationship between instructor and participant. Unlike level one, this type of feedback is necessarily subjective-“it makes me feel,” or “I believe…”. This is appropriate as long as both the learner and instructor recognise that the comments are subjective. 3. Level Three Feedback This level of feedback is based upon the experience of the instructor, and includes a prediction of the outcome of a situation if the learner does not correct their performance, highlighting the gap between intended and actual results. For example, an instructor who is teaching the workstation on shoulder dystocia may say to a learner: “If you continue to pull with that much force, you are likely to increase the likelihood of the infant developing a nerve palsy, or an unintentional clavicle fracture.” This type of feedback emphasizes not only the process, but also what is to come, allowing the learner to consider the consequences of their actions.
Levels of Feedback
Principles of Effective Feedback
There are some guiding principles that will help instructor candidates become effective in providing feedback to ALSO® Provider Course participants. ALSO® courses have many mnemonics, here is another to consider: TOFF Feedback should be: Timely Ordered Focused Forward-looking
1. Feedback should be timely Feedback should be delivered as close in time to the observed incident as possible. It will be most relevant and most useful if given as soon as the learner has completed the task - not during a meal break or the next day at the megadelivery testing station! At an ALSO® course, feedback is likely to be given within a group setting, where it can benefit the learner as well as others in the group. However, when the feedback may be emotionally charged or difficult for the learner to receive, it may be better to provide in private. 2. Feedback should be ordered. Feedback should start with instructors inviting learners to assess their own skills. A British psychologist, David Pendleton, found when studying consultations in General Practice (Family Medicine) that feedback worked best if the learner was first invited to describe what they did well, then to comment on what might have been done differently. Only after this did the instructor comment, again noting what went well before offering any advice about altering practice. Often, the learner will recognize the problem without the instructor having to provide feedback, and it is usually easier for learners to receive feedback if they have provided it themselves. When possible, learners should be given the opportunity to react to the feedback and be involved in creating plans for improvement. It is helpful to end the process on a positive note, as it is easier to take bitter medicine if one is allowed fruit juice to wash it down afterwards! 3. Feedback should be focused. Feedback is most useful when it is focused on behavior and performance. Simply saying, “Good job” or “You need to work on improving your skills” does not identify specific areas for the learner to work on. Feedback should be tied to specific actions which the instructor observed and should not include the instructor’s speculation regarding reasons for a performance gap, or a learner’s level of motivation. It would not be effective for an instructor to say: “At the shoulder dystocia workstation, you didn’t seem interested in mastering the Wood’s screw manoeuvre.” A better way of stating this problem would be for the instructor to say: “You correctly diagnosed a shoulder dystocia and called for help, but seemed to have trouble performing the Wood’s screw manoeuvre. Let’s do just that portion again, with you discussing each step as you do it.” 4. Feedback should be forward looking. If the purpose of feedback is to improve future performance then it should include the development of a plan for improving knowledge or skills, preferably using learner input. Unlike the rocket, students can not only be put back on track, but can learn from feedback how to avoid problems arising in the future. It may be helpful for the teacher and the student together to develop an action plan. This, like the feedback itself, needs to be focused: “You need to go over forceps again,” is not as helpful as, “Your knowledge of forceps is very good, but you could benefit from more practice to improve your manual skills in positioning them properly.”
Most learners in an ALSO® Provider Course are well prepared and eager to learn and accept feedback. However, instructors occasionally encounter a learner who is challenging to teach. Many of these learners fit into certain patterns of difficulty which will need specific responses from the teacher for the learner to benefit from feedback (and to avoid the teacher inviting a hostile response). 1. The Overachiever: This learner is well prepared and wants to be sure that the instructor (and everyone else!) knows that he or she has mastered the material in the ALSO® Syllabus. Effective strategies for dealing with this type of learner include: • • • Be polite but firm: “Thanks for that suggestion, but I’d like a colleague to answer this question…” Don’t allow yourself to be side tracked — acknowledge the student’s contribution but return to the agenda “you obviously have some strong opinions on this, but we really must get onto the next topic” Don’t get into arguments — “We appreciate hearing your perspective, but this is what we are suggesting, in keeping with the materials for this course…”
Dealing with Difficult Learners
2. The Uninterested Learner: This learner sits in the back of the small group workstation and never says a word. Assessing their knowledge and skill level will be difficult at best. Specific strategies for dealing with this student are: • • • • Make eye contact Ask specific questions using the learner’s name Ask the learner for specific contributions (e.g. reciting parts of a mnemonic) Privately ask the learner about their lack of participation, and attempt to understand possible reasons for this behavior. These include shyness, tiredness after a night oncall, feeling unwell and depression. This student may respond better to private feedback and the teacher should try to find a chance to discuss this privately.
3. The Angry Learner: This participant may have been made to take the course by supervisors or employers. They do not really wish to be at the course, especially as it is occurring over a weekend. Specific strategies for dealing with this learner include: • • • • Acknowledge the emotion: “I can see that you feel angry about something…” Ask for feedback: “What has happened to make you feel…” Ask learner to suggest solutions: “What could we do to improve…” Do not let yourself be bullied!
4. The Fearful or Unprepared Learner: They are fearful that they do not know the information adequately, or that the instructor will be too harsh in assessing their knowledge; this learner is particularly uncomfortable “presenting” in front of other learners. Specific strategies for dealing with this learner include:
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Emphasize to the learner what was done well. Put any negative feedback into the context of the whole assessment: “X, Y and Z were done very well. The area which needs development is A, because…” Focus this learner on development of skills: “How do you think you could do X better?”
5. The Argumentative Learner: This learner has been practicing maternity care for many years and knows everything there is to know about intrapartum emergencies. Strategies for dealing with the argumentative student include: • • • Acknowledge this learner’s position: “It’s clear you feel strongly about this topic” Restate your position: “The reason I think you need to improve in this area is…” Always remember that you cannot make another person accept your point of view. This is why feedback is so much more effective if the learner can provide it himself. (“A man convinced against his will is of the same opinion still.”)
Every learner can benefit from effective feedback. Even a “star” student can feel more secure knowing that their knowledge and skills have been validated. A learner who is struggling and feels lost can be encouraged and brought back from the wilderness by a teacher who can lead the way. However, feedback is a potent teaching tool and must therefore be used with great care. Any instructor doubting this need only think back to the last time that they were given feedback. However strong and grown-up we may appear by the time we take an ALSO® course, inside we are still capable of being badly hurt by the clumsiness of others, especially if that “other ” is in a position of authority. The best guideline for giving feedback is as with much else in life - provide feedback the way you would want to receive it. Feedback should be given respectfully and honestly, with the purpose being to help the learner enhance their efforts to reach the goals set before them.
Original Author: Gavin Young MA FRCGP, General Practitioner, Temple Sowerby, Penrith, Cumbria, U.K. Modified by ALSO® NZ Ltd 2005