1. Eric Bater Trainers’ group 7th December 2010
Giving feedback
Eric Bater
Trainers’ group
7th December 2010

2. Personal aims for workshop

3. Principles of feedback
Relating to purpose of feedback
Relating to substance of feedback
Relating to the practicalities of feedback

4. Section 1
Purpose of feedback

5. Blindfold exercise

6. If we don’t give feedback what is the learner gaining (or assuming)?
The blindfold game
If we don’t give feedback what is the learner gaining (or assuming)?
Failing to give feedback sends false messages, and can lead to a lack of trust in the teacher.

7. ‘Oh wad some Pow’r the giftie gie us To see oursels as others see us!
It wad fre mony a blunder free us
And foolish notion
Robert Burns 1786

8. The Johari Window

9. So, what is feedback?
Feedback is structured information that one person offers to another, about the impact of their actions or behaviour

10. Why give feedback? Influence someone to change Recognise and reward
Improve quality of work
Build and maintain relationships
Clarify expectations
Influence motivation
Manage performance

11. Why give feedback?
Helps learners to maximise their potential at different stages of training
Raises awareness of strengths and areas for improvement
Identifies actions to be taken to improve performance

12. ......Or as the man said
‘Without feedback, mistakes go uncorrected, good performance is not reinforced, and clinical competence is achieved empirically, if at all’
Jack Ende ‘Feedback in Clinical Medical education’
JAMA 1983

13. Party time

14. Linking feedback to the learning process The Kolb cycle 1984

15. Hill 2007
‘Feedback plays an important role in helping learners move round the cycle. For example feedback supports the process of reflection and the consideration of new or more in-depth theory. Through negotiation it can help the learner plan productively for their next learning experience’
For that we need an understanding of :-
Where is the learner in terms of their learning, level reached, past experience, goals and understanding of learning needs’
Learning goals in terms of knowledge, technical skills and attitudes

16. The Pygmalion effect
Might our expectations as teachers affect the performance of our learners?

17. ‘The Pygmalion effect’
‘I shall always be a flower girl to Professor Higgins because he treats me as a flower girl..But I know I can be a lady to you because you always treat me as a lady, and always will’

18. ‘Pygmalion in the classroom’ Rosenthal and Jacobson 1992’
Students whom their teachers believed to be high performers achieved higher increase in IQ scores after 1 year than pupils whom teachers believed to be lower performers. The ‘selection’ test was random.

19. Treat a man as he is and he will remain as he is
Treat a man as he is and he will remain as he is. Treat a man as he can and should be and he will become as he can and should be. Johan Wolfgang Van Goethe

20. Section 2
Substance of feedback

21. So, what are our sources of evidence?

22. RCGP competence areas Relationships Diagnostics Management
Professionalism

23. Feedback should be......

24. And here’s one I made earlier

25. Principles of effective feedback (1)
Descriptive
Specific
Focussing on behaviours
It should be for the learner’s benefit
Sharing information rather than giving advice
Limited to the amount the learner can use, not the amount you want to give
Solicited rather than imposed
Feedback only about something which can be changed

26. Principles of effective feedback (II)
9. Feedback should be timely and regular
10. Focus on the positive
Give feedback privately (especially negative feedback)
Linked to learner’s overall professional development
Stay in the ‘here and now’
Use ‘I’ and give your experience of the behaviour

27. Principles of effective feedback (III)
15. When giving negative feedback suggest alternative behaviours 16. Give suggestions rather than prescriptions 17. Be sensitive to the impact of your message 18. Congruence between verbal and non-verbal messages 19. Balanced 20. Encouraging reflection 21. Clear and direct

28. Principle 1 It should be descriptive
Giving an accurate description of the behaviour you are talking about
Avoiding ‘judging’ or ‘labelling’

29. Principle 2. It should be specific
Be clear about what aspect of performance or behaviour you want to talk about
Not generalised.

30. Principle 3. Performance focussed
Concentration on the things that can be changed, linking feedback to the task or role.
Not person focused (personality, character, attitude, or things the person cannot change)

31. Principle 4 Feedback should be for the learner’s benefit

32. Principle 5 Feedback should be sharing information
Not giving of advice

33. Principle 6 Don’t overload
Identify two or three key messages that you summarise at the end

34. Principle 7. Feedback should be offered
Signal that you would like to give some feedback, and why you want to give it – wait for the person to accept the offer
Not imposed

35. Principle 8 Give feedback only about something that can be changed

36. Principle 9 Feedback should be timely and regular
Talk at the appropriate moment soon after the incident. Offer feedback often. Frequent feedback gives more practice.
Not rare, after incident is ‘stale’, not ‘batched’.

37. Principle 10 Focus on the positive

38. Principle 11 Give feedback privately
Especially more negative feedback

39. Principle 12 Feedback should be given as part of a communication process
Used as part of a ‘developmental dialogue’ Using skills such as rapport, developing respect, and trust with the learner

40. Principle 13 Stay in the ‘here and now’
Don’t bring up old concerns and previous mistakes unless this is to highlight a pattern of behaviours

41. Principle 14. Feedback should be owned
Speak for yourself – showing the words and feelings are your own
Not side-stepped, mixing your thoughts and feelings with those of other people

42. Principle 15 Solution-focused
Show willingness to give ideas about how the person can tackle the issues raised.
Not focusing on the problem and its potential outcome.

43. Principle 16 Offer suggestions
Rather than giving ‘prescriptions’

44. Principle 17 Show sensitivity
Be sensitive to the impact of your message Feedback is for the recipient, not the giver

45. Principle18 There should be congruence between verbal and non-verbal messages

46. Principle 19 Feedback should be balanced
Include a positive message to balance points about less effective behaviour Not one-sided

47. Principle 20 Encourage reflection
‘Did it go as planned?
How did you feel the patient felt? What have you learned?
What would you differently next time?

48. Principle 21 Be clear and direct
Use plain clear language Be brief and to the point Poor feedback leaves the recipient in doubt about what was meant

49. Practicalities of giving feedback
Section 3
Practicalities of giving feedback

50. The old feedback sandwich
Praise
Criticism

51. Pendleton’s rules Check learner is ready for feedback
Let learner give comments /background on the material being assessed
The learner states what was done well
Observer(s) state what was done well
Learner states what could be improved
Observer(s) states how it could be improved
An action plan for improvement is made

52. The new feedback sandwich
Ask
Tell

53. Ask learner to assess their own performance
Ask learner to assess their own performance. Phrase questions to encourage reflection

54. Tell what you observed, using specific observed behaviours

55. Ask about recipient’s understanding and strategies for improvement
What could have been done differently?
Offer own suggestions
Commit to monitoring improvement together

56. A visit to the office

57. Let’s give it a go

58. Gibbs cycle 1988

59. The SET-GO Approach to Feedback, Silverman et al (1997)
Describe what was Seen/experience; be descriptive, specific , non-judgemental
Probe to discover what Else was seen/experienced; what happened next in descriptive terms?
Trainee describes what was Thought at the time; reflect back to experience
Clarify what Goal the trainee would like to achieve; use an outcome based approach
Explore Offers on how to achieve the goal; take suggestions and discuss alternatives

60. Additional cautions for trainers:- Parsloe (1995)
Don’t take the relationship for granted, especially if you’ve worked with learner for some time
Learner may be in dependant or subordinate role
Be clear about expectations
Aim for supportive, relaxed, informal environment

61. Common pitfalls in giving feedback
A negative emphasis
A ‘flavour of the month’ approach
A lack of confidentiality
Poor communication
Having no action or support

62. Barriers to feedback process. 1) Difficulties in giving feedback
Believing the feedback is negative and unhelpful
Worrying the other person won’t like you
Believing the other person can’t handle feedback
Previous experience where no change occurred, or reaction was hostile
Feeling feedback isn’t worth the risk

63. Barriers to the feedback process 2) Receiving corrective feedback
Having the urge to rationalise, since criticism can feel uncomfortable
Believing self-worth is diminished by suggestions for improvement
Previous experience where feedback was unhelpful or unjustified

64. End on Ende
‘The important things to remember about feedback in medical education are that:-
It is necessary
It is valuable
After a bit of practice and planning it is not as difficult as one might think’

69. More Hot Tips on Feedback
Congruency, Consistency & Honesty are important
“Feedback that doesn’t talk about the other is just talking about yourself”. Often, criticism is disguised as feedback. Criticism is NOT feedback and is often delivered more to make the giver feel better than to really help the recipient improve their performance.
The “See-Hear” Method
Tell the person what you saw or heard and the effect it had on you, rather than merely something was good or bad.
For example, “the tone of voice as you said that really made me feel you were concerned.” Is better than “that was good”
Start with the positive.
Accept and digest the feedback, especially the positive. It often helps for the receiver to hear what he/she did well first before going on to what can be done differently. Unfortunately we live in a culture that emphasises the negative. If the positive is registered first, any subsequent negative is more likely to be listened to and accepted.
Don’t overload the receiver. And remember, it has to be BALANCED.
You may have that urge to impart all your wisdom by giving lots of feedback, but if it all appears negative, then the receiver will just feel deflated and torn to shreds.
So, you’ll need to prioritise your feedback in a way to ensure there is a balance between the positive and the negative.
Be clear about what the individual did well and what he or she could do to improve
Be careful of using a positive-negative-positive sandwich method of feedback such as “The first part of your presentation was well structured, but the second part was not as clear; overall though you did really well.” This approach leaves the individual with the impression that everything is OK.
Ask questions when giving feedback
Don’t make the conversation one-sided; ask the individual what he or she thinks they did well, and where he or she thinks there’s room for improvement and whether they agree with you. If not, explore further…. don’t just let it go!
Time your feedback
Say it while it’s fresh; don’t wait until a long time after the event (when recall difficulties set in!).
Own the feedback.
Don’t feed back on behaviour that you have not observed but that has been reported to you by someone else. Use “I” comments eg “I noticed that xxxxx and wondered whether yyyy”
Leave the recipient with a choice
Don’t demand a change because it is more likely vs no change, but it cannot involve prescribing change.to meet with resistance.
Skilfully delivered feedback offers people information about whether to act on it or not.
It can help us to examine the consequences of change

70. Common Pitfalls in Giving Feedback… things to avoid doing
A negative emphasis
It is a mistake to concentrate exclusively on a person’s weaknesses. The feedback also reveals areas of strength about which the participant should be encouraged to feel proud and to develop further.
A "flavour of the month" approach
Where everyone is compared to each other in a displayed graphical form. Individuals may see their results as interesting, but there is no emphasis on action for improvement. Consequently, any small benefits soon fade away.
A lack of confidentiality
For respondents to tell the truth, they need to feel they will not be identified. If people do not trust the organisation to respect this, they are less likely to answer truthfully.
Poor communication
If participants and respondents are not told the purpose of feedback, there will inevitably be some who invent their own reasons. The way the feedback exercise is presented and the time invested in explaining it are crucial to the results obtained.
Having no action or support
For feedback to be useful it must result in action. It lays the responsibility fairly and squarely on the shoulders of the participant, but they will probably need help from a number of sources. A good facilitator can help them see the priorities and work through an action plan.

71. Feedback skills Active listening Observation Clear verbal expression
Structure your message
Plan and prepare your message
Timing
Self awareness
Resilience
Assertiveness

73. References
Heskett EA, Laidlaw JM 2002 ‘Developing the teaching instinct’ Medical Teacher 24(3) 245-8

74. BMJ 7200 Volume 318: Saturday 26 June 1999 Career focus
Giving feedback
Providing feedback is central to training doctors. Jennifer King considers theoretical and practical aspects of this important skill for all who teach or appraise

75. Principles of constructive feedback. Kurtz, Silverman & Draper 1998
Feedback should be descriptive rather than judgemental or evaluative
Make feedback specific rather than general
Focus feedback on behaviour rather than personality
Feedback should be for the learner’s benefit
Focus feedback on sharing information rather than giving advice
Check out interpretation of feedback
Limit feedback to the amount of information the recipient can use rather than he amount you’d like to give
Feedback should be solicited rather than imposed
Give feedback only about something that can be changed

76. Principles of constructive feedback Kurtz, Silverman & Draper 1998
Feedback should be descriptive rather than judgemental or evaluative
Make feedback specific rather than general
Focus feedback on behaviour rather on personality
Feedback should be for the learner’s benefit
Focus feedback on sharing information rather than giving advice
Limit feedback to the amount of information the recipient can use rather than the amount we would like to give
Feedback should be solicited rather than imposed
Give feedback only about something that can be changed

77. Principles of feedback I(London deanery)
Give feedback only when asked to do so or when your offer is accepted
Give feedback as soon after the event as possible
Focus on the positive
Give feedback privately, especially more negative feedback
It needs to be part of the overall communication process and ‘developmental dialogue’. Use skills such as rapport, developing respect and trust with learner
Stay in the ‘here and now’, don’t bring up old concerns or previous mistakes unless these highlight a pattern of behaviour

78. Principles of feedback II
Focus on behaviours that can be changed, not personality traits
Talk about and describe specific behaviours , giving examples, and without assuming motives
Use ‘I’ and give your experience of the behaviour (when you said, I thought you were.)
When giving negative feedback suggest alternative behaviours
Be sensitive to the impact of your message – feedback is for the recipient, not the giver
Consider the content of the message, the process of giving feedback, and the congruence between verbal and non-verbal messages
Encourage reflection (‘Did it go as planned, what would you do differently next time,how would you feel about doing it again?.How did you think the patient felt, what did you learn from this session))

79. Principles of feedback III
Be clear about what you are giving feedback on,and link this to learner’s overall professional development
Don’t overload- identify two or three key messages that you summarise at the end

80. What constitutes effective feedback?
Descriptive
Performance focussed
Clear and direct
Offered
Owned
Specific
Balanced
Timely and regular
Solution-focussed

81. Brown and Leigh’s rules for giving constructive feedback (from ‘The GP Educator’s handbook)
Descriptive
Specific or focussed
Directed towards behaviour that can be changed
Timely
Selective
( Suggestions rather than prescriptions)

82. Criteria for effective feedback
Descriptive - of the behaviour rather than the personality
Specific - rather than general
Sensitive - to the needs of the receiver as well as the giver
Directed - towards behaviour that can be changed ("You're too tall" is unhelpful)
Timely - given as close to the event as possible (taking account of the person’s readiness, etc)
Selective - addressing one or two key issues rather than too many at once

83. Giving informal feedback
As soon afterwards as practical
Positive, specific, and focussing on trainee’s strengths
Negative feedback should be specific, non-judgemental, and accompanied by suggestions for alternatives.
Encourage learners to seek feedback themselves ‘Feedback works best when sought’
Hesketh and Laidlaw 2003

84. F. Hill
‘Feedback to enhance student learning:- Facilitating interactive feedback on clinical skills’ Medical Teacher 24:245-8

85. Nicol & Macfarlane 2006
Formative assessment and self regulation in learners Studies in Higher education 34(i)