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

Personal aims for workshop

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

Section 1 Purpose of feedback

Blindfold exercise

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.

‘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

The Johari Window

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

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

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

......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

Party time

Linking feedback to the learning process The Kolb cycle 1984

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

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

‘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’

‘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.

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

Section 2 Substance of feedback

So, what are our sources of evidence?

RCGP competence areas Relationships Diagnostics Management Professionalism

Feedback should be......

And here’s one I made earlier

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

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

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

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

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

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)

Principle 4 Feedback should be for the learner’s benefit

Principle 5 Feedback should be sharing information Not giving of advice

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

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

Principle 8 Give feedback only about something that can be changed

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’.

Principle 10 Focus on the positive

Principle 11 Give feedback privately Especially more negative feedback

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

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

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

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.

Principle 16 Offer suggestions Rather than giving ‘prescriptions’

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

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

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

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?

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

Practicalities of giving feedback Section 3 Practicalities of giving feedback

The old feedback sandwich Praise Criticism

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

The new feedback sandwich Ask Tell

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

Tell what you observed, using specific observed behaviours

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

A visit to the office

Let’s give it a go

Gibbs cycle 1988

  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

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

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

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

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

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’

  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

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.

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

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

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

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

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

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

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))

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

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

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)

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

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

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

Nicol & Macfarlane 2006 Formative assessment and self regulation in learners Studies in Higher education 34(i)199-218