Learning in Healthcare Helps Faculty to Improve Their Skills in Giving Feedback and Moving Towards Feedforward.

Feedback is part of growth, but at times can be difficult for both the giver and receiver. Feedback is a component of debriefing, but debriefing and feedback are not synonymous. Unfortunately, for many adults, feedback has a negative connotation, so we will focus on how to change feedback to feedforward, a process that is intended for future improvement. (Note: The term feedback will be used due to its widespread use for clarity throughout but the intent is to move towards using Feedforward as a concept) Giving useful feedback is a skill that will need to be built over time, but there are basics that can improve your feedback skills immediately.

The first principle of giving effective feedback is that it needs to be provided in a psychologically safe environment for learning. Both the learner and the facilitator need to have a relationship and understanding that feedback is there for improvement, and is not a ‘grade' or that the learner is ‘bad'. In this way, feedback becomes formative feedback (for learning) rather than summative assessment (of learning). Formative feedback (which is part of moving towards feedforward) implies that if the learner improves, all is good, and there will not be a negative ‘mark' on their record. Learners should know in advance of an experience if the goal is formative or summative as it helps the learner ‘understand' the feedback and be comfortable with it.

Feedback is at the core of learning. We all need to build skills in both how to give and receive feedback.

Jay Zigmont, Learning Innovator/Founder

The second principle of effective feedback is that it needs to be timely and specific. All too often, people avoid or put off giving, (in this case) feedback, which may cause a delay and lessen the opportunity to apply the feedback for learning. At its worst, delayed feedback can reflect a ‘telephone game,' where someone does not want to give feedback directly so they give it to the learner's supervisor or attending, in hopes that it will one day get back to the learner. The result is that feedback, or feedback loses context and applicability.

Ideally, feedback should be given directly after an experience, and should be both positive and corrective. In following the experiential learning cycle (Learning Card 3), feedback should be part of the reflection process directly after an experience. Defusing before giving feedback (Learning Card 6) will help the learner to address their feelings from the experience so that communication comments are focused on the event, not the feelings (or just reactions).

The ‘feedback sandwich' (i.e. one good feedback point, one negative, followed by one good) has grown in popularity in some areas as a ‘softer' way to give feedback. Unfortunately as adults, if someone says "You did a great job…" we wait for the "but…" and may only hear the negative comment (even if it is in a ‘feedback sandwich'). In the English language, ‘but' negates (or contradicts) what is said before. So, if you are going to use the “sandwich method,” avoid ‘buts', and be specific about both the good and corrective feedback (i.e. you did a good job with the depth of your compressions. Next time you may want to start CPR earlier as it took you 2 minutes to start compressions.) In a truly safe learning environment, facilitators can give both positive and corrective feedback without ‘counting' or ‘ordering' as the intent is for improvement in both directions. Some facilitators have been able to change their own personal language so that all ‘buts’ become ‘and’, which makes every comment inclusive, a great habit for all.

Your intent is crucial in shifting from feedback to a true Feedforward environment. In a feedforward approach, the intent is always about improving in the future. By focusing on the future, the assumption is that the learner can (and will) improve, which is vital.

It can be easy to focus feedback on the person rather than their actions. Feedback that is centered on the person comes with labels such as ‘good' or ‘bad' rather than focusing on areas to improve in the future. Personal feedback can be seen as an attack on the individual (and therefore easily dismissed). The most obvious format of personal feedback is the ‘halo' or ‘horns' bias. A learner with a halo can do no wrong (i.e. Mike is an excellent student, he must have just made a mistake and had a bad day, as he would normally do much better) while the learner with a set of horns can do nothing right (i.e. Matt messed up again. I know he got the diagnosis correct, but it took him forever, just like it always does). Unfortunately, feedback that is centered on the person can ‘turn' via ‘group think' (i.e. an outspoken member of the faculty does not like Matt so they continuously point out Matt's errors, which causes everyone to look actively for errors in Matt).

Feedback that is personal in nature can quickly turn into discrimination and bias. Check yourself and your intent first before giving feedback. If you have had negative experiences with the learner in the past, make sure that you are giving them “a fresh shot” today. If you ever feel like you can ‘get someone' by giving them negative feedback, you probably should excuse yourself from giving them feedback.

If the feedback truly does need to be summative in nature (such as for competency assessments or milestones), the learner needs to be aware that the nature of the feedback has changed. Summative assessments measure if the learner demonstrated the knowledge or competency at a point in time and should be used for high-stakes (such as grades, licensure, privileges, etc.). Learners should know what standard they will be measured against, and how the feedback will be used. In this case, the feedback is not for learning (or feedforward) but is just a snapshot of their current performance.

A word on helping learners to receive feedback (or feedforward, as discussed)…

There is a lot of discussion in both popular media and education as a whole, that the current generation of learners has difficulty receiving feedback. The moniker, the "trophy generation," comes with bias that everyone has to win a trophy and be told they are the best. There is probably some truth in these generalizations. However, generalizations are dangerous and lead toward personal feedback, so be careful. Ask yourself, what can I do to give effective feedback to ensure that there is a safe learning environment and that feedback is continuous, both good and corrective.

Part of the difficulty that learners have with feedback is they may not be used to receiving feedback and learning from their experiences in general. The current university system requires learners to learn how to pass a multiple choice test, but practice requires them to learn how to receive feedback and learn from both real and simulated experiences. This dichotomy is difficult both for the learner and facilitator.

Some facilitators have tried to adapt by focusing only on positive feedback (or avoiding giving feedback altogether). The avoidance (or positive only) approach takes pressure off the facilitator as it prevents having to deal with negative reactions from the learner, but it cheats the learner out of valuable ways to improve their practice.

Some facilitators go so far as to say it is not our responsibility to teach people how to learn or receive feedback, but I disagree. It would be nice if learners built skills in receiving feedback earlier, but the second best time would be to teach them today. We need to not only give them feedback but give them feedback on how they receive feedback. One of my favorite moments with a learner was when I gave him feedback that he had difficulty receiving feedback, and his response was "no I don't, give me an example of when I didn't listen to feedback…."

We, as facilitators of learning, need to model continuous feedback cycles in safe environments (both as the receiver and giver of feedback). Feedback needs not to be just annual reviews, grades, etc. but needs to be ongoing. Feedback should not be seen as a negative or hidden. Yes, many suggest giving corrective feedback in private (and praise in public), in a safe environment, and a focus on feedforward; however, we can make feedback just part of our regular conversations, rather than an event.

This part of a series called "Learning That Works" by Jay Zigmont, Ph.D., CHSE-A (jay.zigmont@gmail.com ). For a video on this topic and more information, visit http://L15.LearningInHealthcare.com . The principles above are part of the core content (Learning Card 15) of the Foundations of Experiential Learning Manual (http://FEL.LearninginHealthcare.com ).

Source: Learning in Healthcare