Best Practice & Research Clinical Anaesthesiology 26 (2012) 77–87

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Best Practice & Research ClinicalAnaesthesiology

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7

Giving feedback – An integral part of education

Scott A. Schartel, DO, Professor & Associate Chair for Education, ResidencyProgram Director *

Department of Anesthesiology, Temple University, 3401 N Broad Street, Philadelphia, PA 19140, USA

Keywords:clinical competenceeducation medical/standardsfeedbackknowledge of results (psychology)learningself-assessmentself-conceptteaching/methodsteaching/trends

* Tel.: þ1 215 707 3326; Fax: þ1 215 707 8028.E-mail address: schartel@temple.edu.

1521-6896/$ – see front matter � 2012 Elsevier Ltdoi:10.1016/j.bpa.2012.02.003

Feedback is an integral part of the educational process. It provideslearners with a comparison of their performance to educationalgoals with the aim of helping them achieve or exceed their goals.Effective feedback is delivered in an appropriate setting, focusseson performance and not the individual, is specific, is based ondirect observation or objective date, is delivered using neutral,non-judgemental language and identifies actions or plans forimprovement. For best results, the sender and receiver of feedbackmust work as allies. Negative feedback can create an emotionalresponse in the learner, which may interfere with the effectivenessof the feedback due to dissonance between self-evaluation andexternal appraisal. Reflection can help learners process negativefeedback and allow them to develop and implement improvementplans. Both delivering and receiving feedback are skills that can beimproved with training. Teachers have a duty to provide mean-ingful feedback to learners; learners should expect feedback andseek it.

� 2012 Elsevier Ltd. All rights reserved.

Introduction

Feedback is an essential component of the educational process, but one inwhichmedical educators,especially those who teach clinical medicine, have little education. Many medical educators lacka theoretical understanding of feedback, practical skills for providing effective feedback, or both. It isuseful to begin by exploring the meaning of the term ‘feedback’. The earliest use of the concept offeedback came from engineering.1 The concept was later extended from science to the humanities.Studies of feedback in the areas of learning and performance are found in the psychology, education

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and management literature. Both within and among these disciplines, there has not been a consistentdefinition of feedback.

The definition of feedback in the Oxford English Dictionary that is most relevant to education is “[t]he modification, adjustment, or control of a process or system (as a social situation or a biologicalmechanism) by a result or effect of the process, esp. by a difference between a desired and an actualresult; information about the result of a process, experiment, etc.; a response.”2

From the perspective of the educational literature, Hattie and Timperley3 defined feedback as“information provided by an agent (e.g., teacher, peer, book, parent, self, experience) regarding aspectsof one’s performance or understanding.” Ramaprasad,4 writing from the management theoryperspective, identified it as “information about the gap between the actual level and the reference levelof a system parameter which is used to alter the gap in some way.”

In 2008, van de Ridder and colleagues5 conducted an extensive search of the general, social scienceandmedical literature in an effort to arrive at a definition of feedback for use in clinical education. Theyproposed an operational definition of feedback as: “[s]pecific information about the comparisonbetween a trainee’s observed performance and a standard, given with the intent to improve thetrainee’s performance.” Both van de Ridder and colleagues and Ramaprasad include performanceimprovement as an integral component of feedback.

Feedback and learning

The process of learning, whether in a classroom, on a clinical rotation, or on a playing field, can beviewed as a cycle. It begins with establishing educational goals and objectives. Goals are broad andgeneral statements establishing the purpose of the educational activity, while objectives are specificand measurable statements that identify what is to be learnt or achieved. Next is a period ofinstruction, studying or practice during which learners work to achieve the objectives. This is followedby evaluation of their success in meeting the objectives. Evaluation is subdivided into formative andsummative assessment. Formative assessment measures performance compared to goals and usesfeedback to help the learner improve. Feedback can also be used to help high-performing learnersexceed the objectives. Summative assessment is used at the end of the cycle to make final judgementsabout the learner’s success in achieving the objectives. The stakes involved in formative assessment arelow, it is meant to help the learner improve. However, the stakes in summative assessment are high,leading to decisions about success or failure in the learning unit.

A large number of reviews3,6–11 have been published about theories underlying the use and effect offeedback in education and performance. While a comprehensive discussion of this literature is beyondthe scope of this article, a summary of some of the important concepts and research findings will bepresented.

Kulhavy6 in his analysis of feedback in written instruction concludes that feedback does increasewhat is learnt. However, he identifies that if the feedback is available before the student responds (e.g.,answers available before answering examination questions) the feedback leads to students simplycopying answers and moving on to the next question, with limited retention of the material. Bywithholding the answer (feedback) until after the learners attempt questions, the learners have toengage more with the process and may be motivated to further study when they answer incorrectly orwhen they answer correctly, but have little confidence in their answer. Kulhavy states that feedback“confirms correct responses, telling the student how well the content is understood, and it identifiesand corrects errors – or allows the learner to correct them.” He concludes that, “feedback followingwrong responses probably has the greatest positive effect.”

While his paper was specifically concerned with feedback responses to learning written material,the principles have application in clinical education. It is common for medical students and residents toprepare for standardised examinations by using practice question books that provide the correctanswers. The answer key provides feedback, but learners should be advised of the importance ofattempting to answer the questions before looking at the answers. Wrong answers should prompt ananalysis of deficits in their understanding of the material. This type of self-study fulfils both theevaluative aspect of feedback – it measures performance against a standard – and the performanceimprovement or gap closure aspect of feedback, by encouraging additional study.

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In 2007, Hattie and Timperley3 proposed a model of feedback. They stated that for feedback to beeffective it should answer three questions: (1) Where am I going? (2) How am I going? And (3) Whereto next? The first question (where) is related to the goals of the learning experience or task; what is itthat the learner needs to accomplish. The second question (how) provides information about thelearner’s performance compared to the goals. The third (where next) is a plan for further learning andperformance improvement.

Hattie and Timperley also identified that the focus of feedback is an important determinant of itseffectiveness. The focus can be on the task (correct/incorrect), the processing of the task, self-regulationor the self (the learner as a person.) They state that task feedback “is most powerful when it addressesfaulty interpretations, not a total lack of understanding.” When there is a lack of knowledge, ratherthan providing feedback the learner will benefit more from additional instruction.

When focussed at the processing level, feedback may help students develop methods for errordetection (a kind of self-feedback), may lead to better information search and encourage the devel-opment of strategies for achieving the goals. This level focusses on understanding relationships andmeaning and can lead to transference of the learning to new or more difficult tasks. In psychologicalterms, this is metacognitive activity: involving the learner’s knowledge about knowing, about thelearning process, planning and evaluation.

They note that when effective, feedback that is focussed on self-regulation can enhance learners’commitment to the task, learners’ belief in their ability to achieve the task and their willingness tocontinue to work on the task. By contrast, they state that feedback focussed on the self (the learner asa person) is typically not effective. As an example, general praise (“good job”) does not provideactionable information for the learner. It does not address the three questions described above. Insummarising findings from a number of studies, they report that “older students perceive praise aftersuccess or neutral feedback after failure as an indication that the teacher perceived their ability to below. When given criticism after failure and neutral feedback after success, they perceived that theteacher had estimated their ability high and their effort low.” Hattie and Timperley distinguish generalpraise (“good job”) from praise that is directed at learners’ efforts, engagement or self-regulation,which they say may enhance students’ belief in their ability to master the task.

In a meta-analysis of feedback intervention studies, Kluger and DeNisi10 concluded that feedbackinterventions “improved performance on average.” However, they also identified that more than one-third of feedback interventions resulted in a deterioration in performance. Their results suggested thatfeedback interventions became less successful as the feedback moved “closer to the self and away fromthe task.”

Baumeister and colleagues12 studied the negative effects of praise on skilled performance in anexperimental model. They found that when praise was administered immediately after performanceand then the performance was repeated, performance deteriorated. The experiments were designed totry to locate the source of the decrement. Their conclusion was that “praise engenders a globally self-conscious state which impairs the automatic nature of effective skilled performance.” Their conclusionmay not apply to tasks where success is primarily effort based.

Sadler9 identified three key factors for effective feedback: the learner needs a concept of thelearning goal, it must compare actual performance with the goal and it must take action to reduce anydifference between actual performance and the goal. He states that, “for students to be able to improve,theymust develop the capacity tomonitor the quality of their ownwork during actual production. Thisin turn requires that students posses an appreciation of what high quality work is, that they have theevaluative skill necessary for them to compare with some objectivity the quality of what they areproducing in relationship to the higher standard.” Sadler believes that systems that do not makeprovision for students to develop this evaluative ability are deficient. He notes that by failing to helpstudents develop these skills, the learning system may create an artificial limitation on theirachievement.

In 2008, Shute11 published an extensive review of the literature on formative feedback. She iden-tifies that feedback provides learners with information that can be identified as verification or elab-oration. Verification is identifying correct/incorrect responses, while elaborated feedback goes beyondsimple verification and provides information about why responses were correct or incorrect. Elabo-rated feedback is generally more effective. Feedback can also be classified as ‘directive’ when it tells

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what needs to be done or ‘facilitative’ when it guides learners in developing their own plan. Table 1provides some of Shute’s guidelines for effective feedback.

Self-efficacy

Another factor to consider in evaluating the effectiveness of feedback on learning and performance isBandura’s13 concept of self-efficacy. His hypothesis is “that expectations of personal efficacy determinewhether coping behaviour will be initiated, how much effort will be expended, and how long it will besustained in the face of obstacles and adverse experiences.” He identified four factors that affect self-efficacy: performance accomplishments, vicarious experience, verbal persuasion and emotional arousal.

In the performance category, success increases and repeated failure decreases self-efficacy. Theeffect of failure is especially strong early in the process. Strong self-efficacy that develops aftersuccessful performance decreases the negative effect of occasional failures. In fact, occasional failuresmay strengthen an individual’s resolve to persist, if the individual has strong self-efficacy developedfrom prior accomplishment.

Vicarious experience relates the individual’s response to others achieving the same goal (“if theycan do it, so can I”). Seeing that others can achieve the goal can increase self-efficacy, especially if theabilities of the individual and the other are perceived as similar. Seeing others fail may decrease self-efficacy.

Verbal (social) persuasion refers to external encouragement or discouragement directed at theindividual. The effect of verbal persuasion on self-efficacy is weaker than that of performanceaccomplishment. Generally, discouragement will decrease self-efficacy more than encouragement willincrease it. To sustain increased self-efficacy, encouragement needs to be coupled with assistance orguidance to increase accomplishment. Without improved accomplishment, the encouragement will bediscounted.

Physiological stress responses in unusual or stressful situations can decrease self-efficacy if they areinterpreted by the individual to portend failure. Individuals with high self-efficacy can interpret thephysiological responses as being normal and unrelated to the likelihood of success or failure and thus,self-efficacy will not be affected.

Feedback, especially if focussed on the person (self) and not the task may decrease self-efficacy andlead to lowering of goals or quitting the task. For individuals with low self-efficacy, additional supportmay be required to help them accomplish their goals. Individuals with high self-efficacy are likely tohave greater confidence in succeeding and persist even when they meet with failure. In an experi-mental design, Baron14 reported that destructive criticism resulted in a decrease in self-efficacy,a lowering of goals and an increase in undesirable workplace tactics such as avoidance andcompetition.

The effect of negative feedback on performance improvement efforts was studied by Fedor andcolleagues.15 Their investigation was designed to look at this from the management (workplace)perspective. They identified that the power of the supervisor was important in influencing an indi-vidual’s response to negative feedback. Individuals had the highest motivation to improve afternegative feedback given by supervisors who were viewed as being experts in the area (expert power)or who engendered loyalty and were admired (referent power). In their study, self-esteem was notsignificant as a main effect. They did find that when self-esteemwas low, referent power did not exert

Table 1Formative feedback guidelines to enhance learning (adapted from Shute11).

Focus on task not learnerProvide elaborated feedbackPresent elaborated feedback in manageable unitsBe specific and clear with the feedback messageKeep feedback as simple as possible, but no simplerReduce uncertainty between performance and goalsGive unbiased, objective feedbackPromote a “learning” goal orientation (goal is learning not receiving praise for performance)

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an influence. For those with high self-esteem, referent power was important. In considering theinfluence of self-esteem in an individual’s response to negative feedback, they suggest that perhaps“identification with the source of the message is a key moderator. In other words, individuals desire torespond positively to those with high referent power, and individuals with high S[elf] E[steem] haveconfidence in their ability to do so.” Those with high self-esteem are likely to discount negativefeedback, if the perceived expert or referent power of the supervisor is low.

Feedback in medical education

In a study of medical students on an obstetrics and gynaecology rotation, Irby and Rakestraw16

examined student ratings of clinical teaching. Using factor analysis, they identified four factors thataccounted for approximately 87% of the variance in ratings: supervisory skills, knowledge and clarity,interpersonal relationships and demonstrates clinical skills. Of these factors the first, supervisory skills,accounted for appropriately 62 percent of the variance. ‘Provides direction and feedback’ was associ-ated with supervisory skills and was independently strongly correlated with overall teachingeffectiveness.

Isaacson and colleagues17 conducted a survey of residents to determine their perceptions of thefeedback they received. In reporting how frequently they received feedback from faculty, 22 percentresponded “never/infrequently” for verbal feedback and 80 percent responded “never/infrequently” fornegative feedback. In the 2010–2011 resident survey conducted by the Accreditation Council forGraduate Medical Education (ACGME), slightly more than 25 percent of residents reported that theywere “somewhat”, “slightly”, or “not at all” satisfied with the feedback they received at the end ofa rotation or major assignment.18 While medical students and residents value feedback, they do notalways believe the feedback they receive is adequate. However, not all feedback provided by facultymay be perceived as such by students and residents. In a study of medical students learning to tiesurgical knots, Boehler and colleagues19 found that the group of students who received specificfeedback improved following the feedback, while those who received only praise did not. The satis-faction scores for the group that received only praise were significantly higher than for the feedbackgroup. The authors conclude that satisfaction is not a good marker for the quality of feedbackprovided – praise was associated with satisfaction, feedback with learning.

In 1983, Ende1 published a landmark article on feedback in clinical medical education. Early in thearticle hewrites, “[a]s a compendiumof cognitive, psychomotor, and affectual behaviours, clinical skill iseasier demonstrated than described. And, like ballet, it is best learnt in front of amirror.” Feedback is themirror. Ende emphasises the formative nature of feedback, stating that is should be “neutral, composedof verbs and nouns,” not expressed in terms of final evaluation “peppered with adverbs and adjectives.”

Ende points out that one reason feedback is often inadequate is the need for it to be based on directobservations of performance. If the person supervising a medical student or resident does not observethe trainee, then there is little basis for providing meaningful feedback. Because feedback, especially ifit is about inadequate performance, arouses emotional responses it may be difficult for both the personreceiving and the person giving feedback. Teachers may respond to this emotional aspect by beingindirect or unclear in the information provided to the student. Teachers may fear negative evaluationsfrom students, and students may resist receiving feedback that threatens their self-concept.

Developing clinical competence is the major goal for physicians in training. Meaningful feedback isessential for achieving competence. Ende states “[w]ithout feedback, mistakes go uncorrected, goodperformance is not reinforced, and clinical competence is achieved empirically or not at all.”1 Ende’sguidelines for providing feedback are listed in Table 2 and discussed in more detail below.

Because the aim of formative feedback is performance improvement, the learner and the teacherneed to work together as allies in achieving this common goal. In this endeavour, the learner shouldview the teacher as a coach – someone whose goal is to help the learner succeed and improve. It isimportant that goals be clearly understood by both the learner and the teacher, so that in discussions ofthe learner’s achievement there is no confusion about the standard.

Feedback should be timed to achieve the best outcome. In general, feedback should be given whenboth the learner and the teacher can focus on the feedback interaction without distractions. However,some feedback, especially that directed at improving technical skills, must be provided in real time to

Table 2Ende’s guidelines for giving feedback.1

Feedback should: be undertaken with the teacher and trainee working as allies, with common goalsbe well-timed and expectedbe based on first-hand databe regulated in quantity and limited to behaviours that are remediablebe phrased in descriptive nonevaluative languagedeal with specific performances, not generalizationsoffer subjective data, labelled as suchdeal with decisions and actions, rather than assumed intentions or interpretations

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allow the learner to correct performance and succeed. Feedback should occur close in time to theperformance being discussed, with the learner knowing about the session in advance. When feedbackis delayed, memories of the performance being reviewed may have faded, diminishing the effective-ness of the feedback. Advance notice gives the learner an opportunity prepare to receive the feedback.

Choosing an appropriate location to meet is also important. The location should provide privacywith an office or conference room being preferable to a hallway, nurses’ station, or elevator. Both thelearner and teacher should have adequate time to devote to the encounter without interruptions.Arrangements should be made for someone else to answer pages and phone calls during the session.

The session can beginwith the teacher asking the learner to report how she feels she has performed.This allows the teacher to gain some insight into the learner’s understanding of her progress. Theteacher can then provide feedback about performance. The feedback should be based on first-handdata, either from direct observation by the teacher (most desirable), specific first-hand dataprovided to the teacher by another observer, or objective measurements. Basing feedback on reporteddata, as opposed to directly observed or measured data, limits dialogue about the observations, as theperson providing the feedback does not have first-hand knowledge.

The language used to provide feedback should be neutral and non-judgemental. As stated above, itshould avoid adjectives and adverbs (e.g., good, bad, or poorly) and focus on specific behaviours oractions that are remediable. “The discussion of risks, benefits, and alternatives did not include stroke asa possible complication” is preferable to “Your informed consent discussion was poorly done.” Theformer statement is a neutral and non-judgemental statement of fact. The latter statement is judge-mental and does not provide the learner with any actionable information. Without an explanation ofwhy the consent discussion was inadequate, the learner does not know what to change.

The quantity of feedback should be regulated; too much feedback may overwhelm the learner andlimit his ability to process the information, especially when the feedback is negative. It is better toschedule several sessions if the amount of material to be discussed is extensive. This gives the learneran opportunity to reflect on the feedback and seek additional information and guidance at subsequentsessions.

Subjective feedback can be valuable and valid, but it should be clearly identified as being subjective.Use of “I” statements rather than “you” statements identifies the information as the teacher’s obser-vation. For example, after observing a patient interaction it is better to say, “When you explained thatthe patient had anoxic brain injury to the family, I sensed that you were very uncomfortable discussingprognosis.” Saying “You were uncomfortable discussing prognosis with the patient’s family”makes thesubjective observation sound more objective and judgemental. This may make it more difficult for thelearner to process the information. Alternatively, saying, “I noticed that you were sweating whendiscussing prognosis” provides a neutral observation that can then be used to explore the reasonsunderlying the observation.

Feedback should remain focussed on behaviours, actions and decisions and not on the teacher’sinterpretation of the underlying attitude or intention of the learner. Telling a resident that she is lazyand disinterested focusses on the teacher’s inferences based on the resident’s behaviours. It does notprovide the resident with useful information, and it may not reflect the resident’s intentions. It is betterto focus on specific behaviours, actions and decisions. For example: “You were not prepared for yourfirst case 3 days in the past week. The preanaesthesia evaluation for two of the patients did not includean airway exam. You were unable to discuss malignant hyperthermia today even though we agreed

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yesterday that we would discuss it today.” These statements detail those behaviours, actions anddecisions that led the teacher to conclude that the resident was lazy and disinterested. Specific anddetailed feedback provides the resident with clear information about where the problems lie. Thefeedback could also include specific expectations for the future. For example: “You need be ready foryour first patient by 7:15 am. Your preanaesthesia evaluations must include a complete airway exam.When given an assignment to prepare for discussion, it must be completed.” This provides the residentwith clear performance expectations.

A commonly recommended technique for providing negative or corrective feedback is the ‘feedbacksandwich’.20,21 The person providing the feedback begins by identify a positive aspect of performance,then provides the negative feedback and ends with additional positive information. The aim of thesandwich technique is to make it easier for both the giver and receiver of the feedback. The negativeemotional response to corrective or negative feedback may be reduced if there are also positivecomments. However, this technique is not without some potential problems. As discussed earlier,praise – especially when aimed at the person and not at specific aspects of performance – is not a veryeffective feedback technique. In addition, if learners have experienced the sandwich technique, theymay discount the positive information, knowing that it is a being given as a preamble to the negative. Incircumstances where the learner has performed in a seriously deficient manner (e.g., failed to examinea patient before prescribing a treatment, or made a serious medication error), the focus of the feedbacksession needs to be on the breach of practice. Use of the sandwich technique may blur this focus.

Milan and colleagues22 developed a model for feedback based on skill strategies used in clinicalcommunication. They drew from two communication techniques in developing their model: PEARLS(see Table 3) and the stages of change (transtheoretical) model. The PEARLS strategy is designed tocreate a supportive environment for the feedback session. The stages of change model refer to thelearner’s stage of readiness to change. The stages are ‘precontemplation’, where the learner is eithernot aware of the need to change or denies it; ‘contemplation’, where the learner is aware of the need tochange but ambivalent or not committed to change; and ‘preparation’, where the learner is committedto change. The authors’ model incorporates the PEARLS approach to create a supportive climate anduses the learner’s readiness to change to determine the specific types of feedback intervention to use.

For learners in the precontemplation stage, the aim is helping the learner understand the problem,providing additional information, clarifying expectations and encouraging self-assessment. The goal isto move the learner to the contemplation stage. If the learner is at the contemplation stage, theinterventions are aimed at identifying ambivalence, reinforcing the positive reasons for change andidentifying barriers to change. The goal is to move the learner to the preparation stage. At the prep-aration stage, the interventions should reinforce change, support the learner in developing strategiesfor change and establish measurable outcomes to monitor the change. The goal is action. In theirconclusion, Milan and colleagues state, “[c]omplex feedback situations challenge even the mostexperienced educators and require the use of empathic listening and rapport building to create anenvironment of trust.”22

Cantillon and Sargeant21 describe two additional techniques that go beyond the feedback sandwich.In the first, the Pendleton model, the session begins with the learner stating what was good about herperformance. Next, the teacher identifies areas of agreement and expands on areas of good perfor-mance. Next, the learner identifies areas for improvement, followed by the teacher’s assessment ofareas for improvement. This expands on the sandwich model by incorporating self-assessment. Thisapproach may create a more collaborative approach between learner and teacher. However, the arti-ficially imposed structure may distract from focussing on the most important issues.

Table 3PEARLS approach (from Milan et al22).

Partnership for joint problem-solvingEmpathetic understandingApology for barriers to the learner’s progressRespect for the learner’s values and choicesLegitimation of feelings and intentionsSupport for efforts at correction

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Table 4 outlines a model proposed by Cantillon and Sargeant that they call the reflective feedbackconversation. The model includes self-assessment, teacher feedback, learner reflection and planningfor improvement. The authors conclude that, “[t]he reflective feedback conversation approachencourages the development of the learners’ ability to self-assess and leads to a shared view of whatthe agreed improvements will look like.”

Multisource feedback

Among new techniques for providing feedback to residents and practicing physicians is the use ofmultisource feedback (MSF), also called 360� evaluation.23,24Widely used in the business world, its usein medicine is relatively new. MSF typically involves obtaining feedback assessment from peers,supervisors, nurses, ancillary staff and patients, often combined with self-assessment. Obtainingnarrative comments improves MSF. MSF is required for all residents in ACGME-accredited pro-grammes.25 Patient surveys are part of some of the practice improvement modules of the AmericanBoard of Internal Medicine’s maintenance of certification programme.26 The development of an MSFtool for performance appraisal for practicing surgeons has also been reported.27

Lockyer24 points out that the success of MSF is dependent on careful attention to the structure andpsychometric features of the survey tools and the implementation of the process. She concludes thatMSF is not an appropriate tool for providing information about clinical outcomes, but that it is effectivein providing reliable information about interpersonal and communication skills, professionalism andteamwork. In a study of paediatric residents, Brinkman and colleagues28 found that MSF improvedcommunication skills and professional behaviour.

In a study of MSF in family physicians, Sargeant and colleagues29 identified that the emotionalresponse of the physicians studied to feedback was linked to the physicians’ self-assessment. If thefeedback agreed with or exceeded self-assessment, there was a positive emotional response. However,when the feedback reported performance below a physician’s self-assessed level, it created a negativeemotional response, commonly distress. The authors recommend helping individuals understand therole emotions play in processing negative feedback. They emphasise that focussing on data about taskperformance and investing time in reflection helps recipients of negative feedback to process theinformation and make changes.

Sargeant’s group30 also looked at the actions taken by the physicians they studied in response toMSF. They found that if the feedback was positive the physicians made no changes. If the feedback wasnegative, slightly more than half made a change. Among the factors that influenced a change responsewas the source of the feedback, feedback specificity and its agreement with other sources of feedback.The credibility of patient feedback was high. When looking at improvements, all physicians who madechanges reported making changes in patient communication. The credibility of clinical assessments byother physicians was low, likely because thesewere not based on first-hand observations. Sargeant andcolleagues concluded that MSF is probably not a good method to provide feedback about clinicalperformance.

In a study of residents’ receptivity to feedback, Bin-You and Patterson31 interviewed residents usinga semi-structured interview about their perceptions of and response to feedback. Factors associatedwith perceptions of effective feedback included specificity of information, suggestions of an action planfor improvement, timing that was close to the event, a non-judgemental presentation and a chance forthe resident to respond. Sender credibility was an important factor in the residents’ responses to

Table 4Reflective feedback conversation (adapted from Cantillon and Sargeant21).

1. Teacher: asks learner to identify areas of concern or that need improvement2. Learner: describes areas of performance that need improvement3. Teacher: provides feedback about performance and offers support4. Teacher: asks learner to reflect on how performance can be improved5. Learner: offers improvement ideas6. Teacher: elaborates on improvement ideas, modifying or adding to them

assesses learner’s understanding of areas of concern and improvement plan

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feedback. A lack of trust or respect for the sender, a perception of low sender expertise, a lack of directperformance observation by the sender, poor interpersonal and communication skills by the senderand the sender being ill at ease while providing feedback were all associated with the residentsconsidering the feedback invalid. Feedback that was at variance with a resident’s self-assessment,feedback where the resident did not perceive any fault or feedback delivered in a judgementalfashion also was associated with the feedback being discounted. This emphasises that factors related toboth sender and receiver are important in the feedback process.

Self-assessment

Because self-assessment has an influence on how feedback is viewed, it is useful to consider theaccuracy of self-assessment. Kruger and Dunning32 compared self-assessment to actual performance ina series of tests (humour, logic and grammar). They found that those scoring in the bottom quartilewere least able to predict their own performance outcome, significantly overestimating their scores.With training to improve their skills at performing the tasks, self-assessment of ability became moreaccurate.

Davis and colleagues33 conducted a systematic review of self-assessment by physicians. Seventeenstudies met their inclusion criteria with a total of 20 comparisons between self-assessment and anexternal standard. Thirteen comparisons showed little, no, or an inverse relationship between self-assessment and the external standard, while only seven had a positive association. Hodges andcolleagues,34 in their study of familymedicine residents’ abilities to deliver bad news, found thosewiththe worst performance were the least accurate in self-assessment, significantly overestimating theirperformance. Those in the highest performing group tended to underestimate their performance,while those in the mid-range were most accurate.

Reflection

Sargeant and colleagues35 have suggested amodel for reflection and decisionmaking in response toMSF, but the model can be applied to other types of feedback as well. In their model, when feedbackand self-assessment match, the emotional response is accepting, and the period of reflection neededfor processing is short. If the feedback is positive, no action is required. If it is negative, but matchesself-assessment, action will be taken to improve. For negative feedback that does not match self-assessment, there is a stronger emotional response, often distress and/or anger. The period of reflec-tion needed to process the feedback is longer and is followed by a decision to either accept the feedbackand take action or to reject the feedback and take no action. They suggest that facilitation during thereflective period (e.g., external guidance and providing a pathway for the individual to discuss thefeedback) improves acceptance and leads to change.

The metacognitive (knowing about knowing) aspects of learning are an important part of receivingand using feedback in learning. Learners’ understanding of how they learn, process information,evaluate, plan and self-assess all factor into their ability to use feedback to improve. Helping learnersbecome reflective learners will allow them to achieve the maximum benefits from feedback. Bing-Youand Trowbridge36 have explored these issues in their article on why medical educators may fail atfeedback.

In their discussion of feedback and reflection in clinical settings, Branch and Paranjape37 haveobserved that “[r]eflection in medicine – the consideration of the larger context, the meaning, and theimplications of an experience and actiondallow the assimilation and reordering of concepts, skills,knowledge, and values into pre-existing knowledge structures. When used well, reflection willpromote the growth of the individual. While feedback is not used often enough, reflection is probablyused even less.”

Summary

Feedback is essential to learning. Without effective feedback, correct performance is not reinforced,errors go uncorrected and progress is slow or non-existent. Effective formative feedback can be

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compared to good coaching in athletics. The coach and the athlete share a common goal and worktogether as team to achieve the goal. The athlete must do the necessary work, but without feedbackand correction the athlete is unlikely to achieve peak performance. The guidelines that are discussedabove provide a framework for the feedback encounter. Negative feedback, when it is at variance witha learner’s self-assessment, may induce strong emotional responses that may lead to the feedbackbeing rejected. Encouraging reflection among learners is one method to help remove the barriers tochange that emotions may impose. Strategies that help learners improve their metacognitive abilitiesmay improve their self-assessment skills and make accepting corrective feedback easier. Feedbackencounters are enhanced by teaching those who provide feedback how to do so effectively38,39 andteaching those who receive feedback40 how to respond to it constructively. Teachers have an obligationto provide meaningful feedback. Learners should be taught to expect feedback and to seek it.

Practice points

� Feedback should be given in a place that provides privacy and should be temporally related tothe events being discussed.

� Feedback should be focussed on knowledge, behaviours or actions that can be changed.� Feedback should be specific, based on data and direct observations.� The language used for feedback should be neutral and non-judgemental and should befocussed on knowledge, behaviours, actions – not on the person receiving the feedback.

� The credibility of the provider of feedback has an influence on its acceptance.� Reflection by the receiver of feedback can mitigate resistance to accepting negative feedback.� Self-assessment skills may be enhanced by practice and reflection.

Research agenda

� Further exploration of the effectiveness of training in reflective learning in improving self-assessment skills.

� Identification of the best techniques for improving teachers’ skills in delivering and learners’skills in receiving effective feedback.

� Validation of factors necessary to make multisource feedback instruments effective (e.g.,what groups should be used as evaluators, howmany evaluators are necessary per group anddo some classes of evaluator have a more powerful effect on inducing change?)

Role of funding source

None.

Conflict of interest

None.

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