Effective Feedback in the Education of Health Professionals
Clinical educators of health professions training programs are often underprepared for their teaching roles due to a lack of formal training in educational methodology. The emphasis on competency based education in the health professions has led to a re evaluation of the standards for a competent clinical teacher. Feedback is an important aspect of nearly all learning theories. The effectiveness of feedback relates to its double barreled approach that focuses on both the cognitive and motivational aspects of learning. Feedback should be related to progression toward competency to promote self motivated learning. Both the tone and perceived intention of feedback affect how a learner incorporates and uses such information. Descriptive feedback on the performance of tasks is the most beneficial. Characteristics of effective feedback include the creation of a receptive environment, focus on behaviors, specificity, comparison to a standard of competency, timeliness, ensuring an appropriate amount so as to not overwhelm the learner, and encouragement of self directed learning. Faculty development interventions targeted toward learning to provide appropriate feedback are critical in improving the educational process. Introduction The purpose of health professions education is to create competent practitioners. Traditionally, the process of educating practitioners in medicine was an apprenticeship with one on one supervision, and clinicians were assumed to be both competent practitioners and educators following completion of appropriate apprenticeship training (1) Unfortunately, although clinical educators often receive substantial education in their clinical field, most lack formal training in education. In the field of nutrition and dietetics, preceptors often have minimal exposure to education on teaching skills, particularly those related to student assessment and evaluation (2,3) Subsequently, underprepared faculty often engage in ad hoc training to improve their skills after assuming teaching roles (4) In recent years, the shift in emphasis to behaviorally based training in medicine has resulted in competency based education for most health professions training programs (5) In essence, competency based education programs require that learners demonstrate their abilities via a measurable approach with a reasonable degree of consistency serving as proof of their competency to practice in their chosen field. These programs focus on what clinicians should be able to do rather than simply on their completion of a specific period (Continued on next page) Effective Feedback in the Education of Health Professionals Rebecca F. Lara, MD Kris M. Mogensen, MS, RD, LDN, CNSC Jeffrey F. Markuns, MD, EdM of training. This paradigm change has led health professions education stakeholders to re evaluate their standards for a competent educator. Increasingly, professionals recognize that high quality educators are more than merely expert clinicians. Although there are no specific guidelines for competency based training of clinical educators, it is reasonable to expect that competent teachers of health professionals should be able to provide learner centered teaching, appropriately evaluate learners, and provide effective feedback to their students (4,6) The Importance of Evaluation The feedback process can be divided into formative and summative information. Formative feedback consists of ongoing interventions by a teacher to assist the learner in attaining learning objectives. Summative feedback is the final overall impression of performance at the end of instruction, often referred to as evaluation. Evaluation provides tools for measuring competency and methods for determining success in helping students achieve competency. Evaluations can also help learners to understand how they are progressing and in which areas they may need additional study and practice. Assessment tools are frequently used for both formative and summative assessment in dietetic training (7) Direct observation of students in the workplace or clinical setting is perhaps the most practical and effective method of evaluating the competency of learners in practice (3,8) However, studies have identified that the final grades students receive do not always correlate with an evaluator's judgment of a trainee's performance, thus bringing into question the reliability and validity of using direct observation in practice for evaluation (9,10) Among the faculty identified reasons for these inconsistencies is a lack of documentation by faculty preceptors of specific deficits and uncertainty about what specifically should be documented in terms of deficits (10) The development of a structured approach that involves direct observation combined with improved tools for measuring and documenting these observations can help improve the effectiveness of clinical assessment (11) Educators who regularly observe the performance of health professions trainees tend to have higher interrater reliability, suggesting that experience with direct observation is associated with more reliable evaluations (12) Novice dietitian preceptors report difficulty in translating required competencies into the evaluation of clinical performance, further suggesting the importance of experience (3) Additionally, formative assessment tools commonly used in dietetic training can be complex and multifaceted. These instruments, which include a tool for use within DIETetic consultations to assess COMMuncation skills called the DIET COMMS, assume that various skills can be observed simultaneously in unpredictable clinical interactions, which can increase pressure to assess every competency, whether or not clearly observable (7) The addition of descriptors correlating with numerical scoring combined with the simplicity of a scoring system made the DIET COMMS an easy tool to use (7) These difficulties in assessing student performance may ultimately affect an educator's ability to provide useful feedback to learners. Understanding the Feedback Process Nearly all learning theories stress the importance of receiving feedback in the process of learning, especially feedback on the quality of a person's performance (13) In her book, How to Give Effective Feedback to Your Students, Brookhart wrote that "the power of formative feedback lies in its double barreled approach, addressing both cognitive and motivational factors at the same time" (14) Evidence demonstrates that feedback is more effective when providing information on correct rather than incorrect performance and when it is directly tied to a student's desired progression toward competency (15) Once learners understand their progress in relation to educational goals, feedback can encourage the development of self motivated learning. Self motivation is the key to any educational endeavor because the learner has ultimate control over precisely what content is incorporated into his or her knowledge base. Previous studies have demonstrated that external feedback and internal self evaluation work together to assist students in deciding on their next learning goals and devising the tactics and strategies needed to reach them (14) One meta analysis of 131 articles identified via searches of the Social Sciences Citation Index (SSCI) PyschInfo, and the National Technical Informational Services analyzed the effects of feedback interventions (16) Included studies all were required to have a treatment group that received some type of feedback intervention and either a control or quasi control comparison group and use performance outcome measures such as memory retention and arithmetic computations. The authors noted that although the effect of feedback on performance overall 4 Support Line March 2016 was positive, several studies within the analysis showed that feedback resulted in worse learner performance on the tested measures compared to the controls (16) This finding demonstrates that the feedback process is one in which information is modified by a learner's perception of the message and its intended purpose. Another investigation on the effect of feedback revealed that formative, freely written comments were associated with greater achievement of learning goals compared to receiving a letter grade or a scripted comment not related to specific performance (17) Interestingly, attempts to replicate these findings were mixed. An analysis of these studies revealed that the feedback in the replicated studies tended to be evaluative or judgmental compared with that of the original study, which specifically focused on providing encouraging comments (14) Additionally, in a study evaluating the effects of feedback on learner motivation, students receiving descriptive, task specific feedback not only performed better, but they reported an increase in self motivation (18) To understand the intentions underlying the feedback process, one analysis elicited four specific types: feedback regarding the performance of specific tasks, feedback about the process of completing tasks, feedback on self evaluation or self confidence, and feedback about the learner as a person (15) Each of these models differs in effectiveness, with descriptive feedback about the task at hand producing the greatest benefit. Procedural feedback is associated with a deeper understanding of the meaning and interrelationships of a task and can shape the learner's strategy for task completion (15) More effective learners have a greater ability for self evaluation. Feedback that encourages self evaluation in an attempt to instill the skills of self directed learning was shown to be beneficial only if the recipient understands the purpose and intention. Feedback about the learner as a person often is uninformative about the task at hand and rarely leads to an increased commitment to learning goals (15) Unfortunately for students in the health professions, an emphasis on summa