Communication Skills Week 7 PDF

Models of feedback What is feedback? Feedback lies at the heart of teaching, learning and assessment and underpins many important developments in contemporary health profession education, such as workplace based assessment, the move towards competency‐based curricula, an...

Models of feedback What is feedback? Feedback lies at the heart of teaching, learning and assessment and underpins many important developments in contemporary health profession education, such as workplace based assessment, the move towards competency‐based curricula, and appraisal, mentoring and coaching. The concept of feedback as an informative process has been at the heart of the ‘apprenticeship’ model used for the development of workplace learning for millennia Black and William proposed that, in the interests of simplicity, the term feedback be used ‘to refer to any information that is provided to the performer of any action about that performance’ Harlen and James concur with the notion of overlapping concepts of feedback and formative assessment: ‘Formative assessment, therefore, is essentially feedback both to the teacher and to the pupil about present understanding and skill development in order to determine the way forward’ Does feedback work? Studies concluded that feedback can change clinical performance when it is systemically delivered from credible sources However, feedback does not always have positive effects. two in every five effects were negative. They explain this by proposing four possible responses when an individual is presented with evidence of discrepancy between actual and desired levels of performance, that is, a ‘feedback‐standard discrepancy’  : first, behaviour may be changed to improve performance to better match the desired standard; second, the standard may be altered to match current behaviour (raised when positive feedback is received, thereby encouraging future improvement, but lowered when negative feedback is received); third, the feedback itself may be rejected in an attempt to deny any discrepancy exists; finally, an individual might abandon the standard completely in an attempt to avoid the situation in future. Obviously feedback information must be received and interpreted by the recipient before it can influence performance. Hattie and Jaeger commented that: Not all students receive the same information in the same way. Some students are more able to seek and assimilate feedback information, and these differences relate to the students’ manner in which they process information relating to the self, that is to their beliefs about self or self‐esteem.  Feedback that threatens self‐esteem is less effective, and negative feedback may be rejected, blamed on external factors or perceived as ‘useless, burdensome, critical or controlling’. He concluded that facilitation is central to feedback success in that it can take potentially damaging negative feedback and use it to create positive outcomes King discussed the tendency for educators to focus mainly on poorer aspects of performance rather than what was done well, thereby reducing the likelihood of repetition of poor performance but also potentially increasing anxiety and reducing the recipient’s openness to further learning  Consideration must be given to whether feedback is to be directive or facilitatory (the latter approach being more appropriate for advanced learners) specificity of feedback (neither too specific nor too general learning will be constrained); further, feedback information should not be too complex Timing is important and may influence effectiveness; generally it seems that immediate feedback is the most effective in the context of skills training. One problem is that people may not recognise feedback from others. This may not seem a problem as a person’s ability to self‐assess is seen as fundamental to the success of feedback and most models purport to promote it. There are many potential barriers to providing feedback  First and foremost, delivering feedback constructively and consistently is not easy, especially in experiential (as opposed to classroom) settings and takes time Second, teachers may worry about upsetting learners or about the impact of ‘negative’ feedback on their relationship with them. Third, many teachers have had no training in giving feedback, thus avoid doing it, especially in challenging circumstances such as a learner with little insight (arguably a situation in which the need for honest, constructive feedback is at its greatest). Notwithstanding the complexity, however, the core features of effective feedback distilled from the evidence are remarkably consistent  focuses on the task and task performance is specific, linked to personal goals and includes information about how to improve; is descriptive and non evaluative; focuses on behaviour, not on personal attributes; does not threaten the recipient or undermine self‐esteem should be given in a context of trust and mutual respect. Models of feedback Perhaps the best‐known approach to feedback is a model formalised by Pendleton, which ultimately became known as ‘Pendleton’s rules’ The model intended to provide balance and safety to counteract the historical tendency for feedback to focus on negative aspects, often with little or no emotional support, turning it into a potentially destructive and de‐motivating process. The aims of the approach are to encourage self‐evaluation and, by focusing on positives first, to reinforce strengths and forestall a spiral of defensiveness. he or she may not actually ‘hear’ the positives when they finally arrive; it uses time inefficiently; the learner’s desire/need to discuss areas of weakness may be blocked; and it becomes repetitious and formulaic. They recommended that their feedback principles should be treated as such and advocated ‘directness and sensitivity’ when providing feedback. An alternative ‘set of strategies for analyzing interviews and giving feedback which maximizes learning and safety in experiential sessions’ was developed by the authors of the Calgary‐Cambridge Guide to communication teaching Known as ‘agenda‐led outcome‐based analysis’ (ALOBA), it is complemented by an approach to providing descriptive, nonevaluative feedback, the so‐called ‘SET‐GO’ approach (i.e. what I saw; what else did you see?; what do you think?; clarify goal; and any offers as to how might get there?). ALOBA starts with the learner’s agenda, which allows early identification of problems experienced by the learner and what help he or she would like from the facilitator and/or group. In theory this helps allay anxiety, reduces defensiveness and is arguably more time efficient. Feedback is focused on what outcomes the learner (and, in the context of a consultation, the patient) is (are) trying to achieve or would have liked to achieve, which encourages problem solving and promotes engagement and ‘ownership’. Another approach developed in the USA is the six‐stepped Chicago model (Brukner et al. 1999). Like ALOBA, it starts with recapping aims and objectives the trainee is supposed to be pursuing. The other steps are to give feedback of a positive nature; ask trainee to appraise his or her own performance; give feedback focused on behaviour not personality, and on observation not opinion; give specific examples; and suggest areas for improvement. Pendleton’s seven tasks (Pendleton et al. 1984), Neighbour’s five stages – connect, summarise, handover, safety‐net, housekeeping (Neighbour 2005) – and the Calgary‐Cambridge framework (Silverman et al. 2005) have been used as a foundation for analysing the consultation for teaching, learning and assessment. For example, the Leicester Assessment Package, which is based in part on Pendleton’s tasks, comprises a checklist that is used to deconstruct the consultation and the processes observed, with the aim of informing feedback and assessment  Patients’ views are increasingly being sought in the context of service (National Health Service 2011), clinical practice (Chief Medical Officer for England 2008) and education. For example, the General Medical Council recommends that ‘All…patients and carers who come into contact with the (medical) student should have an opportunity to provide constructive feedback about their performance’ Burford et al. explored the use of the Doctors’ Interpersonal Skills Questionnaire for feedback to junior doctors in the northeast of England and concluded that, whereas the process was feasible, it must be sensitive to local circumstances, and questions of access, engagement and logistics need to be addressed convincingly for the need to create a learning environment within healthcare in which feedback‐seeking behaviour is the norm and is encouraged with opportunities actively sought by learners, practitioners and teachers. As Archer put it: ‘If the health professions are serious about effective feedback, an evidence‐based cultural shift will also be required’