Saying What the Learner May Not Want to Hear – Providing Feedback

by Regina Ulis, PharmD, PGY1 Pharmacy Practice Resident, Medstar Georgetown University Hospital

Every preceptor will inevitably encounter a learner who must be given “corrective” feedback regarding a less than optimal performance. While it is easy to give praise and reward learners for good behavior, it can be quite difficult to formulate criticism and deliver it in an effective manner. Such criticism may be necessary to help the learner grow professionally or perhaps personally, to protect patients’ health, or for a variety of other reasons.¹ However, it is important to understand that the recipient may see this feedback as a personal attack or may shy away from the learning experience instead of taking the advice in stride and taking action to make a behavior change. So how, then, do preceptors deliver feedback in a positive manner that promotes the learner’s growth?

Several methods have been proposed for giving effective feedback to learners. One of the most frequently used methods is the “Feedback Sandwich”.² A Feedback Sandwich is essentially a negative critique “sandwiched” between positive statements. For example, if a learner needs to be more assertive, the preceptor might say, “You made several excellent recommendations to change the patient’s medication regimen. However, I don’t think you communicated them to the team very effectively.  You seemed unsure of yourself and people could barely hear you. I think that one of your goals for this rotation should be to become more confident in making recommendations to the team. That way the team can take advantage of your clinical knowledge and this will lead to improved patient care.”

The entire purpose of this method is to make the delivery of negative feedback more palatable. This method can be effective because it builds trust, improves comfort, and increases the receptiveness of the listener to the criticisms that are delivered. It has also been documented to increase motivation and engagement²; these qualities are necessary to maximize learning. There are also variations to this technique, such as the “open-face” sandwich, which pairs a negative statement followed by a positive one. Different situations may call for different varieties of “sandwiches,” and it may also become necessary to vary the technique because the learner may begin to anticipate that good feedback is always followed by a negative comment.²

Studies have been conducted to see the effects of the Feedback Sandwich on learning including studies with medical students.²  These results should be applicable to student pharmacists and other health professionals as well. Overall, these studies have shown that this method enhances the learner’s self-esteem. Additionally, using this method allows for more individualized comments, which increases performance even though it may not increase the student's short-term satisfaction. Other results indicated that the number of positive comments provided to a learner predict successful future performance.² This may be a reason why it may be helpful to give positive feedback alongside the negative.

Another common method of giving feedback is the “reflective feedback” technique which focuses on content and its relationship to the receiver. In other words, this message focuses on the message to be delivered and how important it is to the person receiving it. This method consists of a series of 3 steps:³

1.  Ask questions that are clarifying and connected to what was observed
2. Explain the value or potential value to the learner who is receiving feedback
3. Ask a reflective question or put forth a potential action to stimulate thought

The goal of these steps is to make underlying assumptions explicit (step 1), make the recipient feel valued (step 2), and request a response from the recipient and allow them to see others’ point of view (step 3).  One of the positive attributes of reflective feedback technique is that it is intended to come off as less judgmental and more focused on growth and development. Following these three steps opens a conversation between the teacher and learner and allows for a discussion, including justifications and possible observations that each party has made.³

Although these are but two methods that may be used to deliver feedback to learners, both are documented to be effective. They allow for growth and development – often of both parties.^1,3 In health professional education, using these techniques may also lead to improvements in patient care. It is important to note, that many other strategies for delivering feedback exist, and that every situation is unique.  It is important to have a plan prepared for when you have to say what your learner may not want to hear.

References

1.   Hoon A, Olver E et al. Use of the “Stop, Start, Continue” method is associated with the production of constructive qualitative feedback by students in higher education. Assess Eval Higher Educ 2015; 40(5): 755-767.

2.   Parkes J, Abercrombie S, McCarty T. Feedback sandwiches affect perceptions but not performance. Adv Health Sci Educ Theory Pract 2013; 18(3):397-407.

3.   Reilly M. Saying what you mean without being mean. Educational Leadership 2015; 73(4): 36-40.