Should Feedback be Given Verbally or in Writing?

by Mariam M Philip, PharmD, PGY1 Community Pharmacy Practice Resident, Walgreens Pharmacy

Learners thrive in a safe environment where they can freely express their thoughts and opinions. At the heart of learning is feedback.¹ Feedback is critical in the classroom, in clinic, at work … indeed, anywhere learning occurs. It is crucial to knowledge acquisition, patient care, personal development, and growth. As educators, it's critically important to strive to give effective feedback.  Many agree it gets easier to provide over time. Feedback received is not always predicted, positive, effectively delivered, or correctly interpreted. Generally, the feedback provided should be based on direct observations and understood by the learner. Feedback should be provided in a safe environment where learners can discuss the feedback, express their concerns, and participate in developing an action plan.

Feedback is different from an evaluation, and it should be delivered in a conversational yet descriptive manner. When it’s done effectively and periodically, the formal evaluation (which typically occurs at the end of the course or experience) should not be a surprise.¹ Evaluations are more formal and done to determine the learner’s grade (or, in the case of employees, pay raises or promotion decisions).

Feedback can take two forms: verbal or written.  Is one delivery method better than another?  The goal of feedback is to influence the learner and either motivate the continuation of their good work or point out what needs improvement, or both. One of the advantages of verbal feedback is that can lead to a “real-time” discussion and provides an opportunity for both the educator and student to elaborate more with examples. On the other hand, written feedback is often clearer, can be referenced later (e.g. when constructing the final evaluation), and (perhaps) reduces the chance of miscommunication or misinterpretation.

In 2017, a randomized controlled trial that enrolled 44 nursing students assessed the effectiveness of oral and written feedback.  The students were divided equally into two groups. The students filled out a questionnaire after the feedback to determine their reactions, perceptions, and responses to the different forms of feedback. The questionnaire showed no statistical differences between the two groups, and the results were similar. Although there was no statistical significance between the groups, the study might have been underpowered due to the small sample size. Nonetheless, the authors offer some interesting points of view.²

Based on the students’ responses to the questionnaire, 21.3% of the oral feedback group experienced negative reactions; 75.8% were classified as mild, and 24.2% were classified as severe reactions. Conversely, only 14.4% of the students in the written feedback group had a negative reaction; most were classified (92.3%) as mild and 7.7% were severe. While the difference was statically significant, the oral feedback group had a higher percentage of students who experienced negative responses such as arguing, crying, insulting, denying, and inattention. The written feedback group had a higher rate of intimidation, undue self-defensiveness, and confrontation. The satisfaction rate was higher (but not significantly so) in the written feedback group (77.1% indicated high satisfaction with the feedback vs. 50% in the oral group). Lastly, when the delivery of the feedback was assessed, the students in the oral feedback group gave it a higher delivery score.²

Additional studies conducted with medical students who received “well done” feedback showed similar satisfaction from both oral and written methods of communication.³ A similar study was conducted with medical residents from two university-based clinics. To diversify the participants and results, the residents that participated were assigned to medical clinics of various specialties. Sixty-eight internal medicine residents were randomly assigned to receive either written or “face-to-face” feedback. They were then given a questionnaire to assess their overall clinic experience, in which eight of the 19 questions asked about feedback. Six five residents completed the questionnaire. The results showed no differences in the residents’ perceptions of oral and written feedback.³

Both forms of feedback are acceptable and can be effective when delivered following best practice principles. There are advantages to each method of communication when providing feedback. Oral feedback is often less formal and more conversational, which will allow the student to feel safer expressing their concerns or participating in planning for the future. While less efficient, written feedback often promotes deeper reflection. The student can reflect on the given feedback and refer to it periodically. Thus, a teacher should focus on the quality and frequency of the feedback rather than the delivery method.⁴

I believe health professional students benefit from written and oral feedback in both the didactic and experiential settings. Both delivery methods serve a purpose that is important to students’ growth. The thoroughly thought-of written feedback will allow the student to digest the feedback and reflect on their own time. This will increase autonomy and promote self-assessment and planning. Meanwhile, oral feedback allows students to explain themself, ask questions, and brainstorm with the preceptor on the next steps.

A healthy balance between verbal and written feedback should exist between the two forms of communication.  Both should be used to help the student grow. I find oral informal feedback more engaging, which helps build the teacher-learner relationship. It can help shift the “formal meeting” nerves to a mentorship mindset. Periodic written feedback can reinforce verbal discussions and make constructing the end-of-course evaluations easier.

References:

1. Jug R, Jiang X, Bean Giving and Receiving Effective Feedback: A Review Article and How-To Guide. Archives of Pathology & Laboratory Medicine 2019; 143 (2): 244–250. https://doi.org/10.5858/arpa.2018-0058-RA
2. Tayebi V, Armat MR, Ghouchani HT, et al. Oral versus written feedback delivery to nursing students in clinical education: A randomized controlled trial. Electron Physician. 2017;9(8):5008-5014. Published 2017 Aug 25. doi:10.19082/5008
3. Elnicki DM, Layne RD, Ogden PE, et al. Oral Versus Written Feedback in Medical Clinic. J Gen Intern Med. 1998;13(3):155-158. doi:10.1046/j.1525-1497.1998.00049.x
4. Dobbie A, Tysinger JW. Evidence-based strategies that help office-based teachers give effective feedback. Fam Med. 2005;37(9):617-619.

"Blended Learning” Models and Their Effectiveness

by Hannah Black, PharmD, PGY1 Pharmacy Practice Resident, Baptist Memorial Health-North Mississippi

Many of us are familiar with the term, “blended learning.” While it is easy to assume that this teaching model simply involves a combination of in-class and online instruction, there are lots of different ways of accomplishing it. Although blended learning models are now commonplace (thank you COVID-19), there has been a lot of research published in medical education journals over the last 4 decades.¹ Many studies have documented the effectiveness of blended learning in health professions education but given that blended learning methods vary very substantially, what strategies are most effective?

The Journal of Medical Internet Research published a systematic review and meta-analysis examining the effectiveness of blended learning compared to traditional learning in health professions education.¹ Blended learning was stratified into different types of learning support, defined as follows:

• Offline Learning - the use of personal computers to assist in delivering stand-alone multimedia materials without the need for internet.
  • Videos and audio-visual learning materials (as long as the learning activities did not rely on internet connection)
• Online Support – all online materials used in learning courses.
  • Educational platforms (learning management system, LMS like Blackboard)
• Digital Education – a wide range of teaching and learning strategies exclusively based on the use of electronic media and devices
  • Facilitates remote learning for training purposes
• Computer-Assisted Instruction – the use of audio-visual material to augment instruction.
  • Multimedia presentations, live synchronous virtual sessions via a web-based learning platform, synchronous or asynchronous discussion forums
• Virtual Patients – interactive computers simulations of real-life clinical scenarios

The primary outcome of this study was to evaluate the effectiveness of blended learning to achieve knowledge outcomes compared with traditional teaching strategies.¹ Of the 3,389 articles identified in MEDLINE, 56 studies met the inclusion criteria with a total of 9,943 participants. Most of the participants were students in medical schools. Other participant subgroups included nursing, pharmacy, physiotherapy, dentistry, and interprofessional education.

Offline Blended Learning vs Traditional Learning

Some benefits of offline learning have been suggested, such as unrestricted knowledge transfer and enhanced accessibility. This type of learning gives students more flexibility to learn at a convenient pace, place, and time, which can improve retention of content. However, this study showed no significant difference in knowledge outcomes when compared to traditional teaching methods. It was noted that the majority of studies in this group were in nursing. These results were consistent with a previous meta-analysis on offline digital instruction.²

Online Blended Learning vs Traditional Learning

Online blended learning gives students more experience building competency in things that require repeated practice, such as EKG and imaging interpretation. The internet has provided students with an abundance of resources that can be used with the click of a button, so why not use it to the learner’s advantage? As expected, this study did show a significant advantage in knowledge outcomes of online blended learning versus traditional learning alone. Using the internet to deliver instruction does not come without challenges. Learning is highly dependent on the student’s ability to cope with technical difficulties and comfort using computers and navigating the internet.

Digital Learning vs Traditional Learning

Digital learning, or “eLearning,” is being used increasingly in health professional education for improvement of access to training and communication.³ However, the pooled effect for knowledge outcomes in this study suggests no significant difference.¹ This study was broken into subgroups, and the medicine subgroup showed digital learning had a positive effect when compared to the control group.¹ I feel this concept is not one to ignore because it facilitates remote learning, which could help in addressing the shortage of health professionals in settings with limited resources.¹

Computer-Assisted Instruction Blended Learning vs Traditional Learning

Computer-assisted instruction can provide students with innovative methods of instruction for things like physical examination techniques.⁸ The pooled effect for knowledge outcomes in this study suggested a significant improvement. Participants in one study reported difficulties accessing the course due to problems with the university’s internet, so the online discussion board was not used to its full potential.⁵ One could argue that similar problems could have emerged even in the traditional learning setting where students may choose not to or feel intimidated to engage in discussion. 

Virtual Patient Blended Learning vs Traditional Learning

Virtual patients are widely used in simulation-based instruction. These simulations can be used as a precursor to bedside learning, or to be used when direct patient contact is not possible. The groups with supplementary virtual patient learning support showed a significant improvement in knowledge outcomes compared to traditional learning.¹ These results reinforce the results found in a similar meta-analysis, showing that virtual patients have a positive impact in terms of skill development and problem solving.³

When combining all 56 studies, the pooled effect size reflected a significantly positive effect on knowledge acquisition in favor of blended learning versus traditional learning in health professions education.¹ A possible explanation could be that blended learning allows students to review materials at their own pace and as often as necessary. This reinforces the belief that the outcomes of blended learning is most dependent on student characteristics and motivation, rather than the instructional deliver method.

In my opinion, one of the most interesting findings from this study comes from the subgroup analysis. For the top 3 subgroups, the pooled effect difference in the medicine subgroup was 0.91, nursing studies was 0.75, and dentistry studies was 0.35.¹ This reiterates that the effectiveness of blended learning is complex and dependent on the learner characteristics and needs of the student population. One tool that can be used to develop and implement a personalized blended learning curriculum is the six step Kern cycle⁶, described below:

1. Problem identification – The first step begins with the identification and analysis of a specific healthcare need or group of needs. It could relate to the needs of the provider, or the needs of society in general.
2. Targeted needs assessment – The second step involves assessing the needs of your group of health professional students, which may differ from the needs of providers or society in general.
3. Formulating goals and learning objectives – Once the needs have been clearly identified, goals and objectives should be written starting with broad goals, then moving to specific, measurable objectives.
4. Selecting educational strategies – After objectives have been finalized, the content and methods can be selected that will help to achieve the educational objectives.
5. Implementation – In this step the finalized curriculum is implemented.
6. Evaluation and feedback – This final step is important to help continuously improve the curriculum and gain support to drive the ongoing learning of participants.

 Overall, this meta-analysis reinforces the notion that blended learning has a positive effect on knowledge outcomes in healthcare education. However, it also indicates that different methods of conducting blended courses could demonstrate differing effectiveness based on the student population, their needs, and the learning objectives.¹ When strategically developed and implemented, I believe blended learning enhances outcomes.

References

1. Vallée A, Blacher J, Cariou A, Sorbets E. Blended learning compared to traditional learning in medical education: Systematic Review and meta-analysis. Journal of Medical Internet Research. 2020;22(8): e16504.
2. Posadzki P, Bala MM, Kyaw BM, et al. Offline Digital Education for Postregistration Health Professions: Systematic review and meta-analysis by the Digital Health Education Collaboration. Journal of Medical Internet Research. 2019;21(4): e20316.
3. Kononowicz AA, Woodham LA, Edelbring S, et al. Virtual patient simulations in Health Professions Education: Systematic Review and meta-analysis by the Digital Health Education Collaboration. Journal of Medical Internet Research. 2019;21(7): e14676.
4. Song L, Singleton ES, Hill JR, Koh MH. Improving online learning: Student perceptions of useful and challenging characteristics. The Internet and Higher Education. 2004;7(1):59–70.
5. Al-Riyami S, Moles DR, Leeson R, Cunningham SJ. Comparison of the instructional efficacy of an internet-based temporomandibular joint (TMJ) tutorial with a traditional seminar. British Dental Journal. 2010;209(11):571–6.
6. Kern D. Curriculum Development for Medical Education: A Six-step Approach. Baltimore, MD: Johns Hopkins University Press, 2022.
7. George PP, Papachristou N, Belisario JM, et al. Online elearning for undergraduates in Health Professions: A systematic review of the impact on knowledge, skills, attitudes and satisfaction. Journal of Global Health. 2014;4(1).
8. Tomesko J, Touger-Decker R, Dreker M, Zelig R, Parrott JS. The effectiveness of computer-assisted instruction to teach physical examination to students and trainees in the Health Sciences Professions: A systematic review and meta-analysis. Journal of Medical Education and Curricular Development. 2017 Jul 14;4:2382120517720428